Rapid improvements in medical technology are forcing us to rethink our traditional approach to early metastatic prostate cancer. The scans are improved; the therapies are more effective and have fewer side effects, and our understanding of how cancer spreads has been greatly enhanced. Modern theory concedes that men with early metastases may have additional undetected microscopic metastases in other areas of the body. Attempts to cure such patients by simply treating the visible metastases will fail, since the untreated microscopic cancers will eventually grow larger, leading to cancer recurrence. Countering this pessimistic view are the results of recent studies showing that aggressive treatment directed at all the visible metastases can lead to durable remissions. Studies show that durable remissions are more common if metastasis-focused treatment is combined with systemic treatment, which is active against the undetected microscopic metastases. 

An aggressive, combination approach using radiation and TIP seems to give the best results. Studies indicate that Taxotere also enhances survival in men with early metastatic disease. Practically speaking, how can all these different treatments be combined? A possible protocol for Basic-Royal is: 1) Start TIP with Lupron and Zytiga and continue it for a total of 12 months, 2) Taxotere is started immediately and given for a total of 4 to 6 treatments each administered 3-weeks apart, 3) Radiation is administered to the known sites of metastatic disease and possibly to the surrounding lymph-node chain starting a month after the last dose of Taxotere. 

Using an aggressive protocol for Basic-Royal is rapidly gaining adherents. However, this approach is new and many physicians are holding back. Perhaps they are unaware of the studies or maybe they are unconvinced, considering the studies are relatively small.




Jeffrey Turner, MD is a board-certified internist and medical oncologist specializing full time in prostate cancer since 2009. Dr. Turner is an active member of the American Society of Clinical Oncology, American Society of Hematology, and American College of Physicians-Internal Medicine. He was a research associate at UCLA in infectious diseases and molecular biology. He then earned his medical degree in Canada at Memorial University of Newfoundland. He completed his internal medicine residency at the University of British Columbia and fellowship in medical oncology at the Medical University of South Carolina.