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Dayton Physicians Network

Advanced/Recurrent Prostate Cancer

John J. Haluschak, MD

We treat advanced/recurrent prostate cancer right here, close to home.

Historically, advanced/recurrent prostate cancer was treated with anti-androgen based therapy to achieve very low levels of testosterone (androgen). When that therapy stopped working, the cancer was called – castrate resistant prostate cancer. A decade ago, for those patients with castrate resistant prostate cancer and who were in pretty good health, the next step would be to try an older chemotherapy agent – Mitoxantrone.

Thankfully, we have come a long way in helping prostate cancer patients. Since those days we have number of treatments that address androgen (testosterone) dependent and androgen independent prostate cancers.

In the near future prostate cancer specific genetic information will likely dictate treatments but also which prostate cancers are not serious and which are life threatening or will cause serious problems. That is the whole concept behind active surveillance and appropriate watchful waiting. It’s even more important to know if the progressive cancer is dependent on the androgen pathway or not. It’s also important for us to understand the benefits of current, as well as; future immune based treatments.

 

For now I would like to address approved and soon to be approved treatments for progressive life-threatening prostate cancers needing treatment when castrate type treatments (ADT with or without Casodex) stop working.

Treatments approved for this situation includes Xtandi, Zytiga, Xofigo, Taxotere, Jevatana, Provenge and the likely soon to be approved, ARN509, Octorenel, Galetrone. One major questions, is best to try first and should some of these drugs be given together.

In simple terms, when dealing with advanced castrate resistant prostate cancers we have to decide if we want to treat the cancer using approaches that work for androgen dependent prostate cancers or assume this won’t work (we currently call these cancers, androgen independent). In the US it is common to at least try the drugs that work on androgen dependency. This would be Xtandi or Zytiga and likely soon to be approved, Octorenel, ARN509 and Galetrone. Each of these products has their pros and cons. It’s not necessarily Zytiga is better than Xtandi, but which is better for you. We are also studying giving them together.

The other approved treatments are for androgen independent prostate cancers. The first approved immune therapy was for prostate cancer, called Provenge. One collects a patients T-cells (collection usually at the blood collection center taking about 3 hours) that are then modified to recognize the prostate cancer better and the product is then given as an infusion (3-4 days later) to the patient. This is done every two weeks over 3 treatments with the course of treatment lasting just over a month. It’s important to look at the FDA approved information – on the product website, if want wants to learn more about Provenge.  By itself this is not that useful a treatment. But if responding to other treatments, especially Zytiga or Xtandi – a 3rd all patients can attribute their survival at 3 or 4 years just to getting Provenge.

Another treatment that helps survival is Xofigo. This is a monthly injection of a radioactive agent that works for prostate cancer patients when the prostate cancer mainly involves just the bones and is causing significant bone related pain. Fortunately prostate cancer, like breast cancer likes to metastasis just to bones. The pain improvement can be early and dramatic.

Both Provenge and Xofigo can be used with or sequentially with Zytiga, Xtandi, and likely as stated above, works best if those agents work.

 

The remaining approved treatments for prostate cancer are cytoxic or chemotherapy agents. Often people understandably worry about the side effects of chemotherapy, but the majority of time the side effects are much less concerning than the symptoms that often occur from the cancer. The most successful chemotherapy to date is Taxotere and its’ cousin, Jevtana.

Jevtana has the advantage of be very well tolerated with few side effects, including very little nausea, fatigue, or hair loss. The real risk for most patients- will it work. Grade I side side effects are frequently seen,sometimes from the drug, but they are more often not related to the actual product. We still must watch closely for any side effects.

 

Currently, we are interested in allowing our immune system to fight the cancer and recognizing that the cancer cell may produce proteins that resist our immune system. That’s the idea behind Provenge. We are currently exploring a number of treatments that can help with this problem. If we can negate this resistance of the cancer cell resisting our own wonderful immune system, then we should restore our ability to fight the cancer.

The good news is we should only have more options in the future, to deal with advanced/recurrent prostate cancer.

I encourage patients to review the FDA approved product information that provides accurate information on each of the specific products. Fortunately there are numerous helpful web sites to learn more about advanced or recurrent prostate cancer. Here are a few recommended sites that have reliable information; National Comprehensive Cancer Network, American Cancer Society and Cancer.Net

At Dayton Physicians Network we offer one of the country’s best comprehensive prostate cancer programs including clinical trials not available in Cincinnati, Columbus or Cleveland.  We bring the best prostate cancer care to the Midwest and we are privileged to treat these patients, who are the real heroes in this enormous battle against life threatening prostate cancer.

We’re here for you For more information, please call 937.771.2326