So, today Dr. Scholz, I'm very excited because we're going to be talking about adjuvant therapy.
I know we at the PCRI, we get a lot of questions on this topic, and specifically, we're going
to be covering hormone therapy. So, can you talk about what adjuvant therapy means? I
mean this whole concept of Googling it, it's kind of vague actually, if you Google it.
So, can you define that for the audience?
Yeah, it is a bit of an abstraction. The idea is to supplement standard treatment with radiation
or surgery with some sort of medicine that circulates in the bloodstream, kills cancer
cells wherever they may be in the body. Adjuvant means that you're giving medicines to circulate
through the body even though no scans prove that cancer is out in the body somewhere.
I know that sounds a little confusing, too, that the idea is that it is possible to have
small specks of metastatic cancer, "micrometastasis", and there is no technology to determine if
they are present or absent. We can only guess based on how high the PSA is, what the Gleason
score is, and when those numbers are worrisome (high PSAs and high Gleason scores) we know
that there's a greater likelihood of microscopic specks and those microscopic specks are susceptible
to treatment. So, adjuvant treatment is a preemptive strike against the possibility
of some microscopic metastatic disease out in the body in someone who we're trying to
cure with surgery or radiation.
So, you know, you've been a medical oncologist specifically in prostate for what? Over 25
years? So, the reason why I bring that up is when did adjuvant therapy, as a concept,
come into the treatment space?
Pretty early on. The radiation therapists get credit for documenting in well-designed
studies that men who are undergoing at least the older types of radiation and get adjuvant
hormone blockade have better cure rates and better survival rates, and that was demonstrated
15-20 years ago. Similar studies haven't been done for men with surgery except for some
studies where they gave just three months of hormone blockade with surgery. Well-designed
studies that didn't show much of a difference. The study of long-term hormone blockade in
high-risk men having surgery hasn't really been answered. That's an open question. Tanya
Dorff at the City of Hope did one study looking retrospectively at a large group of people
and it seemed like there was a big advantage as you would expect for high-risk men who
undergo surgery and get hormone blockade as well.
When doctors are giving this therapy, is it different from what they're trying to accomplish
with surgery or radiation, or it's just the same thing across the board?
Well, the surgery and radiation effect, generally, is limited to just the prostate or to a limited
degree to the surrounding lymph nodes. But the microscopic metastases can spread to the
bones, to other lymph nodes in the stomach and the chest, and, of course, surgery and
radiation would have effect at all in those people.
So, how does it differ from standard hormone therapy?
Well, there are different forms of hormone therapy, but the actual delivery of the treatment
doesn't have to be different in any way whatsoever. Could simply just be Lupron or Lupron plus
a second-generation hormone treatment, and the word adjuvant actually extends beyond
hormone therapy, so, adjuvant chemotherapy is standard in breast and lung cancer, and
there are vague and not very convincing studies that even adjuvant chemotherapy has a role
in certain individuals with prostate cancer.
When it comes to the whole timeline, you know, when people are researching adjuvant therapy,
or their doctor tells them, they hear the concept of like "neoadjuvant," "adjuvant,"
and then "salvage" comes up when you Google it as well. Can you explain the differences
in the timelines?
Yeah, so "salvage," of course, means something different than adjuvant. That means that someone
had surgery or radiation, the cancer is coming back, and now we're instituting more treatment.
Neo simply means that the hormone treatment is started before the surgery or radiation,
"neoadjuvant." Adjuvant, generally, means "after," starting after, but it doesn't necessarily.
Adjuvant could encompass any timeline, but the bottom line issue, of course, is that
you're treating potentially invisible microscopic disease. That's what adjuvant means.
Okay, so you mentioned a short course of hormone therapy. So, what is the timeline differences
of how long the duration of a patient on adjuvant therapy would be versus standard hormone therapy?
When we do adjuvant treatment, we're thinking usually in terms of two time periods. A shorter
time period for people whose risk of microscopic disease is much less and a longer time period
for people that have greater risk and it breaks down pretty much into the intermediate-risk
(what we call Teal) those men are typically administered 4-6 months of Lupron, Casodex,
sometimes a second-generation hormonal therapy. And then the high-risk patients (what we call
Azure) those men are given from 12-18 months of hormone blockade.
Due to the shorter timeframe, are the side effects lessened in any way or is it the standard
as regular hormone therapy?
It's lessened quite a bit. The side effects are similar, but for the treatment period
to go on for such a long period, there's a wearing down effect that is very notable for
men that stay on it for longer than 4-6 months. Most men tolerate 4-6 months pretty well.
12-18 months is a pretty big deal.
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