So, we have a patient who has been newly diagnosed with metastatic prostate cancer,
so stage four, and their doctor told them that chemotherapy is not an option for them and that
they need to go straight to a clinical trial. Their concern is that the doctor
is more interested in his research than as a patient, and so they're wondering how do
they find another oncologist that they can go to that would even put chemo on as an option?
Well, yeah, it's always hard to guess what people's motivations are for different things.
It is true that doctors that have connections in academia do need to put people on clinical trials
and sometimes that motive can overshadow, perhaps, what might be the most appropriate for a patient.
What this gentleman is talking about is a situation that got resolved in 2021
where they looked at long-term outcomes survival in people with newly diagnosed metastatic
hormone-sensitive disease; these individuals that were treated with a combination of Zytiga,
which is abiraterone, Lupron, and Taxotere did better than the patients that got Zytiga
and Lupron alone and lived substantially longer in these studies. That doesn't mean that the patients
who didn't get Taxotere never got Taxotere; it means that they got Taxotere later when the
Lupron and Zytiga stopped working. So, it's really immediate Taxotere versus delayed Taxotere, and
this question comes up a lot in discussions with oncologists. As an oncologist treating patients,
there's always a concern in the delivery of some treatment, "am I going to run out of options for
this patient? Will I be faced with a day when I don't have anything I can give them that would
help them?" and that's a common situation in the field of cancer, and it's logical that doctors may
want to hold something in reserve so they can have something to give at a future date when
the existing treatment stops working. Clinical trials over and over show that if you have an
effective treatment that can be given safely in combination—that's not excessively toxic—that
it always works better giving it up front, earlier on, rather than waiting until the disease develops
momentum and starts to get out of control. The only reason one wouldn't do that is that as you
pile one treatment on top of another treatment on top of another treatment,
sometimes you'll run into excess toxicity and then there are situations where
certain individuals have such a good outlook they don't need such intensive therapy, and
that's a judgment call of the oncologist, but most people that have metastatic prostate cancer are
going to develop hormone resistance at some point and therefore will end up on Taxotere at
some point and those individuals will do better if they get the Taxotere early on, right when
the disease is less entrenched, as opposed to getting it later on where it will do some good,
but it won't do as much good. So, this has been answered in a randomized prospective trial,
so it's not opinion anymore; it's scientific fact, and not all the doctors are aware of it.
Medicine is moving quickly and the general oncologists out there are treating 100 different
types of cancer, so they're not going to be able to be up to date in every single cancer; they
may not be familiar with these clinical trials yet. So how do you find an oncologist? I think
you shop around; look online; look to see how many stars they have, if patients are happy with them,
and in consulting a new oncologist express your goals in terms of why you're consulting them.
Don't just to throw yourself at their feet and say do to me what you will,
but demonstrate that you're an informed patient and that you're aware of the latest research
and that you want to be treated in an optimal modern fashion and oncologists, in general,
are going to be very open to giving chemotherapy. That's what mostly they do for a living.
So, it's interesting, you know, this person was newly diagnosed at stage
four and this leads me into the next question. Another patient was wondering
how aggressively should you be checking for early metastatic activity? Should
you be getting scans every six months? Like, what's the methodology for checking this out?
PSA, of course, in the prostate cancer world is an amazingly powerful tool and if the PSA is
undetectable whether person had surgery, radiation, or hormone treatment, historically,
we believe that the scans are going to be clear and they're not going to really give you any
additional useful information. We'll find out if that's still true with the new PSMA PET scans that
have just become commercially available. That is a more powerful scan and for the first time
we're able to see much smaller specks of cancer, and so the old rule of thumb was that if the PSA
is less than 0.1, don't bother doing scans because you're not going to find anything,
but that rule has yet to be proven now that we have PSMA PET scans, and I honestly don't know.
There may be situations where these scans will be appropriate to find out if there's something
lurking in a shadow that could be treated even though the PSA is otherwise undetectable.
Well, so if you have like a patient who's on maybe like a second generation
androgen hormone therapy and so they've been, you know, going strong on that,
is PSA the only indicator they need to get? Like yearly PSMA scans...
Well that's exactly the question. I don't think we have an answer. So historically,
if the PSA was undetectable, we would counsel patients that doing bone scans and cat scans
and Axumin PET scans and whatnot are a waste of time they're not going to show anything of
any relevance, but we don't know that's the case with PSMA PET scans;
it's really too early just early to say as this technology has just come out.
Considering we don't know yet, I know a lot of people are wondering if PSMA scans should be,
you know, used at initial diagnosis just to be, you know, see if they have metastatic
activity. Do you think that PSMA will be something that's used in initial diagnosis in the future?
Oh absolutely. PSMA PET scans are a cut above every other scan— more accurate,
more sensitive—and the question about whether or not cancer has spread outside the prostate
has always been the the main issue that needs to be resolved so when people are newly diagnosed
with intermediate- or high-risk prostate cancer they'll routinely get a CAT scan and a bone scan
and sometimes these things will demonstrate something but most times they won't, but experts
know that just because the scans are clear doesn't mean there's not any small metastatic
lesions out there; they just know there's no big ugly metastatic lesions out there, but with PSMA
PET scans we're picking up much smaller spots at a much earlier stage and I really can't imagine
why in 2022 anyone would ever do another CAT scan or a bone scan. The staging process, historically,
which relied on CAT scans and bone scans, now, I think is history, and the only sensible scan to do
is a PSMA PET scan. No one wants to use older cruder technology when you've got modern accurate
technology available to— certainly people that have medicare, I know that with the PPOs
and the HMOs and whatnot, there'll probably be pushback in the early utilization of these scans,
but the standard of care as far as I'm concerned is PSMA PET scans and really no other scan.
And yes, they should be done routinely for every newly diagnosed patient that isn't a candidate for
active surveillance. Men who are Gleason six and are doing active surveillance do not need PSMA PET
scans because we know that that type of prostate cancer doesn't spread outside the prostate.
Thanks for watching. If you would like more information
about prostate cancer you can go ahead and subscribe to our YouTube channel.
we come out with new prostate cancer videos every week, and go ahead and visit our website
pcri.org. We have tons of information on prostate cancer that will help you.