Local treatment & metastatic prostate cancer

[pjoshea13]

Two new papers [1] [2] below.

Before my radical prostatectomy [RP] in 2004, I was warned by the surgeon that if there was lymph node involvement. the operation would be aborted. This was, in fact, the fate of his second patient of the day, who had "less serious" cancer.

Given that my RP was immediately unsuccessful, the obvious question is - did it have any value? In those days, the feeling was that it wouldn't. The second man survived that day with his sex life intact, & presumably began ADT. I wonder how he has fared?

In 2006, from a Mayo study [3]:

"The results of the present study have provided some evidence that radical prostatectomy may be of benefit to patients with Gleason score 10 PCa."

I was told that one should not expect RP to cure a Gleason score [GS] of 8-10. The literature of the time suggested that my GS=4+3 was the highest GS that offered any chance of a cure, & that I shouldn't be thinking RP if GS was higher.

Survival is a different matter. In a recent vblog post, Dr. Myers states that less cancer is always better.

Over the years, there have been studies on the interplay between the stroma & epithelium in the prostate as PCa develops. It's the epithelial cells that represent PCa. With RP, you lose all of the stromal cells, of course, but not the cancerous epithelials that have already escaped. I came to the conclusion that some nasty stuff involving stromal cells was perhaps a good reason to ditch the prostate. The barn door analogy isn't a good one.

Discussion about lethal PCa usually focuses on metastases, as though an intact prostate is no longer of significance when there are mets.

The subject of this post is whether local treatment has any value when there are already known mets. It's the ultimate question & it seems that there is benefit. I wonder how many aborted RPs there have been? Maybe it still happens?

[4] (2015 - Germany) "Local treatment appears to improve oncologic outcomes in metastatic prostate cancer patients. Nevertheless, due to the lack of high-quality evidence, its role needs to be confirmed in future prospective trials."

[5] (2015 - U.S. / Canada / Italy) "Among metastatic prostate cancer patients, the potential benefit of local treatment to the primary tumor depends greatly on tumor characteristics, and patient selection is essential to avoid either over- or undertreatment.

[6] (2016 - U.S. / Germany) "Men with mPCa at diagnosis benefit from LT in terms of OM. This is largely affected by baseline characteristics. Specifically, patients with a relatively low tumor risk and good general health status appear to benefit the most."

Which takes me back to 2002 [7]: how does local treatment affect survival when mets ultimately appear?

"Previous radical prostatectomy in patients with metastatic prostate cancer was associated with a statistically significant decrease in the risk of death (hazard ratio 0.77 ...) relative to those who did not undergo earlier prostatectomy. "

In the new papers:

[1] (2016 - Italy) "Not all patients with metastatic PCa share the same prognosis, in which selected individuals with oligometastatic PCa might benefit from local therapies. These men would harbor a biologically different disease as compared with their counterparts with widespread metastases. Local treatment would eliminate the source of tumor-promoting factors, destroy the origin of metastatic cells, and stop the self-seeding process. Moreover, decreasing tumor burden would eventually allow for an improved response to systemic therapies. Recent clinical studies support an oncologic role of surgery or radiotherapy in metastatic PCa.

[2] (2016 - U.S.) "In this large contemporary analysis, men with mPCa {metastatic prostate cancer} receiving prostate RT {external beam radiotherapy } and ADT lived substantially longer than men treated with ADT alone."

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/273...

[2] ncbi.nlm.nih.gov/pubmed/273...

[3] ncbi.nlm.nih.gov/pubmed/169...

[4] ncbi.nlm.nih.gov/pubmed/249...

[5] ncbi.nlm.nih.gov/pubmed/252...

[6] ncbi.nlm.nih.gov/pubmed/271...

[7] ncbi.nlm.nih.gov/pubmed/121...

[CERICWIN]

At least having the prostate out, even if there were already some small mestastases, having the cancerous organ removed, it is no longer sending out legions of cancer cells, so at least it will slow the progression somewhat. Had the prostate remained in situ, it would still send out cells throughout the body.

In my case, they couldn't remove the prostate, as it had grown so huge that it was invading the bladder and pressing into the colo/rectum wall, and surgery would have meant removing the bladder and a colostomy. I was depressed that the cancer couldn't be cut out of me, and in addition, I have metastases to spine, sacrum and "innumerable" pelvic lymph glands.

So you need not regret the prostatectomy---I feel that it's increased your survival time.

Too many guys don't think about what would have happened if they hadn't had a prostatectomy---they are so upset about having incontinence and ED problems, and lose sight of the fact that removing the prostate has probably saved their lives.

CERICWIN

[EdMiller]

Thanks for posting!

[jgmcbride]

I too personally chose the RP route. I felt it best to remove as many cancerous cells as possible. My RP was followed by radiation treatment and then by ADT. This was six and a half years ago and so far there has been no reoccurrence. I knew that I would be giving up a sex life and suffer some incontinence. I figured it was a good trade off and am glad to have gone this route. I am knocking on the door of 73.

[Dr_WHO]

I have advanced prostate cancer (G8 4+4) with CT scan showing it had migrated to the pelvic lymph nodes. The surgeon at first did not think surgery was the way to go, but I convinced him. Had DaVinci surgery on April 18, 2016 where he removed 15 lymph nodes along with the prostate (73 grams). Pathology report showed that it was a rare form of ductal cancer that effects just 0.4% and that one of the lymph nodes was "100%" cancer. PSA four weeks post surgery was 0.1. Six weeks out is was <0.1%. Started hormonal therapy and will start external radiation once I regain better bladder control. That may still be months away.

For me the operation was worth it, even with the side effects. Finding out it was a rare form of cancer is helping my team customize my treatment. Without the prostate the PSA measurement has more meaning. I was having some luck in the intimacy area using Trimix but that stopped once I started hormonal treatments. Still leaking about seven weeks out but the amount is about 1/3 what it was (~100 grams vs ~300 grams - the surgeon is having me measure the amount for a study).

[Hidden]

2003: radical prostatectomy aborted following discovery of 2 positive lymph nodes. Recommended new therapy was radiation at local hospital. Second opinion at nearby Comprehensive Cancer Center resulted in neoadjuvant hormonal therapy with Casodex and Zoladex, wait 4 months then radical prostatectomy which included extended lymphadenectomy - 6 positive of 26 nodes removed. Gleason 4+3, T3b, Mx, age 59. Several recurrences but excellent quality of life other than no sex (attitude adjustment: no sex first 20 years of my life was ok so if none the last 20 years, I'll survive....if I live that long). Now 71, June 2016 and being treated for slow progression with bone mets and docetaxel therapy. Still hopeful and believe the RP helped get me this far. Would like to get to 78-79 as observation shows the 80s not too good.