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Chemotherapy For Metastatic Prostate Cancer

Types Of Chemotherapy Drugs

Prostate Cancer: Chemotherapy for Metastatic Disease

The most common chemotherapy drug for prostate cancer is docetaxel , which is usually given with prednisone, a steroid medicine. After starting docetaxel, many men experience the improvements in disease-related symptoms, including pain, fatigue and loss of energy.

If docetaxel does not work or stops working, cabazitaxel may be used.

Your Cancer Care Team

People with cancer should be cared for by a multidisciplinary team . This is a team of specialists who work together to provide the best care and treatment.

The team often consists of specialist cancer surgeons, oncologists , radiologists, pathologists, radiographers and specialist nurses.

Other members may include physiotherapists, dietitians and occupational therapists. You may also have access to clinical psychology support.

When deciding what treatment is best for you, your doctors will consider:

  • the type and size of the cancer
  • what grade it is
  • whether the cancer has spread to other parts of your body

Physical Emotional And Social Effects Of Cancer

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

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Surgically Removing The Prostate Gland

A radical prostatectomy is the surgical removal of your prostate gland. This treatment is an option for curing prostate cancer that has not spread beyond the prostate or has not spread very far.

Like any operation, this surgery carries some risks.

A recent trial showed possible long-term side effects of radical prostatectomy may include an inability to get an erection and urinary incontinence.

Before having any treatment, 67% of men said they could get erections firm enough for intercourse.

When the men who had a radical prostatectomy were asked again after 6 months, this had decreased to 12%. When asked again after 6 years, it had slightly improved to 17%.

For urinary incontinence, 1% of men said they used absorbent pads before having any treatment.

When the men who had a radical prostatectomy were asked again after 6 months, this had increased to 46%. After 6 years, this had improved to 17%.

Out of the men who were actively monitored instead, 4% were using absorbent pads at 6 months and 8% after 6 years.

In extremely rare cases, problems arising after surgery can be fatal.

It’s possible that prostate cancer can come back again after treatment. Your doctor should be able to explain the risk of your cancer coming back after treatment, based on things like your PSA level and the stage of your cancer.

After a radical prostatectomy, you’ll no longer ejaculate during sex. This means you will not be able to have a child through sexual intercourse.

Staging Of Prostate Cancer

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Doctors will use the results of your prostate examination, biopsy and scans to identify the “stage” of your prostate cancer .

The stage of the cancer will determine which types of treatments will be necessary.

If prostate cancer is diagnosed at an early stage, the chances of survival are generally good.

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If Treatment Does Not Work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

Can Chemotherapy Prolong Life

Chemotherapy appears to have more significant survival benefits for men who are newly diagnosed with metastatic prostate cancer and have not yet done hormone therapy .

Research also suggests that when chemotherapy is given at the same time as hormonal therapy, it can help make the hormonal therapy more effective. Chemotherapy appears to help delay the development of resistance to the hormone treatment, explains Dr. Pomerantz. This prolongs response time and delays the progression of the cancer.

A landmark multi-center study published in the August 2014 issue of the New England Journal of Medicine found that men with newly diagnosed metastatic, hormone-sensitive prostate cancer lived nearly 14 months longer when they received a chemotherapy drug along with hormone therapy compared with those who received hormone therapy alone.

A variety of chemotherapy known as platinum-based chemotherapy is currently being studied for use in metastatic prostate cancer patients. These drugs include:

While studies done with these drugs so far have been of limited size, platinum appears to be helpful for a subtype of prostate cancer patients with BRCA1 and 2 mutations, explains Pomerantz.

Patients with advanced disease who are not responding to standard chemotherapy can talk to their doctors about whether they might be candidates for platinum chemotherapy.

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Side Effects Of Chemotherapy For Advanced Prostate Cancer

The side effects you get will depend on the chemotherapy drugs you are having. Different drugs cause different side effects. You may get some of the side effects we mention here, but you are unlikely to get all of them. Some side effects are mild and can be treated easily. Your doctor, nurse or pharmacist may prescribe drugs to help control them. Most side effects stop or gradually get better when chemotherapy is over.

Dealing With Prostate Cancer

Docetaxel (Taxotere) for Progressive, Metastatic Prostate Cancer

Some men say being diagnosed with prostate cancer changes the way they think and feel about life. If you are dealing with prostate cancer you might feel scared, worried, stressed, helpless or even angry.

At times, lots of men with prostate cancer get these kinds of thoughts and feelings. But theres no right way that youre supposed to feel and everyone reacts in their own way.

There are things you can do to help yourself and people who can help. Families can also find this a difficult time and they may need support too. Find out more.

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Guide To Managing Side Effects Of Chemotherapy

Follow these simple rules to manage your side effects:

  • Pay attention. Be aware of all expected and unexpected reactions to the drugs.

  • Be proactive. Make a list of your medications. Talk with your health care providers about what signs to look for and when to call them.

  • Relax and get well. Chemotherapy drugs are powerful and can take a toll on the body. Focus on getting well by finding ways to alleviate stress. These may include listening to music, doing yoga or stretching exercises, taking walks or watching TV.

  • Keep a journal. Write down any physical and emotional changes you experience while taking the medications. A written list will make it easier for you to remember your questions when you go to your appointments. It will also make it easier for you to work with your health care team to manage your side effects.

  • Consult your doctor. Talk with your health care providers about any side effects you experience. There are several drugs designed to help ward off or treat different side effects.

Management Of Advanced And Metastatic Disease

AUA/ASTRO/SUO guidelines on advanced prostate cancer separate management considerations into the following four disease states, which encompass the entire continuum of advanced prostate cancer :

  • Biochemical recurrence without metastatic disease, after exhaustion of local treatment options
  • Metastatic hormone-sensitive prostate cancer
  • These disease states are defined by the following:

    • Primary tumor status
    • Presence or absence of distant disease on imaging
    • Testosterone levels
    • Prior chemotherapy exposure

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    Bone Protection In Patients Receiving Androgen Blockade

    Two drugs, the bisphosphonate zoledronic acid and the RANKL inhibitor denosumab, have been approved to treat osteoporosis secondary to androgen deprivation. Zoledronic acid is administered as an intravenous infusion. Denosumab is administered subcutaneously. These drugs are given along with supplemental vitamin D and calcium. Patients should be monitored regularly for hypocalcemia. Both agents are associated with a low incidence of osteonecrosis of the jaw. Both drugs delay the risk of skeletally-related events by relieving bone pain, preventing fractures, decreasing the need for surgery and radiation to the bones, and lowering the risk of spinal cord compression.

    A double-blind, placebo-controlled, multicenter study in men with primary or hypogonadism-associated osteoporosis found that over a 14-month period, treatment with zoledronic acid reduced the risk of vertebral fractures by 67%. New morphometric vertebral fracture occurred in 1.6% of men taking zoledronic acid and in 4.9% taking placebo. Patients receiving zoledronic acid had significantly higher bone mineral density and lower bone-turnover markers. However, the rate of myocardial infarction was higher in the treatment group .

    Possible Side Effects Of Chemotherapy

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    Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow , the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells can also be affected by chemo, which can lead to side effects.

    The side effects of chemo depend on the type and dose of drugs given and how long they are taken. Some common side effects can include:

    These side effects usually go away once treatment is finished. There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting.

    Along with the risks above, some side effects are seen more often with certain chemo drugs. For example:

    • Docetaxel and cabazitaxel sometimes cause severe allergic reactions. Medicines are given before each treatment to help prevent this. These drugs can also damage nerves , which can cause numbness, tingling, or burning sensations in the hands or feet.
    • Mitoxantrone can, very rarely, cause leukemia several years later.
    • Estramustine carries an increased risk of blood clots.

    If you notice any side effects while getting chemo report them to your cancer care team so that they can be treated promptly. In some cases, the doses of the chemo drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

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    In Five Years A Major Treatment Shift

    In men diagnosed with metastatic hormone-sensitive prostate cancer, the cancer is typically driven to grow and spread by androgens that are produced largely in the testes. For many years, treatments that block androgen production have been a mainstay for men initially diagnosed with metastatic prostate cancer.

    Starting in 2014, that began to change after a large clinical trial showed that adding the chemotherapy drug docetaxel to ADT improved how long men with hormone-responsive disease lived. Shortly after, another clinical trial showed that adding abiraterone to ADT also improved survival in these men, although primarily in men with many metastatic tumors, known as high-volume disease.

    However, docetaxel, which works by directly killing cancer cells, can have substantial side effects, and some patients arent healthy enough to tolerate it. And abirateronewhich blocks androgen production throughout the bodycan also cause side effects, including those that affect the liver. It also has to be given in combination with the steroid prednisone, which carries its own toxicity.

    Doing so, Dr. Chi said during a presentation of the TITAN data at the ASCO meeting, might help stave off the typically inevitable development of hormone-resistant cancer, which is more difficult to treat and a key driver of prostate cancer deaths.

    Chemotherapy For Metastatic Prostate Cancer

    In order to appreciate the emerging role of chemotherapy in combination with local therapies such as radiation, it is important to understand the evolution of use of chemotherapy starting with its application in treatment of castration resistant prostate cancer and subsequent application earlier in the disease spectrum. The first chemotherapeutics for prostate cancer, estramustine and mitoxantrone were approved in the United States for routine clinical care in 1981 and 1996 respectively. These approvals were largely based on PSA response and palliative endpoints with no overall survival benefit established .

    The ability of chemotherapy to impact on prostate cancer survival was first defined in CRPC in 2004 and since then additional studies have defined the role of chemotherapy in increasingly earlier scenarios in disease presentation.

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    Early Versus Delayed Treatment

    In the years following the introduction by Huggins and Hodges of hormone therapy for prostate cancer, early institution of such treatment was recommended, based on comparison with historical controls. Later, the Veterans Administration Cooperative Urology Research Group studies resulted in the recommendation to defer hormone therapy until symptomatic progression occurred this was thought to avoid the promotion of early androgen resistance in prostate tumors.

    Subsequently, the controversy of the appropriate timing of ADT was renewed because of the advent of an LHRH antagonist and LHRH agonists. Laboratory studies demonstrated that early hormone therapy does not confer early resistance. Moreover, clinical trials found that it provided significantly longer survival with fewer complications than did deferred treatment.

    Radiation As Adjuvant Or Salvage Therapy After Surgery

    Cabazitaxel (Jevtana) for Progressive Metastatic Prostate Cancer after Taxotere

    Several randomized trials have evaluated the use of adjuvant radiation therapy to the prostatic bed following surgery for patients at high risk of recurrence . Those include EORTC 22911, SWOG 8794, ARO 96-02/AUO AP 09/95, and FinnProstataX, as well as the ongoing RAVES, GETUG-AFU 17, and RADICALS-RT studies. Recent research has further highlighted the role of early salvage radiation therapy with concomitant ADT for those with biochemical recurrence after prostatectomy, to avoid overtreatment associated with adjuvant radiotherapy. This is reflected in the current AUA/ASTRO guidelines.

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    Provenge For Advanced Prostate Cancer

    Sipuleucel-T is a “vaccine” for advanced prostate cancer that helps prolong survival.

    Provenge isn’t your everyday vaccine. It’s an immune therapy created by harvesting immune cells from a patient, genetically engineering them to fight prostate cancer, and then infusing them back into the patient.

    It’s approved only for treatment of patients with few or no prostate cancer symptoms whose cancer has spread outside the prostate gland and is no longer responding to hormone therapy.

    Once a cancer grows beyond a certain point, the immune system has a hard time fighting it. One reason is that cancer cells look a lot to the immune system like normal cells. Another reason is that tumors may give off signals that manipulate the immune system into leaving them alone.

    Provenge bypasses these problems. The treatment first removes a quantity of dendritic cells from a patient’s blood. Dendritic cells show pieces of tumor to immune cells, priming them to attack cells that carry those pieces.

    The patient’s doctor ships the cells to Provenge’s manufacturer, Dendreon, which then exposes them to Provenge. Provenge is a molecule made inside genetically engineered insect cells.

    Once these cells have been exposed to Provenge, they’re shipped back to the doctor who infuses them back into the patient. This is done three times in one month. The first infusion primes the immune system. The second and third doses spur an anticancer immune response.

    Types Of Chemotherapy For Prostate Cancer

    Chemotherapy drugs for prostate cancer are typically given into a vein as an infusion over a period of several hours. This can be done in a doctors office, chemotherapy clinic, or in a hospital setting. Some drugs are given as a pill.

    Chemotherapy is given in cycles, with each period of treatment followed by a rest period to give you time to recover from the effects of the drugs.

    Cycles are most often two or three weeks long.

    The length of treatment for advanced prostate cancer is based on how well it is working and what side effects you have.

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    Emerging Therapies For Prostate Cancer

    Researchers are pursuing several new ways to treat advanced prostate cancer. Vaccines that alter the body’s immune system and use genetically modified viruses show the most promise. One vaccine technique works by manipulating blood cells from the patient’s immune system and causing them to attack the prostate cancer.

    Blood is drawn from the patient. From the blood sample, cells that are part of the immune system are exposed to cells that make up prostate cancer. Then the blood cells are placed back in the body, with the hope that they will cause other immune system cells to attack the prostate cancer. In a more traditional type of vaccine, the patient is injected with a virus that contains PSA. When the body is exposed to the virus, it becomes sensitized to cells in the body that contain PSA and their immune system attacks them.

    Immune or genetic therapy have the potential to deliver more targeted, less invasive treatments for advanced prostate cancer. This would result in fewer side effects and better control of the prostate cancer.


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