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Men who have metastatic prostate cancer at presentation are now quite rare. In the days before psa screening (which clearly works, but picks up way too many patients with low grade disease whom we don’t need to find…see multiple blogs elsewhere) we used to see 70 year old men come in with new bone pain, and then it turned out to be prostate cancer. In any case, since the discovery of the taxanes (docetaxel and cabazitaxel), the first drugs to prolong survival after castrate resistant disease sets in, we have all wondered if they were used earlier whether there would be an advantage. The earliest they could be used would be immediately after surgery – but the trial that attempted to study this was abandoned after 2 years because not enough men/doctors would sign their patients up. (see blogs on this elsewhere as well)
So… what about using taxanes at the time hormone therapy is first started? (This could be after surgery or radiation…many years…or when a rare patient first presented with metastatic disease. They HAD to have metastases, however, not just a rising psa. The study (which we called CHAARTED – and my colleagues at CU and I offered this trial to many patients and we treated quite a few who were willing) randomized to hormone treatment alone vs hormone treatment (ADT) combined with 6 cycles over 18 weeks of docetaxel. The trial has been reported now in preliminary form and shows significant improvement in survival in the men who received the docetaxel. This is really a trial between “early vs late” docetaxel, since I am relatively certain the men who got ADT alone would have eventually received docetaxel as well when they became castrate resistant. This is a BIG deal. It means that we have a shot at eliminating some of the cells that don’t fully die off from ADT alone right at the start. It also paves the way to go back and look at doing similar treatment right at the time of surgery or radiation, like we tried to do a decade ago. And if we add the newer hormonal agents (abiraterone, enzalutamide, Tak700, etc) up front, the results could be even better (please lobby the companies who make these agents to provide them for free to men willing to be treated in such trials)
Hats off to the men who agreed to this practice changing trial and to their physicians. And congratulations to my good friend Chris Sweeney who headed up the trial. (He and I have had some great times together over the years) Gentlemen, this is what our sisters did to advance breast cancer treatment 30 years ago! Don’t ever tell me it isn’t good to sign up for randomized trials, or that just doing what we always have done is adequate. Support research! Only 4% of U.S. cancer patients participate in clinical trials. Let’s work together to beat this disease. Happy holidays!