Dr. Alicia Morgans is a medical oncologist at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. She specializes in treating advanced prostate cancer and is particularly interested in addressing treatment side effects.
Prostatepedia spoke with her about chemotherapy for prostate cancer.
Why did you become a doctor?
Dr. Alicia Morgans: I’ve known since junior high school that I wanted to not only become a doctor but an oncologist. I knew I wanted to do something in science that engaged people on a personal level, and I had always admired the way physicians could do that. When visiting my grandmother during summers, I often went to her doctor appointments. I loved trying to understand things on a biologic level, and seeing the way the physicians she had listened and tried to help her. Even when they didn’t have a fix to a problem, they could at least serve as a witness to validate her experience and lend support in any way they were able. Oncology specifically has always been a really challenging puzzle to understand, and the best opportunity to form long-term relationships with patients.
Medicine is an amazing way for individuals to engage at a very deep level, not only with intricate and exciting science but also with really rewarding human interaction. I’m glad I made the decision.
Have you had any patients over the years who have changed how you view the art of medicine or how you view your own personal role?
Dr. Alicia Morgans: There are always patients who change how we move forward with the practice, art, and science of medicine. As it comes to chemotherapy, in particular, there are a number of men that come to mind who, when offered chemotherapy, said there was no way they could do it.
These statements come probably from their prior experience with family members or loved ones who have had bad experiences with chemotherapy. These are real experiences that certainly need to be acknowledged, but I haven’t met a person who we can’t get through at least one cycle of chemotherapy to see if they truly can’t manage it.
Most everyone can get through chemotherapy for prostate cancer because it’s different than chemotherapy for things like breast cancer or leukemia, where we use many drugs in combination that can be intense. This is typically one chemotherapy drug at a time, unless we’re specifically studying more intense combinations in clinical trials.
Most men do pretty well. There are several men who have been so sick from their cancer that, when I’ve given them chemotherapy, they actually feel a lot better, and that is really rewarding. It’s an experience that I use to guide conversations with patients who are frightened of chemotherapy. Sometimes the people who feel the worst at the start feel much better with chemotherapy.
Because the chemo’s killing their cancer?
Dr. Morgans: Exactly.
That’s a really important point you’re making. Just because, say, your neighbor had chemo for breast cancer and had a terrible time, that doesn’t necessarily mean that you will have a terrible time with chemo for prostate cancer.
Dr. Morgans: Absolutely, and there are a number of men who I’ve taken care of through chemotherapy for prostate cancer, men in their 60s and 70s, who have continued to work. Sometimes, men who are in that phase of their career have a little more flexibility with their job, and they can do half days or relax in the afternoon for a half hour and go back to work. Sometimes these are men with relatively physical jobs, and they’re still able to work, other than the day when they’re actually getting treatment, when they’re not able to be physically at work because they’re getting chemotherapy.
It is different than the treatments that we give to young women with breast cancer or people who are getting treatment in the hospital. This is an outpatient treatment. It typically takes about an hour to an hour-and-a-half to infuse. It’s something that we are sure to monitor very closely because we want to be safe, and we want to support people as they develop symptoms. For the most part, people do much better with this type of chemotherapy than they would expect.
At which points are men likely to encounter chemotherapy for prostate cancer?
Dr. Morgans: There are various points at which men can encounter chemotherapy in their prostate cancer journey. This has changed over the last few years. When men have metastatic disease today, whether that’s hormone sensitive or castrate-resistant, we recommend chemotherapy. As of yet, we do not routinely recommend chemotherapy for men who are having radiation for localized disease or for men with biochemical recurrent disease (though both of those populations have been studied in clinical trials, and there appears to be, at least in some of these patients, potential benefits related to that).
There have also been studies looking at neoadjuvant chemotherapy, which is chemo before prostatectomy. There appears to be a potential benefit to that, particularly in high-risk patient populations. But again, that’s not routinely recommended.
For the most part, men with metastatic disease are more routinely being offered chemotherapy, either in hormone-sensitive metastatic disease in the frontline setting or as one of the treatment options in metastatic castrate-resistant disease.
How is it usually sequenced? Or is there a usual sequence?
Dr. Morgans: There’s not a usual sequence, and every individual who is being treated for advanced prostate cancer is probably aware that we don’t have exact data to say which drug should be first, second, or third. These are conversations between men, their doctors, and their families to choose the treatment option that’s best for them.
For men with brand new prostate cancer that is metastatic from the get-go, or for men who have had prostate cancer treatment in the past and now have recurrent disease that’s metastatic but hasn’t yet been treated, we often recommend chemotherapy, particularly for men who have a high volume or high burden of metastatic disease. In that setting, we use six cycles of chemotherapy, and we can help men live longer and feel better. We have data on both the efficacy for improving survival and on the quality of life that show benefits in that population.
It’s important that we use it in that earliest stage of metastatic disease so that we only have to use six cycles of chemotherapy to get a pretty dramatic benefit whereas, if we use it in the later settings, we may use up to ten cycles of chemotherapy for lesser benefit. That’s a consideration when I’m talking to men with high-volume, hormone-sensitive disease.
In the later stages of disease, if we’ve used androgen receptor or hormonal therapies first, then often we switch to chemotherapy after that hormonal approach because it’s a novel mechanism of action and is expected to be more effective. Rather than continuing to hit on the same androgen receptor pathway, we’re using a different way to approach the cancer and overcome resistance.
What are the side effects of chemo like on its own? What about when you’re sequencing it either before or after hormonal therapy? Is there some sort of synergistic or cumulative effect to the side effects?
Dr. Morgans: Usually, we’re using chemotherapy alone with a gonadotropin-releasing hormone (GnRH) agonist or antagonist therapy. That would include therapies like Lupron (leuprolide), Zoladex (goserelin),
and Firmagon (degarelix), medicines that act to stop the testes from making testosterone. Then we add on Taxotere (docetaxel) chemotherapy when we choose the first chemotherapy for men with prostate cancer. The side effects are generally similar whether you use it earlier or later if you’re using it just in combination with that medicine.
With these injections, the most common side effect is fatigue. The next most common thing is neuropathy, which men would experience as a numbness or tingling in their fingertips or toes that, with repeated exposure, can go up into their hands or feet. It can become a more long-lasting issue, or eventually can lead to permanent numbness, especially as you get higher numbers of cycles. For example, if you use ten cycles in the metastatic castrate-resistant setting versus six cycles in the metastatic hormone-sensitive setting, you’re going to have a higher risk of things like neuropathy.
At any point when we’re using chemotherapy, we expect to cause blood counts to go down. Some men need a blood transfusion of either red cells for anemia or platelets for a low platelet count, though that’s relatively uncommon. What’s more common and possible is that the white count, the infection fighting cells, can go down with each dose of chemotherapy, and that count stays down until the bone marrow starts making more cells. We don’t have a transfusion we can give people to make that improve more quickly. That puts men at risk of what’s potentially a life-threatening infection when their blood counts are down, and the more cycles that they have of chemotherapy the longer it takes for their blood counts to recover. That’s another reason to think about using it when you only have to do six cycles as compared to ten.
As men get older, sometimes the side effect burden can become a little more noticeable to them. If we have the opportunity to use chemotherapy in men in their 50s or 60s as opposed to their 70s, we may see that there are fewer side effects. If they’re having a lot of side effects like loss of appetite and weight-loss, fatigue, and pain related directly to their cancer, the side effects of chemotherapy can actually be reduced fatigue, reduced pain, and improved quality of life between cycles.
Because as we said, it’s killing the cancer?
Dr. Morgans: Yes. There was a clinical trial that reported recently indicating that combined Xtandi (enzalutamide) and Taxotere (docetaxel) in addition to the GnRH agonist or antagonist therapy produced more side effects related to chemotherapy when we piled on an additional androgen receptor-directed therapy with the chemotherapy. Although the trial is done, and we see that people ultimately tolerated that more or less, because there was more toxicity and not a benefit to that triple-therapy approach, we’re not recommending that we do anything more at this point than chemotherapy with a GnRH agonist or antagonist. We’re not using a third androgen receptor-directed type medication in that cocktail, and that’s just to say that the more treatments that you add together, the more toxicity related to chemotherapy.
Is there anything men can do before getting chemo to prevent some of these side effects?
Dr. Morgans: One side effect I didn’t mention is that men can have some hair thinning. Usually, they don’t go completely bald, but they can have some hair thinning and some hair loss. Men can use a cold cap during each cycle of chemotherapy, which can reduce hair loss during chemotherapy.
I’ve had a number of patients whose job requires that they put forth a healthy image. We all want a healthy image, but for some men who work in financial spheres, trying to get people to invest in their companies, or if they work in investing, they have expressed to me that they can’t look sick, they can’t have hair loss.
They’ve used these cold caps and have not lost their hair. It’s impressive and surprising to me how effective the caps were for them.
That is something that they can do to try to reduce hair loss. Cold caps are approved for women with breast cancer who are receiving chemotherapy, and they also seem to work in men. They’re not always covered by insurance, but they can be really effective.
Cold caps were FDA-approved in 2017. You can read the FDA press release here: https:// http://www.fda.gov/news-events/ press-announcements/fda-clears-expanded-use-cooling-cap-reduce-hair-loss-during-chemotherapy.]
Other than that, it’s important that men do their best to stay active. The more active they are before chemotherapy, the better able they’ll be to stay active while they’re getting chemotherapy and to make sure that their bowels are moving as regularly as possible. Some of the medicines that we use for even mild nausea associated with chemotherapy can cause constipation.
Download the issue to read the rest of Dr. Morgans’ comments.