Barricades in combined treatment and paving the way for success
As we discussed in Part 1, 2015 was a milestone in the treatment of early metastasis (metastatic hormone-sensitive prostate cancer or MHSPC). For the first time, the Melancholic The study showed that men with MHSPC who started ADT (androgen deprivation therapy, which closes testosterone) plus chemotherapy (Docetaxel) lived significantly longer of men who began to heal only with ADT.
This study was the first of several to change the treatment standard for early metastatic prostate cancer combination treatment: ADT Plus Docetaxel or ADT plus an inhibitor of the androgen receptor street (ARPI; These drugs include enzalutamide, abiraterone, Apalutamide and Darolutamide) or ADT plus chemotherapy plus an arpi.
With combined treatment, average survival – Again, some men live much longer – It is now about five years, compared to about three years ago a decade ago. Results continue to improve as new drugs develop and doctors continue to push the treatment folder. This improvement is monumental, says Medical Oncologist Neeraj Agarwal, MD, of the Utah University Cancer Institute. Recently the interview for the Prosate Cancer Foundation website. It is particularly so, continues, “when you consider some anti-cancer drugs approved on the basis of three-month Survival benefits. There is no doubt that ADT is not enough. It works much better when combined with one of these arpis. ”
And yet. This is not the case for thousands of American men with MHSPC, the agarwal states: “Many patients in the US – the richest country in the world – is not Taking Adt Plus ARPI or ADT PLUS ARPI PLUS Docetaxel, front. This is unacceptable in our view, Due to the significant advantage of survival and quality of life benefits associated with combination therapy. ”
What is the problem? Unfortunately, there are many.
“There is no shortage of evidence that combined treatment works,” Agarwal says. However, “The number one reason that combined treatment is not used in front of MHSPC patients is Lack of data awareness. “Many clinical doctors have one pre-2015 mentality About MHSPC. “They are afraid that if you use everything ahead, what will you use later? They want to keep these treatments for the time that ADT fails.”
But here’s the thing: Using both treatments in front May delay or even change the course of MHSPC. No one really knows. have been No long -term studies Because this care standard is still very new. However, during my experience for studying and writing prostate cancer over the last 30 years, I will tell you that all the things that have been done as a last solution have done much better when used as weapons against prostate cancer Later and not later, when cancer is more vulnerable. We are not there yet, in the sense that we are able to put all men with prostate cancer in a durable recession, but that is the goal.
Agarwal is the upper author of a impressive study Posted in 2023 in Urology newspaperLooking at how doctors in different specialties treat men with MHSPC. ‘We’ve found it Combined treatment was not used as the first line of treatment in all Urology and Oncology specialties despite data on improved survival,“He says.” In subsequent treatment lines, ADT PLUS ARPI was more often prescribed in specialties “, But these men would be better if they had hit MHSPC with the two barrels from the beginning.
“We have found that many doctors are concerned about the side effects of these drugs,” Agarwal says. “In many medical oncology practices, doctors deal with many different types of cancer in a given clinic so that they have enough time to destroy prostate cancer alone? They don’t know the data.
But it becomes more complicated. There are financial barricadesalso. In our country, medical care is generally expensive and complex and many medical practices are based on a small group of people whose job is Just be on the phone with insurance companies every daysupporting patients.
“The use of combined treatment is linked to more workload for clinical doctors and their practices,” says Agarwal, “especially if you do not have enough support personnel. Many individual practices do not have the support of a nurse, a pharmacist or a large group of financial people who can write letters or. “There are Copay problems with combined treatment. It continues. – Other health problems that require other medicines that can interact with an ARPI against another.
Following is an example: “Eliquis (a blood bloody drug) is quite common, but it has an interaction with Enzalutamide, whether you have to talk to a doctor or cardiologist to see if you can have turned into something else,
With insurance and also Medicare, out -of -pocket copays are a big problem for many patients. A man’s choice in Eliquis can be abiraterone, which has another significant benefit: Abiraterone was long enough to have “generally” and is much less expensive than other arpis. “This man could take Abiraterone for $ 170 per month. But many patients have zero copay For Enzalutamide. It’s $ 15,000 a month, but copay is zero. “If this man only has Medicare,” and has no reserve insurance to help with the cost of out of pocket, it can be very difficult to afford this monthly copay, “which could run at thousands each month, depending on the insurance plan of a patient and not to mention his wife or his wife.
What about a coupon? Unfortunately, coupons do not always help, agarwal continues. “Say you have a coupon from a pharmaceutical company for $ 200 for your Copay. This is not regarded by insurance company as support for Copay. Instead it is regarded as a contribution to the base price of the drug, which is wrong. ”
He is sure to be. Agarwal supports Capitol Hill for legislation to help relieve financial weight for cancer patients. The recent inflation reduction law contains a layout that allows Medicare to negotiate the price of certain prescription drugs. In addition, “patients in Medicare will have an annual maximum of $ 2,000 for the cost of pocket prescription drugs, starting this year,” says Agarwal, “to help”.
Maximize your chances of success
Here’s something that Agarwal always tells his patients before starting the combination treatment: “Yes, you will feel overwhelmed because your life has changed. But I have many patients living for years – over a decade – And I give them this hope: You could be one of them. ”
Just like the best way to target early metastasis is to hit it hard, from the beginning, the best way to approach combine treatment is to Tackle all possible side effects right in front.
Drugs can get tax, says Agarwal. “There is fatigue, loss of muscle mass, a risk of metabolic syndrome, increased fat around the middle section, increased cardiovascular risk, an increased risk of stroke, quality of life – hot flashes, inability to perform your daily life and your daily life. But there are ways to handle all this. ”
Here are some key points for doctors and patients to examine:
Exercise: Cardiovascular exercise with resistance training “is more important than ever.” Agarwal is the main researcher of a study funded by NCI that starts patients with a combination of treatment in an annual exercise program. As we discussed, for men with MHSPC, Any exercise is better than none, and even light weights and short exercises can make a big difference.
Heart care: “Examination for heart problems is more important than ever, says Agarwal. When he starts patients in ADT plus an arpi,” it is routine for me to do ekgs in my clinic, especially in those patients who seem to be prone to heart disease “. They include men who have a history of smoking.
Bone care: “So many times this is lost,” says Agarwal. “If someone already has a low bone density and then starts from ADT and ARPI, it will start to have fractures. Vitamin D and calcium plus exercise really go a long way to help bone strengthen. Diet can also help here: leafy green vegetables are really good for bones.
Social assistance can be huge: “You need a village, especially in the early days,” Agarwal says. “I tell my patients.” You must overcome this immediate obstacle, these seemingly insurmountable obstacles of tests, medicines and insurance – so let’s work together “. So a social worker and financial advisor Play such big roles at first. ”
And then… “These patients themselves, their safety has been resolved, all the checks made, the combination therapy started – their PSA has fallen, they feel great, they have no pain, they feel much better, they return and say ‘thank you very much’. After six months, their whole family has a feel.
In addition to the book, I have written about this story and much more about prostate cancer on the prostate cancer website, Pcf.org. The stories I wrote are under the categories, “understanding prostate cancer” and “for patients”. As we have said for years Patrick Walsh; Knowledge is power: Saving your life can start with the transition to the doctor and know the right questions you need to ask. I hope all men put prostate cancer on their radar. Take a basic PSA blood test in the early 1940s and if you are African descent or if the cancer and/or prostate cancer runs to your family, you should regularly examine for the disease. Many doctors do not do this, so it is up to you to ask for it. NOTE: I am a subsidiary of Amazon, so if you click on the link and buy a book, I will theoretically make a small amount of money.
© Janet Farrar Worthington
