So, Dr. Scholz, today we're talking about high-risk prostate cancer and in regard to
our staging system that's actually High-Azure and talking about unfavorable high-risk prostate
cancer, and Azure is part of our, as you know, our five stages of blue, and so really we're
going to be covering different treatment options and really unorthodox treatments when it comes
to this category.
So our first question is, is there a benefit to adding a second generation anti-androgen
or chemotherapy to standard hormone therapy to treat unfavorable high-azure for prostate
cancer?
I think the simple answer is probably yes. The high-azures are the ones who we're struggling
a little bit more to try to cure them and every resource that can improve cure rates
is desirable, and if you look at the second-generation hormones like Xtandi, Erleada, Nubeqa, and
Zytiga, the side effects really aren't that much worse than Lupron, so there is a clinical
trial called STAMPEDE that has looked at outcomes in these people and it does show better cure
rates when you add one of these second generation hormonal agents to the standard Lupron that's
always used when you treat high-azure.
So what about adding both? Is there any situation where you would add both automatically. Well,
unfortunately, we don't have any clinical trials to see if adding chemotherapy like
Taxotere to a second-generation hormonal agent will translate into enough survival advantage
or higher cure rates to justify the side effects of the chemotherapy, but it's logical to guess
that maybe adding chemotherapy to these second-generation hormonal agents might add survival. It works
by a different mechanism, and, of course, independently, they have been shown to add
survival. So, the kind of people that you want to have a discussion about both a second-generation
hormonal agent plus the Taxotere are those men that younger, have more years of life
at risk, and those that high particularly high-risk from the cancer: very high PSAs,
cancer has spread into the pelvic lymph nodes, seminal vesicle invasion. These all equate
to lower cure rates with standard treatment.
So, in the case that you would only give one or the other, would the second-generation
hormonal therapy (e.g. Xtandi or Zytiga, those are the trade names) or chemo be more beneficial
in some cases and or would they have less side effects?
So, if you're trying to pick between either doing chemotherapy alone or a second-generation
hormonal agent alone (I don't mean alone, everyone gets Lupron, everyone gets radiation)
but the side effects of the second-generation hormonal agents are generally perceived to
be quite a bit less than Taxotere. People are guessing; there has never been a head-to-head
trial, but they're assuming that the improvements in cure rates by adding a second-generation
agent or Taxotere will be about the same benefit, so naturally, you're going to go with the
less toxic one, and I would say the vast majority of men in this situation are being treated
with Zytiga, Xtandi, Erleada, Nubeqa type agents. It is becoming more and more routine.
How well do patients usually tolerate the first-generation, so Lupron plus chemotherapy
when they're getting these treatments?
Pretty well. A lot of the protocols involve six Taxotere treatments which are administered
intravenously every three weeks, and sometimes we'll cut that back to four treatments. We
think the lion's share of the advantage is in the first four cycles, and a lot of the
toxicities in the last two cycles. So, talking about over a 12 week period, getting four
treatments—a little bit of hair loss, some fatigue, inconvenience of going to doctors
and getting blood tests and whatnot, so it's not too bad really, but it can't compare with,
you know, just taking a pill like Zytiga or Xtandi.
What would you say distinguishes a high-risk patient who would benefit from upfront chemotherapy
or a second-generation anti-androgen versus a high-risk patient who would not?
Well, there's quite a broad spectrum in "high-risk." So people can be high-risk with just—if
they have a random biopsy, a single core shows Gleason 4+4; that's a favorable type of high-risk,
and you know, assuming that the PSA is less than 10 and no one can feel any large lumps
on their Digital rectal exam. So, if we're talking about unfavorable high-risk, we're
talking about people with PSAs of 30 or 40, or lymph node spread, and I'd say that, you
know, if you just talk about unfavorable high-risk, you're talking about almost all those people
are going to benefit by a more aggressive stance. Until they get up until their late
70s, maybe, and then you don't pile on with so much treatment.
Thanks so much for watching. If you would like more information on any co-pay programs
or financial assistance when it comes to these 2nd 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 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.