Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.
In this series, we’ve been covering the different stages of prostate cancer. Patients
who go to the PCRI website can figure out their stage by taking a quick questionnaire
and determining whether they fall into one of five categories. In today’s video, we’re
covering “Indigo.” Specifically, we’re covering “High-Indigo.”
Indigo means that someone has undergone previous therapy for prostate cancer, and now, unfortunately,
the disease is returning. It can come back in various forms. High-Indigo means that the
cancer has returned in the lymph nodes surrounding the prostate down in the pelvis. So by definition,
lymph node enlargement from cancer has been documented—usually on a scan—and this
obviously is a serious development. Metastasis, or spread of the cancer, is really the aspect
of cancer that is most feared. That is the first step towards progression of disease,
side effects, and possibly even life-threatening symptoms. So Indigo is the first stage that
we’ve covered up to this point where we know for sure metastases have occurred, they
are actually visible on a scan or possibly they were detected at the time of surgery.
In previous videos, we have been covering the possibility of cancerous spread, microscopic
disease here or there, but it has never been with 100% certainty like we’re dealing with
High-Indigo.
So as you can imagine, the treatment protocols for High-Indigo are going to be altered in
a far more aggressive stance. In certain situations, it’s still possible to cure the disease,
and every effort needs to be made to cure the disease when we know it's dangerous enough
to spread. Having spread to just the surrounding lymph nodes means that the cancer is not as
serious as for example when it’s in the bones or in other lymph nodes higher above
the pelvis. So this may be the last chance to actually cure the disease. In addition,
aggressive therapy gives a much better chance for getting into a complete remission. Complete
remissions—that is PSA levels that are undetectable and lymph nodes that have disappeared—result
in much longer remissions, and it is only the people who go into complete remissions
who can end up cured, meaning five years after treatment the disease still hasn’t returned.
So let’s go into the type of treatment that typically would be recommended to try and
cure High-Indigo (lymph node proven metastasis). The biggest change that has occurred over
the last ten years or so is improvements in radiation technology. Previously it was very
dangerous to radiate lymph nodes in the pelvic region because the intestines surrounding
there would get caught in the crossfire, and the radiation would create all kinds of difficulties
with the intestines with diarrhea, and pain, and difficulties with bowel movements. In
expert hands, these days that risk has been almost totally eliminated, and radiation now
can be given with impunity as long as you are at a center of excellence with modern
radiation equipment to deliver the treatment. So radiation therapy to the lymph nodes is
done without much overthought at this point as of 2019.
But there are other things that need to be done because if we have proven [disease] in
the pelvic lymph nodes, what is the chance that microscopic-metastases in other parts
of the body that won’t be covered by the radiation field? Well, the chances are quite
high, so additional therapy is routinely given along with the radiation. In particular, hormone
therapy such as Lupron. The optimal treatment period is probably to continue the Lupron
for 12-18 months. But in addition to Lupron, we now have second-generation hormonal agents
such as Zytiga and Xtandi that can further enhance the anti-cancer effect of the hormone
blockade. One of those two medicines, in particular, can be given in addition to the Lupron for
the full 12-18 month period to try to enhance cure rates even further.
So this combination of IMRT plus Lupron plus Xtandi or Zytiga is considered fairly routine
as of 2019. A third layer of treatment with a rather mild type of chemotherapy called
Taxotere is also far more widely accepted now than ever before. Taxotere is a medicine
administered every three weeks as an injection. It is a type of chemotherapy so some temporary
hair loss can occur and some fatigue after each injection lasting 2-5 days. But cure
rates have definitely been enhanced by taking six cycles, 6q three-week treatments of Taxotere
in addition to all the other treatments I've already talked about. One thing to keep in
mind and one thing that hasn’t been worked out is that Taxotere can’t be given at the
same time as the radiation. Radiation is a more accepted treatment and oftentimes that
will be given first, then the hormone therapy being given continuously throughout this whole
process, and then the Taxotere started and continued for six cycles after the radiation
is completed.
All of this sounds very complex. Certainly, not everyone is going to be cured with this
process, but the chance for complete remissions is very high—PSAs that are undetectable
and all visible cancer will disappear in most men in the High-Indigo category.
One question that comes up with Indigo (because men have undergone previous surgery or radiation
by definition with this category) and in some cases some cancer might linger where the prostate
used to be—that is in the prostate fossa after surgery or perhaps in the prostate gland
if the individual had previous IMRT radiation and it’s coming back. That situation is
handled just the same as we handle with Low-Indigo, and you should look at the video on Low-Indigo
for how to manage cancer that stayed where the prostate used to be located. There are
all kinds of methods with HIFU and cryotherapy or salvage radiation, but I don’t think
we need to repeat all that in this particular video.
So prostate cancer, even though it’s relapsed, unlike many other types of cancer still can
possibly be cured. Once it has spread as High-Indigo with proven lymph nodes we know unequivocally
that the disease is dangerous. Every effort, every form of modern medicine within reason
should be implemented to try and eradicate the disease to get a complete remission. Out
of those men that are in complete remission, a certain percentage of them will remain cured.
Thanks for watching. Subscribe to our channel and visit our website if you would like more
information about prostate cancer and all its different stages.