A Patient's Guide to Managing Hormone-Refractory Prostate Cancer  

Chapter 8.  An overall strategy for managing HRPCa



Conceptually, we believe that the most effective treatments for HRPCa are those that have already been proven. Our reasoning is that you need to get and keep this cancer under control to protect your life. There is time for experimentation after the cancer has been controlled.

We also follow new therapies with great hope, and we try some that seem to offer hope without risking our well-being. Our experience tells us to be conservative in selecting treatments, to choose those that have been established as effective for most men with HRPCa. Consequently, we spend our time searching for answers in the medical literature. Each man makes his own decisions in selecting treatments; and we respect that right. We have chosen the use of clinically proven therapies as our first line of battle.

The ideas we present here are rather straightforward. You may well be familiar with every treatment we suggest. What is important for you to realize is that there are a good number of available treatments that you can use to keep this disease at bay.

Three vital strategies

To hold back this disease, to extend your survival for years, to maintain your quality of life, you need to adopt these three strategies:

1. Keep your PSA as low as possible at all times.

And verify the blood test values with bone scans and cat scans to avoid being blindsided by a tumor that doesn’t generate PSA. If at all possible, don’t let your PSA run uncontrolled for any reason! A rising PSA should never be ignored or accepted as “normal.” Although it is a truism that PCa is a slow-moving (i.e., slow-growing) cancer, you need to keep it suppressed to take advantage of that characteristic. When the PSA is low, say below 10, a number of supplemental treatments seem to be able to work, whereas they are ineffective against a larger tumor burden. When the PSA is high, say above 100, the risk of metastasis increases to an essential certainty. It is these metastases that cause pain and threaten life by damaging vital organs or leading to broken bones.

2. Prevent and suppress bone metastases with bisphosphonates.

If you are on hormone therapy (testosterone blockade or orchiectomy), you must also start on a bisphosphonate. Don’t accept the argument that it is not necessary! The bisphosphonate set of drugs (Zometa, Aredia, Fosamax, Actonel) has been shown to maintain bone integrity in the face of hormone blockade. If you have had hormone therapy, you are almost certain to lose bone mass (osteopenia or osteoporosis) and suffer the risk of broken bones. Second, these drugs have been shown clinically to help suppress the cancer itself. By getting onto Zometa (a monthly IV) before you experience bone mets, you can realistically expect to postpone that unpleasant prospect indefinitely.

3. Maintain your overall health at the highest level possible.

PCa brings with it the risk of heart disease, among other problems. You’ve not won the battle if you control the cancer but are killed by a heart attack, a blood clot, or an infection. The general practitioner is an important part of your medical team; explain to him that you are in a serious struggle with this cancer and that you will be relying on him to keep from being blindsided by some other unexpected health crisis. Blood clots are a concern with hormone therapy. Chemotherapy leads to a risk of infection, as well as many other health problems. You need to embrace a healthy life style. A low-fat diet, with several supplements, is best. You need to exercise to maintain your psychological health as well as your physiological systems. Do your routine preventive maintenance, including dental checkups to avoid oral infections.

The basic treatments for HRPCa

Most of us with HRPCa have gone through a similar battery of treatments. These are the treatments that have been shown to work in clinical trials. They have also worked for a significant number of men we know. Unfortunately, that also means that some of them don’t work sometimes.

The treatments listed here are also presented in greater detail in ensuing chapters. Issues of dosing, side effects, and monitoring are discussed. The purpose of this list is to let you know that there are many treatments available to control HRPCa.

The treatments are presented in the order in which they are usually tried (although there is no medical rule saying they must be done in this order). This order also runs generally from the treatments with the least severe side effects first.

1. Lupron or Zoladex. Chances are you’ve been on Lupron or Zoladex(or on one of the LHRH agonists provided outside the U.S.), perhaps for some years. Or you may have had an orchiectomy instead. In the case of Lupron or Zoladex, for example, you should plan to stay on this drug for the foreseeable future, preferably on a 28-84 day injection schedule. The Lupron or Zoladex will continue to suppress the testosterone that would otherwise stimulate the cancer cells to proliferate. HRPCa is a mixture of cancer cells, some of them still sensitive to hormone blockade.  The Lupron or Zoladex you continue taking keeps those cells under control.

2. Bisphosphonate. See the discussion above.

3. An estrogenic drug, such as DES (diethyl stilbestrol). This drug has been used more frequently since the herbal remedy PC SPES was taken off the market. That remedy contained rather strong phytoestrogens. Although there is a general search underway for a replacement for PC SPES, we know of no equivalent at this time. With an estrogen, one must be aware of the risk of blood clots. Interestingly, these estrogenic drugs have been shown to work for some period of time with HRPCa, even in addition to the Lupron.

4. HDK + HC or LDK (high-dose ketoconazole plus hydrocortisone). Ketoconazole is an anti-androgen. It works by blocking the hormone receptors on the cancer cells, thus preventing access by cancer-stimulating testosterone. In the advanced stage, prostate cancer cells often acquire an overabundance of additional hormone receptors, with the result that even a minuscule amount of testosterone is sufficient to stimulate proliferation. The hydrocortisone is needed to replace the steroid lost when the ketoconazole shuts down that production by the adrenal glands. Some men have great success with taking HDK, and others have great difficulty with the side effects. Life most of these treatments, we only know if they are effective for a given individual when that person actually takes the drug.

5. Taxotere is the first of a number of chemotherapies that work with HRPCa. It is the most effective one against HRPCa. There are mixed feelings about using chemotherapy to fight cancer. The reactions include (1) a fear of the side effects and (2) a concern that the use of chemotherapy will disqualify them from consideration for clinical trials. The decision is up to the individual. However, it is unwise to let the PSA increase to the point at which there are widespread metastases. It is true that chemotherapy is not an easy treatment; the side effects include fatigue, some nausea, and peripheral neuropathy (numbness in feet and hands) to mention the most bothersome. However, it does bring down the PSA, and it does extend survival (despite some medical claims) when used in a series of treatments. Insofar as the concern about clinical trials goes, one should not let the PSA run out of control purely for the hope that something experimental might work. Most of the members of our support list have had chemotherapy treatments and can answer any questions about the experience.

6. At this point, there are a number of supplemental treatments that are being used to enhance the effectiveness of chemotherapy or to achieve some other advantage against HRPCa. These include high pulsed doses of calcitriol to enhance the chemotherapy; Dostinex to suppress the prolactin level and maybe reduce PSA; Celebrex to inhibit one of the enzymes that promotes cancer growth;  Evista (raloxifene) and HDK are being evaluated as alternating treatments between bouts of chemotherapy. The selection of appropriate supplemental treatments depends on the individual and the disease status. The important thing about these supplements is that they have been shown to help in some cases, with no undue risk due to side effects. The regimen needs to be worked out with a knowledgeable physician—the expert on your medical team.

7 If the Taxotere fails to work, then Emcyt may be added. This chemotherapy, which includes an estrogen, enhances the effectiveness of the Taxotere (or other chemotherapy). The Emcyt causes some problems with nausea.

8. The next chemotherapy may be a combination of Navelbine and Emcyt. Or it may be another combination recommended by your expert. Different chemotherapy regimens work for different people for different periods of time.

9. Next in line is the combination of Taxol (in the taxane family with Taxotere), carboplatin, and Emcyt. Sometimes this combination is used without the Emcyt. There seems to be no way to ensure ahead of time whether a particular chemo regimen will work for a particular individual.

10. At this point, it is important to realize that some drugs fail due to protective mutation by the body’s cells. However, several months off the drug often results in the disappearance of the protective change; and the drug again becomes effective. The second time around may be shorter than the first; nonetheless, the reuse of a drug means that survival time is extended.

11. Another chemotherapy that often works is Novantrone plus prednisone (steroid). Adriamycin is also used sometimes, although there is a risk of cardiotoxicity.

This list of treatments will, hopefully, provide years of extended survival, years in which we will continue the search for better answers. Even during the few years that our support group has been in operation we have seen new ideas introduced that extend survival and improve the quality of life.


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