Sometimes MORE is better
When given the option of another piece of cake, most toddlers will automatically respond with more cake, because more is better, right? In medicine sometimes more is better, and sometimes it’s not.
Recently published in the New England Journal of Medicine (July 27, 2017)1,2 were two large clinical trials looking at the effectiveness of adding two medications to the standard backbone of prostate cancer treatment. They are abiraterone acetate (Zytiga®) and prednisone (a steroid), which lower androgens in a man’s body. An androgen is a hormone and testosterone is an example of an androgen.
This “cocktail” of treatment improved survival more than a single drug in both men who had cancer that spread to other parts of their body at the time of diagnosis as well as men whose cancer was still localized in the prostate, but was at high risk of coming back after radiation therapy. These findings reinforce what researchers have seen over the past two years: for certain patients, combining different types of treatments early on in the disease works better.
Prostate cancer has been treated effectively with what many people call hormone therapy for many years. These treatments use drugs that lower the body’s androgen levels. This remains an essential part of therapy for many men. Some examples of drugs that do this are leuprolide acetate (Lupron®), goserelin acetate (Zoledex®), triptorelin pamoate (Trelstar®) or degarelix (Firmagon®). These drugs are called androgen deprivation therapies. There is also a type of surgery called orchiectomy that does the same thing.
However this approach only tackles the testosterone that comes from a man’s testicles. We now know that hormones from a man’s adrenal glands (little glands that sit on top of the kidneys) and hormones that the tumor makes itself are also important. Abiraterone and prednisone are a medicine combination that decreases hormones from both the adrenal glands and the tumor. By adding these medications to one of the androgen deprivation therapy drugs mentioned above, all androgen hormones are maximally suppressed.
What other newer combinations work?
In two large clinical trials published in the New England Journal of Medicine in 2015 (3) and The Lancet in 2016 (4), the combination of hormone treatments, like leuprolide, when added to docetaxel (Taxotere®) chemotherapy is also very effective at improving survival in men with cancer that is widespread at diagnosis.3,4 Chemotherapy is medication usually given through an intravenous line that kills cancer cells by damaging them so they cannot grow and divide.
What approach is the right path for the “best” prostate cancer treatment?
The answer is different for each patient. Trials are ongoing to try to answer this question. What is clear is the side effects and lengths of treatment are different between the two options. The best approach is decided between the doctor and the patient.
References:
- James ND. Et al. Abiraterone for Prostate Cancer not Previously Treated with Hormone therapy. N Engl J Med 2017;377:338-51
- Fizazi K et al. Abiraterone plus Prednisone in Metastatic, Castration-Sensitive Prostate Cancer. N Engl J Med 2017;377;352-60
- Sweeney, CJ et al. Chemohormonal Therapy in Metastatic Hormone Sensitive Prostate cancer – N Engl J Med 2015; 373:737-746
- James ND, et al. Addition of docetaxel, zoledronic acid or both to first line long term hormone therapy in prostate cancer (STAMPEDE): survival results from an adaptive, multiarm, multistage, platform randomized controlled trial. Lancet 2016;387:1163-77.