The Staging Guide Video Series | Transcription

Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.

In this video we’re going to cover unorthodox treatments for High-Azure. That’s the high-grade type of prostate cancer—men that have been recently diagnosed, but have higher Gleason scores, have possibly lymph node spread in the pelvic region. These are situations that are more difficult to cure, and so it’s logical you’d want to consider pushing the envelope and adding additional therapy.

The standard approach is to give 18 months of hormonal therapy, radiation therapy to the pelvic nodes and to the prostate, and a seed implant boost.

So what more can you do?

Well how about some chemotherapy. There are studies showing that 4-6 cycles of Taxotere can improve cure rates and long-term survival when added to the protocol I just mentioned. There’s also studies showing that adding Zytiga, a more potent type of hormone therapy, can enhance cure rates as well. Now as of yet there aren’t any studies looking at adding both Zytiga and Taxotere to the protocol previously mentioned, which would be a logical thing to consider since you’re really going all out in these circumstances. The possibility of doing them both together therefore is unorthodox.

How big a deal is that? Well no one really knows if you’re going to get enough additional benefit or cure rate by adding say Taxotere—which would be the last thing on your list since it has the most side effects—and simply adding Zytiga alone.

So how do we make these decision? Well you can base it on a patient’s age for example. A younger man is going to tolerate Taxotere better and also has more life years at risk. So the younger the patient is, the more likely you might want to consider some sort of unorthodox therapy. In addition, for example, the patient that has more extensive lymph node disease or let’s say a PSA that’s very high—50, 60, 70 something in that range—which suggests a really entrenched type of prostate cancer. So those would be the two circumstances to consider. A younger patient and a patient who has even more advanced or more worrisome type of prostate cancer.

I’d also like to also talk about another scenario that often comes up because surgery is still popular amongst the urologists even in men that have high-grade disease. I see men undergoing surgery all the time even though they have proven lymph node disease. The chance for these people to stay cured with surgery alone is extremely low—probably only 20% or less—but because it has been the tradition to do surgery many men are given an operation and if their PSA goes to zero they’re just watched. This makes no sense at all because almost certainly there is residual cancer somewhere lurking in the body and we know that medicines like hormone therapy can enhance disease control and cure. There are a variety of studies that show there are benefits. So it’s considered unorthodox to do something like Lupron or Zytiga or both after surgery, but I think it’s a strong consideration for someone in the High-Azure category.

A third thing to consider in the way of unorthodox treatments for men with High-Azure is the addition of some non-cancer related medicines that seem for some reason to improve cure rates and disease control. The reason these medicines are unorthodox is we don’t have prospective clinical trials showing their benefit. These are mostly retrospective trials that have looked at men and it seems like there’s a trend towards better survival. What are these medicines? Well, there’s three. One is Aspirin. Two is a medicine used for diabetes called metformin and it’s often used for weight control as well. And the third one is your common statins. These are medicines such as Lipitor, Crestor, Pravachol. All three of these medicines individually have been shown to have better long-term cure rates compared to men that aren’t taking them, and these medicines typically have relatively few side effects and doctors are very familiar with them. So adding one or more of these medicines to the treatment protocol makes sense even though the studies to evaluate their use are not ironclad.

So in summary when people have a worrisome more advanced type of prostate cancer—high Gleason scores, high PSAs—what we call High-Azure it’s logical to really push the envelope and try and find protocol that’s going to have the best cure rate. Combinations of medicines are the logical way to go.