Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
The PCRI has been trying to help patients understand the different types of prostate
cancer. Treatment varies by the type. Five different types exist, and we're going to
cover "Royal," the more advanced stage of prostate cancer, in this video.
Royal is defined by, actually, five groups. The other five [four] types of prostate cancer
we've had only three subgroups—low, basic, and high—for each of the different stages
of prostate cancer. For Royal, there are also three subgroups—low, basic, and high—but
two of those subgroups (basic and high) subdivide further, leading to five subgroups. I know
this sounds difficult, but once you know your subgroup then you're going to narrow down
your treatment options. So in this video, we're just gonna give an overview of the bigger
picture of Royal and in subsequent videos, we will have educational information about
each of the subgroups and the appropriate types of treatments.
Low, Basic, and High Royal
First, Royal is defined by men that have one of two different characteristics. Either they
are resistant to Lupron (the technical term is castration resistant) or they have proven
metastatic disease outside the pelvic lymph nodes, either in the bones or in other parts
of the body. Men can also have both, of course. But Royal means that the disease has advanced
or has become resistant to Lupron. This is a more serious type of prostate cancer, and
the management is much more aggressive as you will see in subsequent videos.
So let's go through and quickly define these different five subgroups.
Let's start with the men that are Lupron resistant or castration resistant. This group of men,
in Royal, have either Low, Basic, or High Royal.
Low Royal is defined by pure castration resistance, pure Lupron resistance (I'm using those terms
interchangeably). Men have been on Lupron for a number of years for treatment of relapsed
disease, PSAs have been undetectable, and now the PSA starts rising as a sign that the
treatment is no longer working. Resistance has developed. With such resistance, in some
cases, scans are completely clear. Bone scans are clear; CAT scans are clear; there may
be some enlargement of pelvic lymph nodes, but basically, there's no evidence on scans
of disease that has spread around the body. That is the category we call "Low-Royal."
This is a very specific category, requires special treatment, and it is defined only
by resistance to Lupron.
Now, let's go on and talk about what the Basic and High categories are because those are
fairly simple to understand. Basic and High are when metastatic disease has been visualized
on a scan. The number or the breakpoint is five, so five or fewer metastases is Basic-Royal;
greater metastases is High-Royal, and these are treated differently primarily how the
disease is chased with some sort of spot radiation of these metastatic sites.
So, Basic: five or fewer metastases. High: six or more metastases.
So that covers Low, Basic, and High Royal when men have become resistant to Lupron or
are so-called castration-resistant.
There are two additional categories because for whatever reason sometimes men don't have
PSA screening and they can show up in the doctor's office with disease that has spread
throughout the body even though they have never had previous treatment. These men are
also in the Royal category, but they are not resistant to Lupron. So there is no such thing
as a Low-Royal without Lupron resistance. So in men that are hormone sensitive—men
that have never had any previous treatment—there's only the Basic and the High categories, and
those break down in the exact same way based on the number of metastases that are present.
I'd like to make one further comment and that has to do with the fact that Royal is a much
more dynamic situation compared to the other stages. The other stages, in almost all cases,
will result in a complete remission—undetectable PSA with appropriate treatment. People can
get into complete remissions with Royal, but it's not a foregone conclusion like it is
in most of the other stages. Therefore the Royal category is a much more dynamic category
and monitoring with scans and blood tests such as PSA, alkaline phosphatase and others
that we'll go into in further videos becomes much more important consideration when thinking
about the Royal category.
With the other stages, men are going to go into a complete remission in almost all cases,
and the Royal category men can go into a complete remission. If they don't, further therapy
is going to be required. Second-line or third-line therapy is a very important part of getting
optimal treatment for Royal.