Prostate Cancer Staging Guide | Transcription
Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
Today I want to cover relapsed prostate cancer. The PCRI calls this "Indigo." If you think about it you can't be relapsed unless you've had previous therapy, in other words, a previous attempt at cure. But about 25% or so of people with prostate cancer that have had previous treatment develop a rising PSA. We call that "Indigo." The PCRI describes three sub-groups of Indigo: Low, Basic, and High. We covered Low in the previous video and you should review that because all the factors that we talked about in Low-Indigo—treatment to the prostate itself or the prostate fossa—can also apply to Basic or High Indigo. In other words, men can have a relapse in the pelvic lymph nodes (or potentially have a relapse in the pelvic lymph nodes with Basic) but they can also have residual disease in the prostate area, and so men with Basic-Indigo may need treatment like patients who have Low-Indigo—that is, treatment of the prostate area—and may also need treatment to the surrounding lymph nodes.
In fact, that's sort of the premise of Basic-Indigo. Based on a variety of factors such as how high the PSA is, how quickly the PSA is rising, what the scans show, and also is there any evidence of locally advanced disease when they scan the prostate itself? All these factors are brought together to determine if it's likely that microscopic prostate cancer exists in the pelvic lymph nodes. That's what we think of as Basic-Indigo. Microscopic disease. If it gets to the point where scans clearly show metastatic disease in the pelvic area, that's High-Indigo, and we're going to cover that in the next video. So how actually does treatment vary between Low and Basic-Indigo? If you think about it, the surrounding lymph nodes, historically, couldn't be safely treated. People sometimes say they can be surgically removed, but that's not really a treatment. There are literally hundreds of lymph nodes in the pelvic region, and the average surgeon is probably only removing 10 to 30 lymph nodes. In the old days, they tried radiating the whole, the whole pelvic area, in an attempt to eradicate disease in the Basic-Indigo category, but the intestines and the bladder got caught in the crossfire and all kinds of dreadful side effects occurred. The radiation therapists completely abandoned that idea. What changed is with Intensity Modulated Radiation (or IMRT). Now the radiation therapist can safely shoot around the bladder, shoot around the intestines, and just hit the lymph nodes only. In fact, studies show lymph node radiation doesn't cause any more side effects than radiation to where the prostate used to be. So it's much easier now to consider radiation, and this has become a fairly standard idea in people with Basic-Indigo. When men are undergoing pelvic radiation, the total dose of radiation they can be given is someone limited because if you go too terribly high in the dose, you will start to see bowel or bladder problems. For this reason, two studies now show that the radiation works better if you take 6-12 months of Lupron hormone therapy. So, men that are in the Basic category, the standard approach is to treat the pelvic lymph nodes with IMRT, add Lupron for 6-12 months, and then if there's anything residual in the fossa to consider treatment the same way that we did with Low-Indigo in the previous video.
A combination of all these factors is what's required to give optimal treatment to men in the Basic-Indigo category.
Up to this point, I've been talking about methods to try and cure Basic-Indigo. Am I implying that everyone will get cured? Of course not, but some men can be salvaged and cured with this multi-modality approach that I've been outlining throughout this video. In the old days, since pelvic radiation was too dangerous the fallback position was simply to give Lupron on an intermittent basis and suppress the disease. That's still viable if there's some reason that people can't take radiation or don't want it, Basic-Indigo can be suppressed for many years, possibly an average of about 10 years by giving Lupron on a periodic basis. So Intermittent Lupron is an alternative to the multi-modality approach that I have already outlined. The problem is that intermittent Lupron—or Lupron by itself—is not going to cure the disease. It will suppress it for up to 10 years, but it won't cure it.
We can't leave this subject of Basic-Indigo without talking about a new scan out called the PSMA-PET scan. PSMA-PET scans are dramatically more accurate than any scan we've ever had, and for the first time, we're starting to see where the cancer is located in the pelvic lymph nodes even in men with PSAs less than one. We've never had technology like that before. PSMA-PET scans are not yet FDA approved, but they're so good, undoubtedly, they will be in the next year or two. There are ways to get these scans, even now prior to FDA approval. You can go online. UCLA has a program and some of the other universities around the country. There may be an out-of-pocket cost—a substantial cost in some cases—but it may be worth it to know where the cancer is coming from. This enabled the radiation therapist to direct their radiation exactly where the relapse is rather than having to treat a broader field.
The last topic I want to briefly cover in Basic-Indigo is the possibility of taking a short course of Taxotere. Giving chemotherapy to people with High-Indigo is something we're going to cover in great detail and that is starting to become a standard approach. Not the case with Basic-Indigo. There are only a few small trials in men who have clear scans (that's how we define Basic-Indigo) but who have been studied with a short course of Taxotere to determine if you can improve the cure rates. It turns out a couple of small studies suggest that is indeed possible. This is nowhere near what we will consider mainstream treatment, but it is a possibility and a type of treatment that may be beneficial in some men.
So as we go through and talk about Indigo, I'm of course assuming that you've gone online to the PCRI and discovered that you are indeed an Indigo, taken the staging quiz, and then sequentially gone through the different factors to determine whether you're in the Low, Basic, or High category. The actual questions that you need to determine your subtype are in the description below. Treatment recommendations only make sense when treatment is being recommended for the specific stage that is intended. Getting the right treatment for a different stage obviously is wrong.