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Chemotherapy and Surgery

Most often, surgery is a treatment for early-stage prostate cancer that has not spread to distant sites such as the bone and lymph nodes. In this case, the goal of the surgery is to remove all of the cancer. The most common surgery for prostate cancer removes the entire prostate gland, in a procedure called radical prostatectomy.

  • Radical prostatectomy procedures developed at Johns Hopkins in the 1980s spare nerves near the prostate and help up to 70 percent of men retain their potency and 93 percent their continence.
  • Open radical prostatectomy: in this type of surgery, an open incision is made above the patient’s navel to remove the prostate gland and seminal vesicles. The procedure remains outside the abdominal cavity.
  • Perineal laproscopic prostatectomy: in this surgery, small open incisions are made between the rectum and scrotum to remove the prostate gland and seminal vesicles. This procedure is used far less often than open or robot-assisted surgeries.
  • Robot-assisted laproscopic radical prostatectomy: in this surgery, removal of the prostate is done through five to six tiny incisions with robotic instruments controlled by a surgeon.
  • Recovery from a radical prostatectomy usually includes one overnight stay in the hospital, and seven to 10 days with a catheter placed in the bladder.

Hormonal Therapy

Prostate cancer cells depend on hormones like testosterone to thrive. Hormone therapy for prostate cancer involves depriving the cancer cells of this fuel, by either blocking the production or action of androgen hormones like testosterone. In cases where the cancer continues to grow and spread despite hormone deprivation—a condition called metastatic castration-resistant prostate cancer—an oncologist might prescribe another type of drug called an antiandrogen.

Some of the hormones used to treat prostate cancer include:

  • Degarelix (Firmagon): this drug blocks luteinizing hormone-releasing hormone (LHRH) from triggering testosterone production
  • Enzalutimide (Xtandi)— antiandrogen used to treat metastatic castration-resistant cancer
  • Abiraterone acetate (Zytiga)— antiandrogen used to treat metastatic castration-resistant cancer

Johns Hopkins is the only facility in the world that offers clinical testing for the AR-V7 genetic variant, which can help predict whether antiandrogens like enzalutimide will be useful in treating metastatic castration-resistant prostate cancer. (see below)

High-Dose Testosterone Therapy

A team of Johns Hopkins researchers led by Sam Denmeade, M.D. showed in a recent small study that high doses of testosterone may have promise in treating some men with metastatic castration –resistant cancer who are receiving but have stopped responding to antiandrogen drugs. The addition of high-dose testosterone seems to “re-sensitize” the cancer so that it responds to the antiandrogens again, and it may also create catastrophic DNA breaks in cancer cells that have already been weakened by antiandrogens.

The testosterone is injected intramuscularly, and some of the patients in the small study by Denmeade and colleagues had improvements in their quality of life and in metabolic symptoms such as cholesterol and blood pressure measurements. Denmeade and his colleagues are expanding tests of high-dose testosterone in ongoing clinical trials.

Chemotherapy

Chemotherapy is rarely the primary therapy for men with prostate cancer, but it may be used when prostate cancer has spread outside of the prostate gland, especially if hormone therapy is no longer effective. It may be used to slow tumor growth and reduce pain in advanced prostate cancers. Johns Hopkins researchers are working on ways to pair chemotherapy with other types of treatments such as immunotherapy.

  • Docetaxel (Taxotere) is the drug that is most commonly given first for prostate cancer. Kimmel Cancer Center prostate cancer expert Mario Eisenberger, M.D. led a group of institutions that completed a three-year international study showing that docetaxel can prolong the lives of men with prostate cancer that no longer responds to hormone therapy by several months. It is usually delivered along with the steroid drug prednisone, to manage inflammation.
  • Cabazitaxel (Jevtana) is another chemotherapy drug that may be used (along with prednisone) if docetaxel is not effective.

Chemotherapy might also be the preferred treatment for men with advanced prostate cancer who carry the AR-V7 gene variant, discovered at Johns Hopkins. A small clinical trial led by Emmanuel Antonarakis, M.D., and completed in 2015 concluded that men with this variant respond well to chemotherapies like docetaxel and cabazitaxel. This is important because men with the AR-V7 variant who have advanced prostate cancer often do not respond to hormonal therapies such enzalutimide or abiraterone acetate.

Immunotherapy

Immunotherapy works by helping a patient’s own immune system fight back against cancer cells. Several different types of immunotherapy are being tested (alone and in combination with other treatments) by Johns Hopkins scientists. Prostate cancer is also one of the focus areas of the Bloomberg-Kimmel Institute for Cancer Immunotherapy.

One immune therapy that has been approved by the U.S. FDA is a vaccine called sipuleucel-T (Provenge), which spurs a patient’s immune system to attack prostate cancer cells. It is approved for use in men with metastatic castration-resistant cancer. The vaccine is tailored to match each patient’s own immune system by removing white blood cells from the patient and “training” them to recognize prostate cancer cells before infusing them back into the body.

More information on promising immunotherapy research and clinical trials.

 

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