Video: Overview of Relapsed Prostate Cancer (Indigo Stage)

The Staging Guide Video Series | Transcription

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

In today’s video we’re going to cover relapsed prostate cancer. We call it the Indigo stage of prostate cancer. Prostate cancer is an incredibly broad topic and Indigo as a subtype is also a very broad topic. So Indigo gets broken into three subtypes: Low, Basic, and High. We are going to post some questions on the screen that you can answer to determine which of those subtypes you reside within. First, you have to go to the quiz of course and determine which of the basic stages of blue that you reside, and make sure you really are Indigo. Then you can answer the questions on the screen and figure out your subtype. Why is subtype important? The treatment varies greatly from subtype to subtype. You want to get the proper treatment for you subtype.

Let me share a few thoughts about relapsed prostate cancer. First, the outlook is probably much, much better than you think. This is because relapses from other types of cancer (colon, brain, bone, stomach) are incredibly serious and often rapidly fatal. Most men with relapsed prostate cancer end up dying of old age, not the disease. This is because the disease tends to grow slowly, and it responds incredibly well to treatment. Some men with relapsed prostate cancer can still be cured. Relapsed prostate cancer is very common. Somewhere between 25-35% of men who undergo surgery or radiation to cure prostate cancer later develop a relapse. So we’re looking at maybe 50,000 men a year in the United States that develop relapsed prostate cancer.

So in general terms what are we talking about with a relapse?

Well the most common scenario is a steadily rising PSA after surgery or radiation. Now, not every PSA that increases comes from cancer, but if after expert evaluation the rising PSA is determined to be from cancer then these individuals are in Indigo. However, there are some caveats and exceptions. Men that have metastatic disease in the bones or outside the pelvic region are in the Royal (Advanced) category, they don’t have Indigo. Also men who have low testosterone levels or who have been on Lupron, for example, those men are in the Royal category as well.

Another category of Indigo are the men who have had surgery and they have a positive margin or cancer was detected in the lymph node at the time of surgery. They may still have a low PSA, but most of those men are going to relapse and require further treatment. Those men are called Low-Indigo. Another type of a relapse may be in someone who has had a previous radiation treatment, PSA is maybe relatively low (under 1), but a scan or a biopsy shows that the cancer is coming back inside of the prostate. This is another example of what we call Low-Indigo.

So let me give you a brief summary of the Low, Basic, and High sub-categories of Indigo.

Low-Indigo means that the cancer appears to be in the area of where the prostate used to be after surgery (called the prostate fossa) or located inside the prostate in a man who has had previous radiation to the prostate. The thinking is disease in the rest of the body is very unlikely and that’s based on various factors which are addressed in the questions that we posted earlier.

High-Indigo is an indication that cancer unequivocally present in the pelvic lymph nodes. A scan may show enlarged lymph nodes during surgery, or maybe lymph nodes were removed that showed cancer on the pathology review. Men with High-Indigo with proven lymph nodes obviously are going to require more aggressive treatment, and we are going to discuss those treatment options in a further video.

Men with Basic-Indigo have clear scans, there’s no proof of spread to the pelvic lymph nodes; however, microscopic disease is strongly suspected. This is based on the results of those questions that we posted earlier. Examples would be men that have very fast PSA doubling times, men who when undergoing previous surgery or radiation who had a very high Gleason score, or perhaps PSA now has already risen to higher levels. All of those things either together or singly can suggest that microscopic disease may be in the pelvic lymph nodes, and of course precautions and appropriate treatment are necessary.

So why is treatment evolving and changing for Indigo?

What’s changed over the last ten years is the quality and the technology associated with radiation therapy. It can be given much more safely now than in previous times. We’ve also got much more accurate scans that detect early spread of disease. We’ve also learned a lot more about prostate cancer in the last ten years in terms of predicting who’s going to have microscopic mets and who doesn’t. Because of all of this new information we can mix and match therapies. We can give combinations of radiation, first and second generation hormone treatments, sometimes even consider chemotherapy.

The traditional approach which has been around for a long time, and is still in place in many practices is to simply radiate where the prostate used to be, and if that doesn’t work start Lupron indefinitely. That will of course put the disease into remission, but what men are missing out on is optimal chance to be cured, and by tailoring treatment in accordance with whether a man is Low, Basic, or High Indigo he’s much more likely to get the best treatment, limit side effects, and improve his opportunity to be cured or have a long remission.