Dr. Mark Scholz from Prostate Oncology Specialists discusses his approach to treating CRPC (HRPC) prostate cancer, and advanced prostate cancer patient Gilbert shares his journey in a candid interview.
The ROYAL Shade of Blue
Men in the ROYAL shade have metastatic prostate cancer that has spread to bone, or, to lymph nodes outside the pelvis, or, they have a PSA over 100, or, they have a rising PSA with a low testosterone level.
Men with advanced prostate cancer tend to live longer than men with other types of cancer. One major reason is because prostate cancer doesn’t usually spread to critical organs like the brain, the liver or lungs. Another reason is the availability of so many effective treatments.
Treatment for ROYAL
Men with ROYAL who have never had hormone therapy should start testosterone inactivating pharmaceuticals (TIP) beginning with Lupron and Casodex in combination.
Men who have become resistant to Lupron should take Provenge to boost their immune system. Studies show that Provenge works better when treatment is started as early as possible.
Radiation to cancer metastases has historically been reserved exclusively for controlling bone pain. However, newer thinking suggests that radiation directed to all known sites of metastases—when the numbers of metastases is relatively small, say less than five—may occasionally lead to longer remissions
Potent medications to strengthen the bones—Xgeva and Zometa—are routine treatment for bone metastases. There have three benefits: Inhibiting cancer growth in the bones, reducing bone pain; and counteracting calcium loss caused by hormonal therapies.
After Provenge men in ROYAL the first step should be to stop Casodex and start one of the following three options:
1. Second-line TIP such as Zytiga or Xtandi
2. Chemotherapy with Taxotere or Jevtana
3. Xofigo, a form of injectable radiation
Three additional treatment options can be considered if these first three options are no longer effective:
1. Combination chemotherapy using Carboplatin or Xeloda with a Taxane or the combination of both Revlimid and Avastin added to a Taxane.
2. The “off label” use of XL-184, a medication being researched for prostate cancer but already FDA-approved to treat thyroid cancer
3. Other investigational medications
Investigational trials represent an opportunity for patients to get medications prior to FDA approval. A patient’s enthusiasm for embarking on a study however, needs to be tempered by what is actually known about the effectiveness of the specific medication being researched. Some medications are so new that even the investigators performing the trial don’t know if they are going to work or not.
While men are on treatment they need to have their blood monitored monthly by checking PSA, PAP, ALP and CTC levels. Medication side effects and cancer-related problems also need to be screened for with monthly blood tests such as CBC, a metabolic panel and a hepatic panel. A periodic bone scan and body scan should be performed to track the disease status. Two to three months after starting a new treatment, if the blood markers are not improving, a change in therapy needs to be considered.
Reducing the Side Effects
Fatigue is one of the biggest challenges faced by men in ROYAL. Stimulants such as Provigil or Nuvigil may be helpful, but the most important priority is consistent, diligent exercise. A variety of different medications can be useful for reducing side effects from hormone therapy. Low-dose estrogen skin patches can control hot flashes. Excessive mood swings can be stabilized with low doses of antidepressant pills. Breast enlargement can be prevented with Femara.
We have outlined a traditional, sequential approach to treatment selection. Strong consideration, however, should be given to using these active new agents in combination and at an early stage. An aggressive and imaginative treatment plan should be designed that has the specific goal of attaining and maintaining a complete remission.