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

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


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.