Approaching Chemotherapy

For many people, chemotherapy conjures up thoughts of debilitating sickness and end of the line therapy. Today this is no longer the case. With advancements in modern medicine, side effects from chemotherapy can be easily managed and reduced. Chemotherapy treats metastatic disease and prevents relapse in men with prostate cancer.

This episode of PROSTATE PROS covers who will benefit from adding chemotherapy to their treatment plan, chemotherapy protocol and sequencing, and how to manage potential side effects.

Dr. Scholz: [00:04] Welcome to PROSTATE PROS.  I'm Dr. Mark Scholz and this is my cohost, Liz Graves.

Liz: [00:09] This episode we're going to cover chemotherapy.  There's a lot of fear and negative connotations that surround chemotherapy.  I think this reaction is pretty common because we've all heard about or been witness to friends or loved ones who suffered adverse effects from chemotherapy. Dr. Scholz, as a medical oncologist, which is the type of doctor who's trained to administer anti-cancer medication such as chemotherapy, how has this perception of chemotherapy and even medical oncologists developed and changed over the last couple of years? 

Dr. Scholz: [00:41] Chemotherapy, Liz, is a strong medicine that can certainly cause undesirable side effects.  Of course, balancing that can have powerful effects against the cancer.  So this tradeoff is an important consideration whenever doctors are considering the use of chemotherapy.  Fortunately, chemotherapy has evolved and improved dramatically over the last 20 years.  A lot of the negative connotations are attached to the treatments that were given a couple of decades ago.  Modern chemotherapy is much more tolerable and much more effective than what we previously had. 

Liz: [01:24] So chemotherapy may not be as threatening as it as perceived, but it is a way to treat prostate cancer. 

Dr. Scholz: [01:31] Chemotherapy is sort of a grab bag term that covers medicines that are usually given intravenously rather than orally, although now that’s not necessarily the case.  Of course, if the medicines can cause hair loss, or if they can impede your immune system, or lower blood counts, these sorts of side effects are the ones that are attached with what we call chemotherapy.  But chemotherapy is really just a medicine to treat cancer.  And there are many variants and some are very low in side effects and quite effective. 

Liz: [02:10] So chemotherapy has two roles in treating prostate cancer.  The first is to treat metastatic disease and the second is to prevent future cancer relapse.  This means chemotherapy is usually reserved for men with more advanced disease such as men who are in the Indigo or Royal stages. 

Dr. Scholz: [02:30] Exactly right.  The patients that are trying to prevent a future relapse probably have microscopic metastatic disease.  So using chemotherapy is almost always reserved for more advanced or at least aggressive types of prostate cancer 

Liz: [02:49] Is chemotherapy used as a monotherapy? 

Dr. Scholz: [02:53] So in prostate cancer, because you can talk about chemotherapy for a lot of other types of cancers, but with prostate cancer it's extremely rare for men to not be treated simultaneously with some form of hormone treatment while they're getting their chemotherapy. 

Liz: [03:08] So chemotherapy is usually used in combination with hormone therapy.  As we talked about in our previous episode, men can survive a really long time on hormone therapy.  Is there any concern that adding chemotherapy to this is excessive? 

Dr. Scholz: [03:25] Absolutely there is.  It is possible to get over-aggressive and overenthusiastic because sometimes the responses to hormone therapy are so excellent that it's difficult to improve on the results.  So the decision about when to implement chemotherapy requires real expert input and a really good understanding of how serious and how risky the cancer is. 

Liz: [03:51] So chemotherapy can really help when it's administered appropriately to men with prostate cancer. 

Dr. Scholz: [03:58] Yeah, if you think about preventing future cancer relapse, that category is extremely important because someone who is destined to have a relapse could conceivably be converted into an out-and-out cure.  In other words, their cancer would never come back because of the chemotherapy.  But, if they've forgone the chemotherapy, the cancer could relapse in the future.  So this approach of using chemotherapy to prevent a future relapse is a common theme, not only with prostate cancer, but with breast cancer, colon cancer, head and neck cancer, lung cancer, and it is effective in improving cure rates, but it has to be applied in the correct situation. 

Liz: [04:45] This is something that's discussed in The Key to Prostate Cancer. They mention the CHAARTED Trial and they talk about how maybe a combination of chemotherapy and hormone therapy might lead to a slightly decreased quality of life while you're on them.  But, because the chemotherapy can put men into remission overall, it's better. 

Dr. Scholz: [05:07] That's right.  So if you think about getting into a remission, where you’re able to stay off chemotherapy for a long period of time or perhaps even stop the hormonal therapy, which has side effects of its own, the net long-term effect is fewer side effects, even though men pay upfront with some increased side effects when they're taking the chemotherapy. 

Liz: [05:31] One thing I hear you talk to patients about all the time at Prostate Oncology Specialists, is quality of life versus lifespan. 

Dr. Scholz: [05:38] Exactly. And that sort of an analysis is not easy.  It's the sort of thing that you want to discuss with each patient and find out what their priorities are.  But I'm glad that we're able to discuss it today because sometimes these conversations never come up for discussion.  There's no doubt that studies show that a certain segment of men really do benefit by the early use of chemotherapy. 

Liz: [06:03] If a patient is eligible for chemotherapy, what does that look like? What's the protocol?

Dr. Scholz: [06:07] Well, the most common medicine that we use is called Taxotere, or docetaxel, is the generic name.  The most common protocol is an infusion intravenously given every three weeks, requiring a doctor visit that may take an hour or two.  Those cycles, three weeks cycles, are typically continued for four to six to eight total cycles.  Then as this process unfolds, men are monitored to determine how well they tolerate it.  And then of course, is there a good response?  Are PSA levels declining? 

Liz: [06:47] So when they're at the visits, getting the chemotherapy, are you checking their PSAs then?

Dr. Scholz: [06:53] Typically they'll get a PSA check every time they come in, other blood counts will be checked to make sure that excess side effects are not accumulating.  And then we talk to people and find out are they having excess fatigue, have they had any other unusual problems, like issues with their GI tract, or rashes, which are rare thankfully, but can occur on occasion. 

Liz: [07:15] Okay.  So you've mentioned a couple of side effects from chemotherapy and this is something that kind of puts people off from chemotherapy, but there are ways to regulate these side effects and manage them.  Can we talk a little bit about that? 

Dr. Scholz: [07:30] Absolutely.  And I think we've got to start with the same old theme when we were covering hormone therapy and that is exercise.  Studies clearly show that men have much less fatigue if they're able to continue on an exercise program when they're on the chemotherapy treatments.  Fatigue is a very prominent side effect that is cyclical, occurring for two to six days after each infusion.  It's a moderate to severe amount of fatigue.  People feel sort of fluey and they're fighting off something and then it blows over and they get back to normal before the next treatment.  Exercise makes a big difference in that regard. 

Liz: [08:11] Prednisone also can help with fatigue and chemotherapy. 

Dr. Scholz: [08:15] Yeah, some protocols advocate taking prednisone daily throughout the cycle.  In my opinion, that tends to sort of decrease the beneficial effect your body just gets used to it.  A more effective protocol is to take higher doses during and immediately after the chemotherapy, which seems to sort of bridge men through the fatigue side effects. 

Liz: [08:36] What about the nausea that's common with chemotherapy? 

Dr. Scholz: [08:40] Well, it's kind of cool that we don't talk too much about nausea anymore, which was previously such a common problem with all types of chemotherapy and this is because the anti-nausea medications that are routinely administered are so effective.  So, nausea is kind of background noise in this modern era due to the effectiveness of the counteracting medications. 

Liz: [09:03] Chemotherapy can also reduce platelet count or white blood cell count, which can lead to infection and sicknesses, but there's also medication that can help with that. 

Dr. Scholz: [09:13] The most common serious problem with any type of chemotherapy is the possibility of lowering the white blood cells, that's the immune system, to such a degree that people can become susceptible to infections, serious infections with bacteria.  Amgen makes a product, an injectable product that stimulates the white blood cells during the chemotherapy and counteracts most sometimes all of the effects on the low blood counts and thus greatly reducing the risk of infections.  We use Neulasta, Neupogen or their other such products routinely whenever we give Taxotere chemotherapy.  Some physicians prefer to reserve these medicines for the people who develop infections, which I think is a bad policy.  The infections can be life threatening and they're certainly unpleasant and usually require hospitalization.  Prophylactic use of these medications, such as Neulasta, in my opinion should be a standard approach.

 Liz: [10:10] What about the red blood cells?

Dr. Scholz: [10:13] So low red blood cell counts are otherwise known as anemia.  If people become too anemic as a result of treatment and they can get short of breath, feel very fatigued and tired.   Thankfully there are medicines to counteract the anemia of chemotherapy that are also produced by the same company, Amgen, it’s an injection that builds up the red cells.  So whenever the anemia starts to become problematic, people should discuss with their doctors whether they can start on medicines such as Procrit or Aranesp.  These medicines will help build up the red cells.

Liz: [10:50] One last side effect that I think can be difficult emotionally is hair loss. 

Dr. Scholz: [10:56] So yeah, the official name is called alopecia.  It tends to be moderate, sometimes mild and sometimes severe with Taxotere chemotherapy.  The effects are reversible but can be unpleasant.  Men that are determined to not lose their hair can use a form of an ice cap, which keeps blood flow and chemotherapy away from the scalp.  It's a bit of an involved process and unfortunately it's only covered for breast cancer, not for prostate cancer yet, so there could be some expense.  But it is possible to control for the hair loss.  Most men just endure it and then their hair grows back normally or at least grows back fully after the treatment is finished. 

Liz: [11:42] You can see how men who've been private about their prostate cancer diagnosis may struggle with these visual changes.  Remember that prostate cancer is a silent disease, meaning it might never have symptoms or might not have symptoms until very late stages.  Let's say you have a patient who's struggling with some of these side effects.  Are there any alternatives? 

Dr. Scholz: [12:03] Absolutely.  There's a couple.  One is to switch to another taxane, a closely related medication called Jevtana.  Studies seem to indicate that the side effects are somewhat less, but without any reduction in effectiveness.  Jevtana might even be used before Taxotere if insurance companies didn't tend to nudge people towards Taxotere first, I think primarily for cost reasons.  Men that have the option, or who develop side effects, can then switch to Jevtana and probably enjoy a little better quality of life.  Another option is to take the Taxotere and cut the dosage.  Instead of giving it every three weeks, give a smaller amount on a weekly basis.  That has less fatigue and less hair loss. There's a slightly higher incidence of low platelet counts, so that has to be watched.  The platelets are the substances in the blood that help blood clot normally.  So sometimes the dosing has to be adjusted if the platelets drop too much. 

Liz: [13:08] Okay. So we've talked about treatment schedule, which can be changed to help side effects, but when chemotherapy is being used in combination with say, hormone therapy, how do those treatment schedules work together? 

Dr. Scholz: [13:22] The hormone therapy thankfully doesn't interact with the chemotherapy to a great degree.  The medicines are usually administered on a monthly or a quarterly basis.  When I say medicines, we're talking about hormone injections like Lupron.  Whereas the chemotherapy is given as an infusion every three weeks or as we mentioned, sometimes even weekly.  The inconvenience of simultaneous admission really doesn't present too many problems. 

Liz: [13:49] Can chemotherapy be administered at the same time as all different kinds of treatments? 

Dr. Scholz: [13:55] There are some debates about using second generation hormonal therapies in conjunction with chemotherapy, that is.  It seems that they can be safely administered at the same time.  Small studies don't show any problems.  Historically whenever we've used abiraterone or Zytiga, which is a second generation hormonal agent, we've held the pills a day before, day of, and the day after the Taxotere.  But some studies suggest that a precaution really isn't necessary. 

Liz: [14:23] Chemotherapy can be used safely with hormone therapy and with radiation.  But what about immunotherapy? 

Dr. Scholz: [14:29] Right. And there are some hesitations in giving radiation and chemotherapy together because they can both lower blood counts.  So usually we'll sequence radiation before or after chemotherapy.  But the immune therapy issue is a good one because chemotherapy causes cyclical suppression of the immune system, which is exactly the opposite of what you're trying to accomplish when you give immune therapy.   When you give immune therapy, you're trying to build up the immune system and make it stronger.  Not only are immunotherapy and chemotherapy not given simultaneously, doctors like to have a space, a period of time, separating these things so that the benefits of the immunotherapy or the chemotherapy aren't immediately counteracted by using them right after each other. 

Liz: [15:17] So this is all very complex.  Deciding which dosage is best and how to sequence chemotherapy with other medications.  So I just wanted to address that it's very important to see a specialist who is very used to dealing with these sorts of little jigsaw puzzles. 

Dr. Scholz: [15:36] We need to remind people that most patients with prostate cancer are being treated by urologists who are surgeons.  It's only about one in one hundred urologists that would be comfortable giving any kind of chemotherapy.  Some question whether even that 1% should be doing that at all.  Patients with advanced disease or patients with high risk disease, where this question of chemotherapy comes up, should be consulting with a medical oncologist. 

Liz: [16:02] So with all of the modern improvements in prostate cancer medication, many men find that they can push off chemotherapy for a very long time and when it finally becomes an option, they're afraid it's like a last-ditch effort. 

Dr. Scholz: [16:17] Yeah, I think that perception is true.  Of course the good news is that we have all these other alternatives now and it has allowed us to reduce the use of chemotherapy.  But my experience with men who do start on Taxotere or Jevtana is that many are pleasantly surprised that the side effects are a lot less.  That the specter of all these things that we've discussed, which sounds so daunting, really in practical day to day practice don't turn out to be as bad as they thought.  In West Los Angeles, where we practice, sometimes the traffic driving back and forth to the office visits every three weeks represents one of the big side effects that men would love to be able to avoid. 

Liz: [16:59] Do you have men in your practice that are just so resistant to go on chemotherapy? 

Dr. Scholz: [17:05] Yes, the word chemotherapy was generated 30, 40 years ago when the medicines were really quite dreadful, really bad side effects and relatively modest, if any, benefits.  So the word itself is scary and the idea that it may represent sort of a last-ditch effort as you said, Liz, that is, that is indeed scary.  To counterbalance that is these medicines really work well and response rates are high.  You can see dramatic declines in PSA and resolution of spots on scans.  So it's very gratifying to know that we have this, if we want to call it a backup treatment.  The other situation we already talked about is using it as a preventative for future problems as well.  And that's a select group of men that is also reducing because of the effectiveness of hormone blockade alternatives.  But there still a role for chemotherapy as a preventative too. 

Liz: [18:06] Here's an update on the recent news and developments in prostate cancer.  In September 2019, Erleada was FDA approved for men with metastatic castration-sensitive prostate cancer. Following that approval in December 2019, Xtandi, another second-generation hormone therapy, was also FDA approved for men with metastatic castration-sensitive prostate cancer. These new indications allow Erleada and Xtandi to be options for men much earlier in their prostate cancer treatment journey.  A study funded by the World Cancer Research Fund and Cancer Research UK looked at physical activity among roughly 79,000 men with prostate cancer and 61,000 men without prostate cancer.  They found that compared to the least active men in the study, the men who were the most active had a 51% reduced risk of prostate cancer.  One of the lead researchers said “this suggests there could be a larger effect of physical activity on prostate cancer than previously thought.  So this will hopefully encourage men to be more active.”  As we open up 2020 remember to register for the PCRI Mid-Year Update, which is March 28^th.  We hope to see you there.  You can register at pcri.org.  That's the news update at this time.  Chemotherapy is important for men in the Azure, Indigo, or Royal stages.  If you're a new listener or haven't yet taken the prostate cancer staging quiz, visit keytopc.com to find out your stage of blue. 

Dr. Scholz: [19:56] I first started giving Taxotere back in 1998, even before it was FDA approved for prostate cancer.  At that time, it was only used for lung cancer.  Taxotere has been a mainstay for controlling advanced prostate cancer for decades.  The experience has grown and the methods to reduce the side effects have been refined over the years.  It's a really effective medicine and when it's used in appropriately selected cases it can be life-saving. 

Liz: [20:25] As we end this episode.  We also wanted to thank Peter Bowes, the host of the Live Long and Master Aging Podcast for having Dr. Scholz on his show recently to talk about prostate health, cancer, and longevity. 

Peter Bowes:  [20:38] Hello and welcome to the Live Long and Master Aging Podcast.  I'm Peter Bowes. This is where we explore the science and stories behind human longevity.  Dr. Scholz, it's good to see you, welcome to the Live Long and Master Aging Podcast.  

Dr. Scholz:   [20:51] Thank you very much, Peter. 

Peter Bowes:  [20:53] Do you work exclusively on prostate cancer?

Liz: [20:54] You can listen to the episode on llamapodcast.com, that's llamapodcast.com.  We've loved getting emails from listeners, so if you have any comments or questions, please email them to [email protected].  Remember to rate and review on Apple Podcasts.  Talk to you next time!