Video: Unorthodox Treatments for Recurrent Prostate Cancer (Indigo Stage) | Prostate Cancer Staging Guide

Prostate Cancer Staging Guide | Transcription

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

In today’s video, we’re going to cover unorthodox treatments for Indigo. Unorthodox means outside the mainstream of medicine. There are different ideas for treating prostate cancer that haven’t really been proven with large trials but seem to make a lot of sense or maybe there are smaller trials that looked very positive and we don’t have any balancing negative trials. So we’re going to cover a few of those things and kind of jump around in this video today, all within the stage of Indigo.

Now remember, Indigo is men who have developed a rising PSA or have relapsed disease after previous surgery or radiation. We divide Indigo into three subcategories: Low, Basic, and High. Just for a reminder, Low means that the disease is where the prostate used to be, High means that pelvic nodes are enlarged and involved with metastatic cancer, and Basic means that we have a rising PSA but we haven’t been able to prove metastatic disease—we suspect it, that there’s probably microscopic metastasis in the pelvic lymph nodes. 

So traditionally we try and cure Indigo. That’s the first step. Even if we don’t cure it we may get a long remission, and this involves multi-modality therapy with radiation, possibly chemotherapy, hormonal therapy. But as you know, prostate cancer occurs in aging men and sometimes Indigo represents sort of a slow indolent process. This is judged by what we call the PSA doubling time. If the PSA is doubling at a relatively slow rate, say more than every nine months, perhaps just a modest suppressive dose of mild hormonal treatment like Casodex would suffice, especially if someone is older. Casodex has been used in conjunction with Lupron in what’s called combination hormone blockade for years to try and block the flare reaction when Lupron is started, but Casodex alone has probably about 20% of the side effects of Lupron, but perhaps 80% of the anticancer activity. This is a nice trade-off. The main side effect of Casodex alone is a higher risk of breast enlargement, so we routinely give an estrogen-blocking pill called Femara in conjunction with the Casodex. The Femara doesn’t add any additional side effects. Casodex alone may cause essentially no side effects whatsoever, and in other men it will suppress libido to some degree; occasionally it will cause some mild fatigue. But it’s quite good at keeping the disease suppressed for many years. I have a patient who started on low-dose Casodex 20 years ago and he still maintains a low PSA with no side effects. It has been a great option for him. The nice thing is that Casodex is a very simple prescription medicine; 50mg or 100mg per day, take it morning or night, with or without food, very simple to use and any physician can prescribe it. Typically, you’ll see PSA levels drop very nicely with the medication. Of course, if you don’t see that decline in PSA, you’ve got to look at other options.

Alright, Let’s talk about an unorthodox approach to Basic-Indigo. High-Indigo is commonly treated with chemotherapy these days based on some large randomized trials. Basic-Indigo is typically not given Taxotere Chemotherapy. However, there are three small intriguing clinical trials showing that men with rising PSAs after surgery or radiation who have very low PSAs can actually be cured, at least a minority of men can be cured, if they start when their PSA is very, very low. These men are typically given hormonal therapy at the same time for about a year plus Taxotere, and in the studies that I’m referring to no radiation was given, and of course these days radiation is standard, but Taxotere has been shown to cause persistent low PSAs level lasting more than five years in certain individuals, perhaps 20% of men with basic Indigo, who start when their PSA is very low, say less than one. We’ve given other videos on side effects of Taxotere and its management, so we won’t go into that in this particular video. 

The third unorthodox approach to managing Indigo, and in this case we’re talking again about Basic-Indigo—those are the men that have rising PSA levels, but no proven metastases—is an immunotherapy called Leukine. Leukine was originally FDA approved to help men undergoing Chemotherapy to enjoy a more rapid recovery of their immune system after each cycle of chemo. It never became super popular because it has a more broad-spectrum effect than a competing agent from Amgen called Neulasta or Neupogen. But interestingly, studies have shown suppression of PSA levels simply with Leukine injections, which is a subcutaneous shot (kind of like an insulin shot) given either daily or three times a week—there are a variety of different protocols. Dr. Eric Small from the University of California San Francisco reported on a series of 30 men that were treated with Leukine alone who had rising PSAs after surgery or radiation, and about 15-20% of these men maintained stable low PSA levels for five years with Leukine alone. The medicine itself is well-tolerated. It has occasional side effects such as some fevers or chills, and sometimes it’s a little challenging to get insurance to cover it, but it is definitely a tolerable agent that can have beneficial effects in men with rising PSAs after surgery or radiation. 

So prostate cancer treatment is continually evolving, and there are a lot of alternative options. The PCRI is trying to bring you both the standard mainstream therapies and also help you be aware of some of the out-of-the-box options that can be useful in certain individuals. Thank you for watching. Subscribe to our Youtube channel, and if you need more information go to the PCRI’s website, PCRI.org.