Video: Understanding Treatment for High-Risk Prostate Cancer

The Staging Guide Video Series | Transcription

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

In today’s video we are going to cover the Azure stage of prostate cancer.

We always talk about stages of prostate cancer because the whole topic of prostate cancer is so vast that you gotta break it down into categories. The Azure category is actually a relatively small segment of prostate cancer which varies from harmless to people that have cancer that has spread or metastasized. Azure means someone that is newly diagnosed, but it appears that the disease is localized at least into the area of the pelvic region. However, Azure men have certain factors that suggest a higher-risk type of prostate cancer. As you no doubt know, some types of prostate cancer are harmless; others are minimally dangerous. Azure needs real treatment and the best chance to cure it is on your first effort. Now that doesn’t mean that with prostate cancer you don’t have second chances and third chances, which is one of the unique aspects of prostate cancer. Many other types of cancer you have one chance to cure it. Even so, it’s best to try and cure prostate cancer with the first effort. Your quality of life is better. Who wants to go through another treatment down the line and who wants to experience anxiety that’s associated with the possibility of a cancer being out of control?

When we’re talking about Azure we divide it into Low, Basic, and High. Low-Azure is basically small amounts of grade 8 that can be treated in many ways very similar to High-Teal. And I’ll let you look up the video on that for further information about how to treat Low-Azure. Basic and High-Azure are more consequential types of prostate cancer. The real issue is the possibility of spread outside the prostate and Basic-Azure or High-Azure have at least some risk of spread outside the prostate—possibly into the lymph nodes and the surrounding area. It is possible to calculate the risk of microscopic spread outside the prostate with something called the Yale Formula. Y-A-L-E Formula. You can Google that and put your numbers (your PSA, your clinical stage) into that formula, and it will tell you the percentage likelihood that there’s cancer spread outside the gland. This is an incredibly consequential fact because you can do things about the possibility of spread. You can give radiation to the lymph nodes, you can take hormone therapy, you can take augmented hormone therapy (things like Zytiga or Xtandi), you can even take chemotherapy (although that’s usually reserved for men who have scans that show unequivocal spread into the lymph nodes, not just people who have a possibility of microscopic spread).

Basic-Azure, High-Azure—how do you make that distinction? Anyone that has a Gleason 9 or 10 grade, a PSA above 40, or has a scan showing spread into the seminal vesicles or into the pelvic lymph nodes has High-Azure. Other men in the Azure category (and you know how to find out of you’re in the Azure category, you have to take the PCRI staging quiz) other men in the Azure category if they’re not High-Azure are Basic. So how do you treat those differently? Well, Basic-Azure typically is managed with a seed implant, intensity modulated radiation (IMRT), and 18 months of hormone therapy. Whether or not the radiation—the IMRT radiation—is directed to the lymph nodes is based on the results of the Yale Formula we talked about previously. If the chance of spread according to the Yale Formula is over 15% you should probably treat the pelvic lymph nodes. How do we treat High-Azure? We give all the same treatments that we give to Basic-Azure except we consider adding Zytiga or Xtandi for the 18 month period, or if a person has unequivocal lymph node enlargement on a scan, then even the possibility of four to six cycles of a type of chemotherapy called Taxotere.

So in summary, Azure is a more consequential type of prostate cancer. We always like to emphasize that most men with Azure are curable, and of course curable means getting optimal therapy. There are many centers that are still recommending surgery for Azure, and I don’t think that’s a good idea. The cure rates are much lower and the side effects tend to be even higher with surgery compared to the other options that we have already covered.