Treating Non-Metastatic Castrate Resistant Prostate Cancer | Ask a Prostate Expert, Mark Scholz, MD

PCRI's Alex asks Dr. Mark Scholz, a medical oncologist specializing in prostate cancer, all about the "M Zero" (M0) stage of prostate cancer. This is a specific stage of prostate cancer in which a man develops a rising PSA while on hormone therapy, but wherein there are no visible metastases outside of the pelvic lymph nodes.
0:07 What is the "M Zero" (Non-Metastatic, Castrate-Resistant) space? The M0 space occurs when a man who has previously been treated has relapsed, begun intermittent hormone therapy, and then the PSA begins to rise despite the man having a low testosterone, but there are no metastases visible on scans.
1:39 Does a clear scan and a rising PSA mean that micro-metastases exist? The prevailing thought is that there is micrometastatic disease.
2:03 Does non-metastatic cancer have symptoms? There may be side effects from treatment, but not from the disease.
2:25 Are drugs like Xtandi, Nubeqa, and Erleada being used on non-metastatic castrate-resistant patients? Yes, some of these drugs have recently been approved for the non-metastatic space, and they may even be more effective in this space than in the metastatic space.
2:59 What are the effects of these new drugs on the treatment of M0 patients? They can delay the onset of metastases for around two years.
3:29 How are Erleada, Xtandi, and Nubeqa different from Zytiga? Zytiga bocks the chemical synthesis of testosterone inside the cancer cell whereas Erleada, Xtandi, and Nubeqa block the androgen receptors.
4:10 What are the differences between first-generation and second-generation hormone therapies? First-generation hormone therapies stop the testicular production of testosterone, and second generation hormone therapies are designed to stop the production
4:59 Are second-generation therapies associated with the same side effects as first-generation ones? Are they more intense? The side effects are not necessarily more intense, but the second generation medicines do have some potential unique side effects that men need to be aware of. Zytiga can cause irritation of the liver and a change in potassium levels that need to be monitored. Xtandi has been associated with more fatigue, and Erleada has been associated with rashes.
5:47 Where in a patient's sequencing (or order of treatments) should Provenge be used? While it may be ideal for a man to use Provenge early in the M0 stage, insurance companies have only approved Provenge for men with visible metastases. Some men in M0 may have visible lymph node metastases in the pelvis, and so that would qualify him to receive Provenge, but otherwise, men will have to wait until metastases begin to develop before they can have Provenge covered by insurance.
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[@gavinfoster9118]

A very informative discussion.
Thanks for the update

[@tropypelle2689]

Is sex advisable during active surveillance?

[@sputnik8407]

So these drugs also cause testosterone to be low ? Or can testosterone be normal ? Thank you !

[@ThePCRI]

I am not sure if second-generation anti-androgens, alone, would lower testosterone or by how much, and our helpline may be able to help with that question (pcri.org/helpline) however, I have only ever heard of them being prescribed alongside standard hormone therapy which stops testosterone production in the testicles.

[@sputnik8407]

@@ThePCRI Thanks