Prostatepedia

Conversations With Prostate Cancer Experts


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Dr. Ken Pienta: Chemo For Prostate Cancer

Dr. Kenneth J. Pienta, of the Johns Hopkins University School of Medicine, is an international expert in the development of novel chemotherapeutic agents for prostate cancer. He was the recipient of the first annual American Association for Cancer Research Team Science Award and is the author of more than 300 peer-reviewed articles. He frames this month’s conversations about chemotherapy for us.

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In 2018, chemotherapy for prostate cancer continues to be one of the many options we have to lengthen the lives of patients suffering from metastatic prostate cancer. There are still multiple other therapies that we don’t consider chemotherapy. Second-generation anti-androgen therapies like Zytiga (abiraterone), Erleada (apalutamide), and Xtandi (enzalutamide) are all now standards of care in castrate-resistant prostate cancer. We also have Xofigo (radium-223) as an option for patients with bony metastases.

There are two chemotherapies that have been approved for prostate cancer: Taxotere (docetaxel) and Jevtana (cabazitaxel). Now, the real challenge for patients and providers is when to use those chemotherapies.

Multiple studies have demonstrated that, when you’re newly diagnosed with metastatic prostate cancer, it may be beneficial to receive a limited number of doses of Taxotere (docetaxel) at the start of hormone therapy. That’s especially true if you have multiple places where the cancer has spread. That’s not correct for all people, but for some patients, it is a good option. More and more physicians are prescribing Taxotere (docetaxel) with a luteinizing hormone-releasing hormone (LHRH) antagonist at the start of therapy.

However, that doesn’t mean you cannot use Taxotere (docetaxel) after other things have failed. If you failed second-line hormone therapy or have failed radium therapy, Taxotere (docetaxel) is still a good option that helps people live longer.

Jevtana (cabazitaxel) continues to be a good chemotherapy option if patients have failed Taxotere (docetaxel).

Thank goodness we’ve seen over the last several years an increase in the number of drugs available to treat metastatic prostate cancer in addition to chemotherapy. Chemotherapy has been around for quite a while now, but there is still a role for it.

Again, the challenge for all of us is: when do we slot them in for you? The chemotherapy we use for prostate cancer is really a single agent chemotherapy, either Taxotere (docetaxel) or Jevtana (cabazitaxel). This is not the multi-agent therapy we use for other cancers, so the idea of major side effects is a bit overblown. For example, nobody vomits from chemotherapy for prostate cancer. The drugs we use to prevent that are too good.

We also have gotten much smarter about limiting the number of doses we use. We don’t necessarily give chemotherapy until it doesn’t work anymore. Often, we just give several doses and then take a break. If you get more than a couple doses of chemotherapy, you will still lose your hair temporarily.

Chemotherapy can make you feel more tired when it lowers your blood count, and it can make you more susceptible to infections, but people are very rarely hospitalized now for an infection from chemotherapy. It’s virtually unheard of that somebody would die as a side effect of chemotherapy.

The major side effect of Jevtana (cabazitaxel) tends to be diarrhea, but again, as we’ve learned about the dosing of that drug, that has become more manageable.

Another side effect of both drugs can be peripheral neuropathy, which is tingling in the fingers and toes. But we watch for that too. If you start to develop that, we tend to stop the drug. These are very tolerable medicines.

The word chemotherapy always evokes images of horror, but chemotherapy in 2018 is a lot different than it was even five years ago. We just know how to give chemotherapy much better. When I started in the field 30 years ago, if you had metastatic castrate resistant prostate cancer, survival was 6 months. Now, with the advent of all these newer therapies, we’ve gotten much better. The landscape of how to treat prostate cancer has changed completely in the last five years. It will change completely again in the next five years. The challenge is in what order are we going to use all these powerfully good drugs rather than having only one drug to give or none at all.

For us as physicians, it’s an exciting time to take care of men with prostate cancer.

Join us to read this month’s conversations about chemotherapy for prostate cancer.


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Conversations About Chemo For Prostate Cancer

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There are very few people who don’t immediately panic when they hear that they’ve been diagnosed with cancer. Am I going to die, most wonder, even if they don’t voice that fear to their friends and family. Many patients have a similar reaction when their doctor suggests chemotherapy. But just as cancer itself is not always a death sentence, chemotherapy is not as bad as most think.

Chemotherapy for prostate cancer today is not your grandfather’s chemo. Most side effects are manageable and don’t stop men from going about their daily lives. And studies suggest that using chemotherapy earlier and not waiting until your disease has progressed has tangible benefits.

This month we take a deep dive into chemotherapy today.

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Dr. Ken Pienta frames this month’s discussions and points out that the cultural view of chemotherapy as catastrophic to the patient is largely unfounded.

Dr. Nicholas Vogelzang outlines the history of chemotherapy for prostate cancer and muses about future directions.

Dr. William Oh explains the role chemotherapy plays in a prostate cancer treatment today.

Dr. Cy Stein talks about side effects associated with Taxotere (docetaxel) and Jevtana (cabazitaxel) and how to manage them.

Dr. Oliver Sartor explains the development of Jevtana (cabazitaxel) for prostate cancer.

Dr. Emmanuel Antonarakis talks about the potential impact of switching from Taxotere (docetaxel) to Jevtana (cabazitaxel) midway through treatment and vice versa.

Dr. Channing Paller introduces her clinical trial looking at combining Taxotere (Docetaxel) with intravenous Vitamin C. She’s recruiting patients, so if you think you might be a fit for the trial, be sure to contact her.

Finally, both Mark Slaughter from Us Too! and Bill R. tell us about their experiences with chemotherapy for prostate cancer and their advice for men in similar situations.

The bottom line is that, if you’ve been prescribed either Taxotere (docetaxel) or Jevtana (cabazitaxel) for prostate cancer, there is no need to panic. Both drugs can have a dramatic impact on your survival, and their side effects can be managed with a little forethought and careful monitoring. Talk to your doctor about any concerns you have. Reach out to other men with prostate cancer who’ve had either of these medications. As with anything in life, the more you know going into the experience, the easier of a time you’ll have. Many times we fear the unfamiliar.

And, as always, be sure to share this issue of Prostatepedia with your doctor. Use these conversations as a jumping off point for an honest discussion. She may agree or disagree with some of the points made in the interviews that follow. Talking about why she is taking a certain approach with your disease will help you feel more comfortable with any decision that the two of you agree upon.

There has never been a better time to be a prostate cancer patient, friends. Your doctor has many tools in her wheelhouse to fight your cancer.

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Chemotherapy For Prostate Cancer

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This month we’re talking about chemotherapy for prostate cancer.

Dr. Snuffy Myers offers his thoughts about this month’s conversations:

Patients are often under the impression that chemotherapy drugs like Taxotere (docetaxel) and Jevtana (carbazitaxel) won’t significantly improve survival and will only dramatically impair quality of life. A patient once said to me, “That sounds like a bad deal.” I hope this issue of Prostapedia changes your view of chemotherapy.

The potential benefit of chemotherapy depends on where you are in the natural history of metastatic prostate cancer. If you have just been diagnosed with widespread metastatic prostate cancer, Lupron (leuprolide) plus Taxotere (docetaxel) can have a major benefit in terms of your survival. At this point, you are likely to tolerate chemotherapy better than you would if you had already been through multiple other treatments. However, even in patients who have been extensively treated before chemotherapy, this treatment can often provide significant relief of bone pain that outweighs the drug side effects.

The major alternatives to Taxotere (docetaxel) in this setting are the new androgen blocking agents, such as Zytiga (abiraterone), Xtandi (enzalutamide) or Erleada (apalutimide). Each of these drugs can cause side effects more severe than Taxotere (docetaxel) in some patients. Also, Taxotere (docetaxel) treatment extends for just six treatments done every 3 weeks. In contrast, the androgen blocking agents are typically given continuously until they fail to control your cancer.

In many other cancers, patients benefit greatly when we combine drugs. While the search for effective Taxotere (docetaxel)-based combinations has been going on for decades, no combination has survived rigorous Phase III testing. I, and many others in the field, think that this may be because prostate cancer is a very heterogeneous disease. The path to success requires that we understand at a molecular level the various forms of this disease and the key vulnerabilities of each variation.

One example is the sensitivity of prostate cancers with a BRCA2 mutation to Paraplatin (carboplatin). Another example is the activity of Jevtana (carbazitaxel) + Paraplatin (carboplatin) in anaplastic prostate cancer.

There are several reasons to be optimistic about progress. First, research into the molecular heterogeneity of prostate cancer and the clinical implications thereof is proceeding rapidly. Second, leads that emerge from this research are being tested more rapidly and with greater sophistication than at any time in the past.

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