Hi, I’m Dr. Scholz. Let’s talk about prostate
cancer. We’ve been through a lot of these videos,
and we’ve been following the format of going through each of the 15 stages of prostate
cancer. Today we’re going to cover “High-Royal” which is the fifteenth stage. For those of
you that aren’t familiar with the PCRI color system for staging, “High-Royal” would be
considered advanced prostate cancer. Advanced prostate cancer falls into three
broad categories. We call them Low, Basic, and High-Royal. High-Royal means more than
five metastases visible on a scan and at least one of those spots has to be outside the pelvic
region. The pelvic region is right around where the prostate is. So High-Royal means
something’s spread outside there and more than five spots. The treatment approach for High-Royal is to
be aggressive. When we’re talking about the most advanced stage of prostate cancer, we’re
talking about when this condition starts to become life-threatening. There’s a couple
of basic principles—this is an overview of High-Royal. We could probably do ten videos
on High-Royal and not run out of different topics, and we will come back at some point
and talk about different treatments in more detail. This is just an introduction to make
sure that you have an overview and you aren’t missing something obvious. So one of the principles is that we have multiple
life-prolonging therapies now. Treatments that have been approved by the FDA that are
proven to make people live longer. It’s a terrible shame if people don’t get exposure
to each and every one of these treatments to optimize longevity which is the goal of
effective treatment. We also want to give them as early as possible. Over and over,
studies show that the same treatment is given at an earlier stage—I don’t mean before
High-Royal, but you can imagine there are earlier stages of High-Royal and more advanced
stages of High-Royal—when you give effective treatments at an earlier stage of High-Royal
it enhanced longevity to a very significant degree. It makes sense. The treatment is the
same, but in an earlier stage there is less cancer to fight and the disease is more vulnerable
to the therapy. So in a perfect world, if all these different treatments had no side
effects whatsoever, you’d give them all simultaneously at the first stage of entering into High-Royal.
That would give you the best overall anti-cancer effect. Practically speaking, that’s not possible.
These medicines have side effects. Sometimes they can’t be given simultaneously, and so
there’s sort of a pathway or a sequence that people often fall into when selecting therapy
for High-Royal. Usually, people start with less toxic treatments and then subsequently
implement treatments that have more side effects down the line. The thinking for that, of course,
is that quality of life needs to preserved at all costs as well. So we’re balancing between
preserving quality of life and optimizing longevity. Close monitoring of therapeutic results is
essential to be able to know when a shift in treatment needs to occur. Everyone sort
of know what these things are. PSA response, changes on scans, new spots on scans, high
rising PSAs, or PSAs that fail to continue declining are all signs that the treatment”s
effect are running out of gas and it may be time for a change. Those principles again
could be the subject of a video in and of themselves and the whole idea being is that
if the PSA stops dropping or if new spots are appearing on a scan, you need to be talking
to your doctor about a change in therapy. Since this is just an introduction I want
to briefly go through the different FDA-approved medicines for High-Royal and sort of in the
sequence of what one normally think about using them. To start off with, not everyone with metastatic
disease has developed resistance to Lupron, so-called hormone resistance or androgen resistance.
That doesn’t mean that people who are starting Lupron for the first time shouldn’t do additional
therapy at the same time. Lupron alone is effective but not as effective as using things
in combination. So, typically people will initiate both Lupron plus a second-generation
medication that block hormones (i.e. testosterone) more effectively—medicines such as Xtandi
or Zytiga. So it’s very common for people who are either Lupron resistant or people
who can still respond to Lupron to be treated with a combination of Lupron plus Xtandi or
Zytiga. And I use those two medicines more or less
interchangeably. There are pros and cons with each one, but they seem to have similar effectiveness. If those medicines stop working, the next
tier of therapy is to think about some sort of immune therapy such as Provenge, which
is FDA-approved to treat men with prostate cancer. Provenge is a very convenient, easy
to administer treatment, that is given over a six-week period. Immune cells from your
body are removed in sort of a dialysis type procedure, they’re shipped off to Seal Beach,
California, and the cells are activated to fight prostate cancer. Subsequently, they
are then reinfused into the body to fight the disease. Provenge has been controversial
for a number of reasons. One is that we typically don’t see sharp PSA declines after Provenge.
This doesn’t mean that it’s not working. Studies clearly show prolonged survival. Some of the
early studies, which were done in very advanced disease, showed sort of a modest improvement
in survival of three to four months. Subsequent analyses of those studies show that men that
get started in a more timely fashion can prolong their lives by well over a year. Provenge is given over such a short time period
it’s easy then to quickly move on to some other form of therapy. The next tier of treatment
would be something like either chemotherapy with Taxotere or Jevtana or an injectable
form of radium called Xofigo. Both of these medicines have been shown to prolong life.
We’ll tend to lean towards Xofigo as long as people don’t have terribly rapidly advancing
disease because the side effects are less. Xofigo is given as a simple, once-a-month
injection. Sometimes it’ll cause a little nausea, sometimes a little diarrhea, but generally
very well tolerated. After that therapy has been administered it’s
logical to consider some of the standard chemotherapies that have been around now for 15 years: Taxotere
and Jevtana. Typically, Taxotere is started first. It’s a medicine that’s infused intravenously
every three weeks. It’s given with supportive medications to boost the immune system (medicines
such as Neulasta, Neupogen, and other types of agents) and that treatment is monitored
because PSA declines are expected to occur and if they are not occurring then these medicines
are stopped early. There’s been some studies recently suggesting that Jevtana, a medicine
very similar to Taxotere has fewer side effects than Taxotere, and some people like to switch
over to the Jevtana to try and improve quality of life. These are the standard things that are used
for High-Royal. What if all these medicines have been used up? What’s the next step? Well,
typically people start thinking about clinical trials, and this is a vast and rapidly changing
landscape. One thing that has come to attention in the last year or so is a new injectable
form of radioactive medicine called lutetium-177. Clinical trials are running all across the
country and responses have been remarkably good with relatively few side effects. So
if you’re facing a situation where a clinical trial is being proposed, look into Lutetium-177
injections. When a person is in the High-Royal category,
he’s in a fight. These medicines that we’ve been talking about can cause fatigue and other
side effects. It’s important to maintain fitness throughout. I’m often asked about diet as
well, and it does appear that modest diets, vegetarian diets, do have an inhibitory effect
on the cancer’s growth. The simplistic view would be, if you don’t feed the cancer well,
it doesn’t grow as well. So staying away from the typical American diet—the hamburgers
and the high fatty foods, the animal products—is probably beneficial. Lastly, long-term hormone blockade leeches
calcium out of the bones and can cause Osteoporosis. There’s a number of medicines that are available
to counteract that. A popular one is called Xgeva, an injection that’s traditionally given
once a month. It’s very effective. The problem is, in cumulative doses, it can have issues
related to the teeth or to the jawbone, and many physicians have backed off from the standard
format of monthly injections and are using it a little less frequently to reduce this
risk. I hope this has been helpful for you to just
introduce you to the broad field of advanced prostate cancer. We’re going to revisit a
lot of these different medications in more detail and try and expound upon the advantages
and disadvantages of each one.

1 thought on “Treatment Options for Advanced​ Prostate Cancer (High Royal Stage) | Prostate Cancer Staging Guide”

Leave a Reply

Your email address will not be published. Required fields are marked *