Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
We've been through a lot of these videos, and we've been following the format of going
through each of the 15 stages of prostate cancer. Today we're going to cover "High-Royal"
which is the fifteenth stage. For those of you that aren't familiar with the PCRI color
system for staging, "High-Royal" would be considered advanced prostate cancer.
Advanced prostate cancer falls into three broad categories. We call them Low, Basic,
and High-Royal. High-Royal means more than five metastases visible on a scan and at least
one of those spots has to be outside the pelvic region. The pelvic region is right around
where the prostate is. So High-Royal means something's spread outside there and more
than five spots.
The treatment approach for High-Royal is to be aggressive. When we're talking about the
most advanced stage of prostate cancer, we're talking about when this condition starts to
become life-threatening. There's a couple of basic principles—this is an overview
of High-Royal. We could probably do ten videos on High-Royal and not run out of different
topics, and we will come back at some point and talk about different treatments in more
detail. This is just an introduction to make sure that you have an overview and you aren't
missing something obvious.
So one of the principles is that we have multiple life-prolonging therapies now. Treatments
that have been approved by the FDA that are proven to make people live longer. It's a
terrible shame if people don't get exposure to each and every one of these treatments
to optimize longevity which is the goal of effective treatment. We also want to give
them as early as possible. Over and over, studies show that the same treatment is given
at an earlier stage—I don't mean before High-Royal, but you can imagine there are
earlier stages of High-Royal and more advanced stages of High-Royal—when you give effective
treatments at an earlier stage of High-Royal it enhanced longevity to a very significant
degree. It makes sense. The treatment is the same, but in an earlier stage there is less
cancer to fight and the disease is more vulnerable to the therapy. So in a perfect world, if
all these different treatments had no side effects whatsoever, you'd give them all simultaneously
at the first stage of entering into High-Royal. That would give you the best overall anti-cancer
effect. Practically speaking, that's not possible. These medicines have side effects. Sometimes
they can't be given simultaneously, and so there's sort of a pathway or a sequence that
people often fall into when selecting therapy for High-Royal. Usually, people start with
less toxic treatments and then subsequently implement treatments that have more side effects
down the line. The thinking for that, of course, is that quality of life needs to preserved
at all costs as well. So we're balancing between preserving quality of life and optimizing
longevity.
Close monitoring of therapeutic results is essential to be able to know when a shift
in treatment needs to occur. Everyone sort of know what these things are. PSA response,
changes on scans, new spots on scans, high rising PSAs, or PSAs that fail to continue
declining are all signs that the treatment"s effect are running out of gas and it may be
time for a change. Those principles again could be the subject of a video in and of
themselves and the whole idea being is that if the PSA stops dropping or if new spots
are appearing on a scan, you need to be talking to your doctor about a change in therapy.
Since this is just an introduction I want to briefly go through the different FDA-approved
medicines for High-Royal and sort of in the sequence of what one normally think about
using them.
To start off with, not everyone with metastatic disease has developed resistance to Lupron,
so-called hormone resistance or androgen resistance. That doesn't mean that people who are starting
Lupron for the first time shouldn't do additional therapy at the same time. Lupron alone is
effective but not as effective as using things in combination. So, typically people will
initiate both Lupron plus a second-generation medication that block hormones (i.e. testosterone)
more effectively—medicines such as Xtandi or Zytiga. So it's very common for people
who are either Lupron resistant or people who can still respond to Lupron to be treated
with a combination of Lupron plus Xtandi or Zytiga.
And I use those two medicines more or less interchangeably. There are pros and cons with
each one, but they seem to have similar effectiveness.
If those medicines stop working, the next tier of therapy is to think about some sort
of immune therapy such as Provenge, which is FDA-approved to treat men with prostate
cancer. Provenge is a very convenient, easy to administer treatment, that is given over
a six-week period. Immune cells from your body are removed in sort of a dialysis type
procedure, they're shipped off to Seal Beach, California, and the cells are activated to
fight prostate cancer. Subsequently, they are then reinfused into the body to fight
the disease. Provenge has been controversial for a number of reasons. One is that we typically
don't see sharp PSA declines after Provenge. This doesn't mean that it's not working. Studies
clearly show prolonged survival. Some of the early studies, which were done in very advanced
disease, showed sort of a modest improvement in survival of three to four months. Subsequent
analyses of those studies show that men that get started in a more timely fashion can prolong
their lives by well over a year.
Provenge is given over such a short time period it's easy then to quickly move on to some
other form of therapy. The next tier of treatment would be something like either chemotherapy
with Taxotere or Jevtana or an injectable form of radium called Xofigo. Both of these
medicines have been shown to prolong life. We'll tend to lean towards Xofigo as long
as people don't have terribly rapidly advancing disease because the side effects are less.
Xofigo is given as a simple, once-a-month injection. Sometimes it'll cause a little
nausea, sometimes a little diarrhea, but generally very well tolerated.
After that therapy has been administered it's logical to consider some of the standard chemotherapies
that have been around now for 15 years: Taxotere and Jevtana. Typically, Taxotere is started
first. It's a medicine that's infused intravenously every three weeks. It's given with supportive
medications to boost the immune system (medicines such as Neulasta, Neupogen, and other types
of agents) and that treatment is monitored because PSA declines are expected to occur
and if they are not occurring then these medicines are stopped early. There's been some studies
recently suggesting that Jevtana, a medicine very similar to Taxotere has fewer side effects
than Taxotere, and some people like to switch over to the Jevtana to try and improve quality
of life.
These are the standard things that are used for High-Royal. What if all these medicines
have been used up? What's the next step? Well, typically people start thinking about clinical
trials, and this is a vast and rapidly changing landscape. One thing that has come to attention
in the last year or so is a new injectable form of radioactive medicine called lutetium-177.
Clinical trials are running all across the country and responses have been remarkably
good with relatively few side effects. So if you're facing a situation where a clinical
trial is being proposed, look into Lutetium-177 injections.
When a person is in the High-Royal category, he's in a fight. These medicines that we've
been talking about can cause fatigue and other side effects. It's important to maintain fitness
throughout. I'm often asked about diet as well, and it does appear that modest diets,
vegetarian diets, do have an inhibitory effect on the cancer's growth. The simplistic view
would be, if you don't feed the cancer well, it doesn't grow as well. So staying away from
the typical American diet—the hamburgers and the high fatty foods, the animal products—is
probably beneficial.
Lastly, long-term hormone blockade leeches calcium out of the bones and can cause Osteoporosis.
There's a number of medicines that are available to counteract that. A popular one is called
Xgeva, an injection that's traditionally given once a month. It's very effective. The problem
is, in cumulative doses, it can have issues related to the teeth or to the jawbone, and
many physicians have backed off from the standard format of monthly injections and are using
it a little less frequently to reduce this risk.
I hope this has been helpful for you to just introduce you to the broad field of advanced
prostate cancer. We're going to revisit a lot of these different medications in more
detail and try and expound upon the advantages and disadvantages of each one.