Patients frequently ask their physicians, “Am I stage A, B, C or D,” without realizing that the original purpose of a lettering system was simply to guide urologists in the selection of candidates for surgery. While stage matters, a combination of PSA level and the Gleason grade is a better way to assess disease status. So rather than using stage, it’s best to incorporate all three factors together—PSA, Gleason and stage—to divide prostate cancer into five broad categories or Shades of Blue.
Using standard doctor terminology, the AZURE Shade of Blue is essentially the same thing as “High-Risk” prostate cancer. “Risk” refers to a higher probability of relapse after surgery or radiation compared to men in SKY or TEAL shades. Therefore, men in AZURE are usually treated with combination therapy consisting of IMRT, a seed implant and testosterone inactivating pharmaceuticals (TIP) for 18 months.
Here are the specific factors that define AZURE.
1. No previous treatment with surgery or radiation.
2. Bone and body scans without metastasis.
3. One or more of the following three factors:
a. PSA above 20 and less than 100, or
b. Gleason score above 7, or
c. A prostate tumor felt by digital rectal exam extending across the midline of the gland or outside the capsule.
Men with two or three of these factors are still classified as AZURE. Men with spread to pelvic nodes are classified as INDIGO. Men with metastasis that has spread to bones or to nodes outside the pelvis are ROYAL. Radiation—rather than surgery—is the preferred treatment for AZURE because of the risk for cancer infiltration outside the prostate. Safe surgical removal is next to impossible when the disease extends into surrounding organs. Incomplete cancer removal means radiation will be required to “mop up” the residual cancer anyway. Therefore, most experts recommend radiation because the risk of needing both surgery and radiation is so much lower.
Within the AZURE category exist subcategories of men who have a relatively more advanced type of AZURE. For example, some men have larger tumors, higher PSA levels above 40 and Gleason grade 9 or 10. Men in this situation might want to try to further enhance their cure rates by adding a more potent form of TIP such as Xtandi or Zytiga to their therapeutic plan. Also, a short course of Taxotere chemotherapy can be considered.
My last blog (about TEAL) reviewed potential side effects from surgery and radiation. The side effects of TIP become more severe when treatment duration is prolonged. The three most troublesome TIP-related problems are low libido, weight gain and fatigue. However, libido recovers after TIP is stopped. Weight gain and fatigue can be reduced with diet and exercise. Yet as we all know, maintaining a consistently good diet and getting adequate exercise over long periods of time can be very challenging. Obtaining professional support from a trainer or a physical therapist is one way to sustain a disciplined program on an ongoing basis.
Other common TIP side effects can be controlled with medications. Hot flashes regress with a low-dose estrogen patch. Calcium loss from the bones can be prevented with an injection of Prolia every six months, a Fosamax pill weekly or with an Actonel or Boniva pill monthly. Mood swings can be reduced with low-doses of an antidepressant called Effexor. Effexor also has salutary effects on hot flashes. Breast growth can be prevented with an estrogen-blocking pill called Femara. When libido is chronically low, men tend not to care about getting erections, so taking daily Cialis should be considered standard for men receiving TIP.
Unfortunately, many doctors have limited knowledge about how to prevent TIP side effects. Patients, therefore, need to protect themselves by getting as much education as possible. Certain side effects, such as breast growth, erectile atrophy and osteoporosis, are preventable with appropriate intervention. However, once they are allowed to occur, these effects can be permanent.
While side effects are an important consideration, men in the AZURE group have a relatively more dangerous type of prostate cancer compared to men with SKY or TEAL. The appropriate treatment stance, therefore, is to be aggressive—to get cured.
The good news is that the majority of men with the AZURE stage of prostate cancer will be cured with the treatment approach outlined above. Studies have shown that the best results come from using IMRT, radioactive seed implantation and testosterone inactivating pharmaceuticals (TIP) in combination with each other.
So if you do find yourself in the AZURE zone, don’t despair: There is good reason for hope.