Video: Introduction to Advanced Prostate Cancer (Royal Stage) | Prostate Cancer Staging Guide

Prostate Cancer Staging Guide | Transcription

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

The PCRI has been trying to help patients understand the different types of prostate cancer. Treatment varies by the type. Five different types exist, and we're going to cover "Royal," the more advanced stage of prostate cancer, in this video. Royal is defined by, actually, five groups. The other five [four] types of prostate cancer we've had only three subgroups—low, basic, and high—for each of the different stages of prostate cancer. For Royal, there are also three subgroups—low, basic, and high—but two of those subgroups, basic and high, subdivide further, leading to five subgroups. I know this sounds difficult, but once you know your subgroup then you're going to narrow down your treatment options. So in this video, we're just gonna give an overview of the bigger picture of Royal and in subsequent videos, we will have educational information about each of the subgroups and the appropriate types of treatments. 

Low, Basic, and High Royal. 

First, Royal is defined by men that have one of two different characteristics. Either they are resistant to Lupron (the technical term is castration resistant) or they have proven metastatic disease outside the pelvic lymph nodes, either in the bones or in other parts of the body. Men can also have both, of course. But Royal means that the disease has advanced or has become resistant to Lupron. This is a more serious type of prostate cancer, and the management is much more aggressive as you will see in subsequent videos. So let's go through and quickly define these different five subgroups. 

Let's start with the men that are Lupron resistant or castration resistant. This group of men, in Royal, have either Low, Basic, or High Royal. Low Royal is defined by pure castration resistance, pure Lupron resistance (I'm using those terms interchangeably). Men have been on Lupron for a number of years for treatment of relapsed disease, PSAs have been undetectable, and now the PSA starts rising as a sign that the treatment is no longer working. Resistance has developed. With such resistance, in some cases, scans are completely clear. Bone scans are clear; CAT scans are clear; there may be some enlargement of pelvic lymph nodes, but basically, there's no evidence on scans of disease that has spread around the body. That is the category we call "Low-Royal." This is a very specific category, requires special treatment, and it is defined only by resistance to Lupron. 

Now, let's go on and talk about what the Basic and High categories are because those are fairly simple to understand. Basic and High are when metastatic disease has been visualized on a scan. The number or the breakpoint is five, so five or fewer metastases is Basic-Royal; greater metastases is High-Royal, and these are treated differently primarily how the disease is chased with some sort of spot radiation of these metastatic sites. So, Basic: five or fewer metastases. High: six or more metastases. 

So that covers Low, Basic, and High Royal when men have become resistant to Lupron or are so-called castration-resistant. There are two additional categories because for whatever reason sometimes men don't have PSA screening and they can show up in the doctor's office with disease that has spread throughout the body even though they have never had previous treatment. These men are also in the Royal category, but they are not resistant to Lupron. So there is no such thing as a Low-Royal without Lupron resistance. So in men that are hormone sensitive—men that have never had any previous treatment—there's only the Basic and the High categories, and those break down in the exact same way based on the number of metastases that are present. 

I'd like to make one further comment and that has to do with the fact that Royal is a much more dynamic situation compared to the other stages. The other stages, in almost all cases, will result in a complete remission—undetectable PSA with appropriate treatment. People can get into complete remissions with Royal, but it's not a foregone conclusion like it is in most of the other stages. Therefore the Royal category is a much more dynamic category and monitoring with scans and blood tests such as PSA, alkaline phosphatase and others that we'll go into in further videos becomes much more important consideration when thinking about the Royal category. 

With the other stages, men are going to go into a complete remission in almost all cases, and the Royal category men can go into a complete remission. If they don't, further therapy is going to be required. Second-line or third-line therapy is a very important part of getting optimal treatment for Royal.