So, this is kind of going back into the intermediate-risk. I know a lot of patients are
kind of like, "Is there a way that we could get more aggressive treatment in an intermediate-risk
category so it doesn't, you know, progress." So, for intermediate-risk, would it make sense
if somebody is on Lupron, to automatically start a second-generation hormone therapy?
Really, no. Intermediate-risk patients have excellent cure rates with what we're already
doing, so to improve on those outcomes is quite difficult since there isn't a lot of room for
improvement. It's already an excellent cure rate. The argument in favor of using medicines
like that is that they are well-tolerated. They're expensive sometimes, and, of course, that would be
difficult to get insurance coverage for them. So, I think treatment for intermediate-risk is going
the other direction. As the radiation therapies are getting so much better there's more and more
discussion about skipping the hormone therapy altogether. Especially now that we have these
new PSMA PET scans that can confirm the absence of any metastatic spread. It is feasible to give
second-generation agents to intermediate-risk, but I don't think there's a lot of push to do that.
So, in regard to these second-generation hormone therapies, we have
Xtandi (enzalutamide), Erleada (apalutamide), Nubeqa (darolutamide)—
are there any studies evaluating the use of these in those unfavorable high-risk categories?
Well, there is for Zytiga and—I mentioned before—the STAMPEDE trial, and the general
assumption is that these second-generation hormonal agents have about the same amount
of anti-cancer horsepower and that they can be used interchangeably. So, usually, selection
is based more upon what insurance will pay for or possibly minimizing side effects. The side
effects of these medicines are not that common, but they do have a slightly different profile.
What would you say the difference in the outcome would be between a patient who would
add chemotherapy or second-generation hormone therapy versus somebody who wouldn't do it?
Well, I think that if you're looking at an unfavorable high-risk patient,
you could improve your cure rates 10%-15%-20% and the studies do show better survival.
So, it's a very meaningful addition to the way we treat these people.
So, per Dr. Tanya Dorff's study—she's with City of Hope—she did a study with hormone
therapy on high-risk men who had radical prostatectomies, and the question is,
"Should men with high-risk disease who decide to have a radical prostatectomy
consider hormone therapy, and if so, for how long?"
I think they should. The concern with doing radical prostatectomy in high-risk is that
a vast majority of these people are going to have the cancer come back. They won't be able to get it
all out, and in her study which was published in "The Journal of Clinical Oncology," they
showed almost 90% 5-year disease-free survival in men that took a year's worth
of hormone treatment after the operation. So, compared to relapse rates that are almost 50%
or higher for high-risk disease, to have a 5-year disease-free survival of
90% with the use of Lupron right after surgery seems to make a lot of sense.
Would you say the same for,
I guess, high-intermediate risk as well who have a radical prostatectomy?
One of the things, of course, one of the—you know, there aren't a whole lot of advantages to surgery
anymore—but one advantage is that they have the information after the operation as to whether
the disease is completely organ confined, and then, of course, they can do genetic testing on
these samples now with things like Decipher and actually provide the patient with a percentage
likelihood that they will stay cured, and if it's an unhappy number—let's say they tell the
patient there's a 40% chance this is coming back in the next five years—those patients
may be very interested in taking some hormone treatment to try and improve on those numbers.
The next question is, "How will the recent PSMA approval
affect high-risk prostate cancer patients?"
Oh, wow. We don't know for sure. This is a very powerful new imaging technology that answers the
question that we've always struggled to answer which is, "has the cancer spread outside the
gland?" And PSMA PET scans are not 100% accurate. It is possible to have cancer spread outside it
in very small amounts that could be missed by the scan, but substantial amounts of cancer
are going to be rarely missed, and this may allow us to back off on some of the intense
therapy that we've been discussing. So the idea of Taxotere and second-generation hormonal agents
is a precaution against the possibility that there's some metastatic disease out there that
was missed on the standard bone scans and CAT scans. If we have a PSMA PET scan that shows
that everything is all clear, that everything is confined inside the prostate, might that allow us
to skip or reduce the amount of hormone treatment or chemotherapy? People are going to be talking
about that because these hormone treatments and chemo treatments have quite a few side effects.
Thanks so much for watching. If you would more information on any co-pay programs
or financial assistance when it comes to these second-generation hormone therapies,
you can visit our website at PCRI.ORG and also contact our helpline. There are many
programs out there that can help you pay for these somewhat expensive drugs. Also, if you would like
more information on anything that we discussed today, you can visit our website at PCRI.ORG,
and also subscribe to our YouTube channel. We come out with new prostate cancer videos every week.