Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
We're in the middle of a series about prostate cancer staging. At the PCRI we have a Staging
Guide and we're loosely following the format in here. In this video, we're going to cover
"Low-Royal." We have five different stages of prostate cancer, each subdivided into three
subtypes: Low, Basic, and High. Today's video is about Low-Royal.
Low-Royal is an advanced—Royal is the most advanced stage—so, Low-Royal is an advanced
stage of prostate cancer. And Low-Royal is defined as a man who was Indigo, who's been
on hormone therapy (Lupron for example) for usually many years, but now even with a low
testosterone, the PSA is starting to rise.
Just for review, Basic and High-Royal are men that have scans showing cancer outside
the pelvic region, in the bones. Basic-Royal: Five or fewer metastases. High-Royal: Six
or more metastases.
So Low-Royal is without metastases except for perhaps some enlarged lymph nodes in the
pelvic region. It's defined as Royal because of the resistance to Lupron and it's other
cousins such as Eligard and Firmagon, Zolodex and the like. Resistance to the best available
therapy, which is hormone therapy, is a very serious development with prostate cancer,
and that is why this category qualifies as Royal and not one of the earlier stages. Untreated
men go on to develop metastases in the bones after about an average of 18 months. This
is a very serious development and the advent of metastases needs to be prevented with appropriate
therapy.
Historically, there's been no treatment for this category and doctors have often reassured
their patients that it's okay to have a rising PSA and not take any immediate action. That,
of course, is a big mistake. Why would people think that it's okay? Well, many men have
been in remission for as long as 10 or more years and nothing's happened. Fears related
to cancer have been dissipated. But the rising PSA with a low testosterone is a signal that
things are changing quickly and something must be done.
So what can be done? It turns out that modern, second-generation hormonal therapy such as
Xtandi, Erleada, and there is a new medicine coming out called Darolutamide can delay the
onset of metastases for about two years. That's a healthy amount of time considering that
these medicines have relatively few side effects beyond what the Lupron is already causing.
The studies have been done that show this delay in the onset of metastases with these
medications are very high-quality studies, randomized prospective trials. What's interesting
though is that at the research centers where these studies were done, the men had fairly
high PSA levels, even though their scans were clear, the average PSA was in the 8-10 range.
Men can be detected with Lupron resistance with much lower PSAs—less than 1, easily.
Men who get on treatment earlier do even better. So if we can get an average two-year delay
in metastases with someone starting with a PSA of 8-10 there's probably going to be much
longer remissions in men that start earlier. In our own practice, we've seen men go on
medicines with PSAs less than 1, and some of them have remained in remission for years
and years, and there's no sign of them progressing at all.
So, it's clearly important to identify this sub-category of Low-Royal and get on the right
treatment. When you hear doctors talking about Low-Royal, the common terminology is "M0."
M0 means "M" for metastases, "0" means no visible metastases in the bones. So it's important
to remember that even though scans are all clear, we're talking about a very serious
stage of prostate cancer. Men who don't get treatment in a timely fashion are going to
develop bone metastases in an average of 18 months. This can be prevented with modern
new agents. Men who have rising PSAs who are on Lupron need to start treatment as quickly
as possible.