Patients frequently ask their physicians, “Am
I stage A, B, C or D,” without realizing that the original purpose of a
lettering system was simply to guide urologists in the selection of candidates
for surgery. While stage matters, a combination of PSA level and the Gleason
grade is a better way to assess disease status. So rather than using stage,
it’s best to incorporate all three factors together—PSA, Gleason and stage—to divide prostate cancer into
five broad categories or Shades of Blue.
Using standard doctor terminology, the AZURE
Shade of Blue is essentially the same thing as “High-Risk” prostate cancer.
“Risk” refers to a higher probability of relapse after surgery or radiation
compared to men in SKY or TEAL shades. Therefore, men in AZURE are usually
treated with combination therapy
consisting of IMRT, a seed implant and testosterone inactivating
pharmaceuticals (TIP) for 18 months.
Here are the specific factors that define
AZURE.
1.
No
previous treatment with surgery or radiation.
2.
Bone
and body scans without metastasis.
3.
One
or more of the following three factors:
a.
PSA
above 20 and less than 100, or
b.
Gleason
score above 7, or
c.
A
prostate tumor felt by digital rectal exam extending across the midline of the
gland or outside the capsule.
Men with two or three of these factors are
still classified as AZURE. Men with spread to pelvic nodes are classified as
INDIGO. Men with metastasis that has
spread to bones or to nodes outside
the pelvis are ROYAL. Radiation—rather than surgery—is the preferred treatment
for AZURE because of the risk for cancer infiltration outside the prostate.
Safe surgical removal is next to impossible when the disease extends into
surrounding organs. Incomplete cancer
removal means radiation will be required to “mop up” the residual cancer
anyway. Therefore, most experts recommend radiation because the risk of needing
both surgery and radiation is so much lower.
Within the AZURE category exist subcategories
of men who have a relatively more advanced type of AZURE. For example, some men
have larger tumors, higher PSA levels above 40 and Gleason grade 9 or 10. Men in this situation might want to try to
further enhance their cure rates by adding a more potent form of TIP such as
Xtandi or Zytiga to their therapeutic plan.
Also, a short course of Taxotere chemotherapy can be considered.
My last blog (about TEAL) reviewed potential
side effects from surgery and radiation.
The side effects of TIP become more severe when treatment duration is
prolonged. The three most troublesome TIP-related problems are low libido,
weight gain and fatigue. However, libido recovers after TIP is stopped. Weight gain and fatigue can be reduced with
diet and exercise. Yet as we all know, maintaining a consistently good diet and
getting adequate exercise over long periods of time can be very
challenging. Obtaining professional
support from a trainer or a physical therapist is one way to sustain a
disciplined program on an ongoing basis.
Other common TIP side effects can be
controlled with medications. Hot flashes
regress with a low-dose estrogen patch. Calcium loss from the bones can be
prevented with an injection of Prolia every six months, a Fosamax pill weekly
or with an Actonel or Boniva pill monthly. Mood swings can be reduced with
low-doses of an antidepressant called Effexor.
Effexor also has salutary effects on hot flashes. Breast growth can be
prevented with an estrogen-blocking pill called Femara. When libido is chronically low, men tend not
to care about getting erections, so taking daily Cialis should be considered
standard for men receiving TIP.
Unfortunately, many doctors have limited
knowledge about how to prevent TIP side effects. Patients, therefore, need to
protect themselves by getting as much education as possible. Certain side
effects, such as breast growth, erectile atrophy and osteoporosis, are
preventable with appropriate intervention.
However, once they are allowed to occur, these effects can be permanent.
While side effects are an important
consideration, men in the AZURE group have a relatively more dangerous type of
prostate cancer compared to men with SKY or TEAL. The appropriate treatment stance, therefore,
is to be aggressive—to get cured.
The good news is that the majority of men
with the AZURE stage of prostate cancer will be cured with the treatment
approach outlined above. Studies have
shown that the best results come from using IMRT, radioactive seed implantation
and testosterone inactivating pharmaceuticals (TIP) in combination with each
other.
So if you do find yourself in the AZURE zone,
don’t despair: There is good reason for hope.
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