Video: Treatment for Low and Basic Azure (High-Risk) Prostate Cancer

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 Azure prostate cancer that in standard terms is called “high-risk prostate cancer.” I don’t really like that term “high-risk” because it’s suggests that there’s a high-risk of dying which is truly not the case. The high-risk is relative to the other even more innocuous prostate cancer like low-risk and intermediate-risk. High-risk means that there’s a higher risk of relapsing after standard treatment, particularly after surgery. So, how are these risks calculated? Well, we subdivide Azure into three subtypes: Low, Basic, and High. In this video we are going to cover Low and Basic and we’ll reserve High-Azure for another video.

We make a distinction between Low, Basic, and High with Gleason score and other factors. Specifically, to be a Low-Azure (that would be “favorable high-risk”) you need to have only Gleason 8 (can’t be 9 or 10), PSA has to be less than 40, only a couple of cores can contain Gleason 8 on the random biopsy, and neither can be over 50% replaced, and assuming one has had a multiparametric MRI there can’t be any extra capsular extensions, seminal vesicle invasion, lymph node involvement. So if all those criteria are met, that is Low-Azure. Basic-Azure is everything that’s not Low-Azure or High-Azure. High-Azure means that you do indeed have something outside the prostate, PSA is over 40, where you have a Gleason 9 or 10.

So let’s start with Low-Azure, the most favorable type of high-risk prostate cancer. These are all men who are newly diagnosed, and with Low-Azure we’re looking at a treatment along the lines of someone who has a High-Teal. Standard fare would consist of a seed implant, intensity-modulated radiation, and four months of hormone blockade—Lupron, Casodex type of therapy. That is a fairly universal approach and the cure rates are quite good. Many people wonder about using surgery for Low-Azure, and if anyone is going to undergo surgery for an Azure category prostate cancer, it should be Low-Azure only. As the Azure category rises, the risk of disease outside the gland is very high and cure rates with surgery start to drop off very quickly. Before we move on to talking about Basic-Azure, in the Low-Azure category there is now some preliminary research indicating that men in this category can benefit and have good cure rates with a seed implant alone, that is to forego the intensity modulated radiation and skip the hormonal therapy. Unfortunately, we don’t have phase 3 randomized comparative trials to confirm that this is as safe as it sounds, but there are a number of phase 2 observational trials that seem to be giving good results. So then just a review for Low-Azure: a combination of short course hormone therapy, a seed implant, and IMRT would be considered the standard approach for Low-Azure. Back up options for people to consider would be either seed implant monotherapy (that’s a seed implant with nothing added) or even perhaps a radical prostatectomy although I’m not a fan of that because side effects with surgery in general tend to be higher.

Basic-Azure is everything but Low or High, and let’s just reiterate High-Azure is PSA over 40, Gleason 9 [or] 10, disease coming outside the prostate (seminal vesicles, lymph nodes), and all of those people should be treated differently. Basic-Azure, everything below Low and High is a seed implant, intensity modulated radiation therapy to the prostate and probably the surrounding lymph nodes, and hormonal blockade with something like Lupron for 18-24 months. This is going to give the highest cure rates, and the reason why cure rates are superior with this approach is that cancer in the Azure stage can have microscopic spread outside the gland into the lymph nodes, so hormone blockade which circulates through the bloodstream has an anti-cancer effect throughout the body, and if that’s combined with radiation to the surrounding lymph nodes (the most common jumping off spot for prostate cancer) the possibility of rescuing someone with early microscopic spread exists and thus you’re looking at a somewhat higher cure rate than simply doing surgery or simply doing radiation alone.

So other issues for Basic-Azure (probably the most common type of high-risk prostate cancer) are considerations for a lot of different therapies options for radiation include proton and SBRT, IMRT, and whatnot, and the differences between these are so small that you can sort of think of them interchangeably. The real issues are to add the ancillary seed implant to boost the dose of radiation inside the prostate and improve cure rates there, to give some sort of beam radiation to the lymph nodes, and then to take systemic therapy with hormone blockade to cover both the lymph nodes and other parts of the body.

So since we’ve been covering both Low and Basic-Azure, the main differences in treatment selected would be shorter versus longer-term hormone blockade 4 months vs 18 months, and in some cases with Low-Azure although it’s a bit avant-garde men could even forego hormone therapy all together and just undergo a seed implant without any additional types of treatment.