The Staging Guide Video Series | Transcription
Hi, I’m Dr. Scholz. Let’s talk about prostate cancer.
In this series we’ve been covering the different stages of prostate cancer. Patients who go to the PCRI website can figure out their stage by taking a quick questionnaire and determining whether they fall into one of five categories. In today’s video we’re covering “Indigo.” Specifically, we’re covering “High-Indigo.”
Indigo means that someone has undergone previous therapy for prostate cancer, and now unfortunately the disease is returning. It can come back in various forms. High-Indigo means that the cancer has returned in the lymph nodes surrounding the prostate down in the pelvis. So by definition, lymph node enlargement from cancer has been documented--usually on a scan--and this obviously is a serious development. Metastasis, or spread of the cancer, is really the aspect of cancer that is most feared. That is the first step towards progression of disease, side effects, and possibly even life-threatening symptoms. So Indigo is the first stage that we’ve covered up to this point where we know for sure metastases have occurred, they are actually visible on a scan or possibly they were detected at the time of surgery. In previous videos we have been covering the possibility of cancerous spread, microscopic disease here or there, but it has never been with 100% certainty like we’re dealing with High-Indigo.
So as you can imagine, the treatment protocols for High-Indigo are going to be altered in a far more aggressive stance. In certain situations it’s still possible to cure the disease, and every effort needs to be made to cure the disease when we know it's dangerous enough to spread. Having spread to just the surrounding lymph nodes means that the cancer is not as serious as for example when it’s in the bones or in other lymph nodes higher above the pelvis. So this may be the last chance to actually cure the disease. In addition, aggressive therapy gives a much better chance for getting into a complete remission. Complete remissions--that is PSA levels that are undetectable and lymph nodes that have disappeared-- result in much longer remissions, and it is only the people who go into complete remissions who can end up cured, meaning five years after treatment the disease still hasn’t returned.
So let’s go into the type of treatment that typically would be recommended to try and cure High-Indigo (lymph node proven metastasis). The biggest change that has occured over the last ten years or so is improvements in radiation technology. Previously it was very dangerous to radiate lymph nodes in the pelvic region because the intestines surrounding there would get caught in the crossfire, and the radiation would create all kinds of difficulties with the intestines with diarrhea, and pain, and difficulties with bowel movements. In expert hands these days that risk has been almost totally eliminated, and radiation now can be given with impunity as long as you are at a center of excellence with modern radiation equipment to deliver the treatment. So radiation therapy to the lymph nodes is done without much overthought at this point as of 2019.
But there are other things that need to be done because if we have proven [disease] in the pelvic lymph nodes, what is the chance that microscopic-metastases in other parts of the body that won’t be covered by the radiation field? Well the chances are quite high, so additional therapy is routinely given along with the radiation. In particular, hormone therapy such as Lupron. The optimal treatment period is probably to continue the Lupron for 12-18 months. But in addition to Lupron we now have second-generation hormonal agents such as Zytiga and Xtandi that can further enhance the anti-cancer effect of the hormone blockade. One of those two medicines in particular can be given in addition to the Lupron for the full 12-18 month period to try to enhance cure rates even further.
So this combination of IMRT plus Lupron plus Xtandi or Zytiga is considered fairly routine as of 2019. A third layer of treatment with a rather mild type of chemotherapy called Taxotere is also far more widely accepted now than ever before. Taxotere is a medicine administered every three weeks as an injection. It is a type of chemotherapy so some temporary hair loss can occur and some fatigue after each injection lasting 2-5 days. But cure rates have definitely been enhanced by taking six cycles, 6q three-week treatments of Taxotere in addition to all the other treatments I've already talked about. One thing to keep in mind and one thing that hasn’t been worked out is that Taxotere can’t be given at the same time as the radiation. Radiation is a more accepted treatment and oftentimes that will be given first, then the hormone therapy being given continuously throughout this whole process, and then the Taxotere started and continued for six cycles after the radiation is completed.
All of this sounds very complex. Certainly not everyone is going to be cured with this process, but the chance for complete remissions is very high--PSAs that are undetectable and all visible cancer will disappear in most men in the High-Indigo category.
One question that comes up with Indigo (because men have undergone previous surgery or radiation by definition with this category) and in some cases some cancer might linger where the prostate used to be--that is in the prostate fossa after surgery or perhaps in the prostate gland if the individual had previous IMRT radiation and it’s coming back. That situation is handled just the same as we handle with Low-Indigo, and you should look at the video on Low-Indigo for how to manage cancer that stayed where the prostate used to be located. There are all kinds of methods with HIFU and cryotherapy or salvage radiation, but I don’t think we need to repeat all that in this particular video.
So prostate cancer, even though it’s relapsed, unlike many other types of cancer still can possibly be cured. Once it has spread as High-Indigo with proven lymph nodes we know unequivocally that the disease is dangerous. Every effort, every form of modern medicine within reason should be implemented to try and eradicate the disease to get a complete remission. Out of those men that are in complete remission, a certain percentage of them will remained cured.
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