Twitter

[Blair77]

I look on Twitter daily with the hashtag " metastatic prostate cancer" the following feed has been flooding all day. It's toted as being a " potential" cure for metastatic disease using multimodal therapy. It's from a reputable source being retweeted by other reputable sources. Thoughts?

[Dan59]

Blair, I am unable to follow the links as they here, can you make a link? Thanks, Dan

[Blair77]

dx.doi.org/10.1016/j.urolog...

[Dan59]

I had not seen this study, but it would appear to represent a paradigm shift in the way advanced Pca is handled at diagnosis. After 10 plus years surviving high grade M1B (spread to distant sites in bones) I always had a feeling that debulking the primary tumor was the best way to go,But no Doctor thought it was worth it, ( I suppose they all thought I would be dead in 2 yrs) this article seems to say that multimodal (surgery, adt, and radiotherapy in metastatic prostate cancer produces the best results, of 20 men with metastatic disease 19 achieved undetectable with the multimodal approach. This study appears to be out of Memorial Sloan Kettering as that is where many of them practice . Thank You.

Dan

[AlanMeyer in reply to Dan59]

Dan,

If my interpretation of the study is right (see my reply to the original posting), it does not provide any evidence in favor of debulking the tumor burden. I think they were trying to destroy ALL of the tumors, not remove part of them - which is what debulking does..

I think we still don't know if debulking works. I've been suspicious of it myself. I've always wondered if the theory was promoted by surgeons or rad oncs who make their living doing surgery or radiation and want to do more - possibly convincing themselves that this was in the interest of the patients.

I also wonder why debulking would work. If you have metastases in your lungs, bones, heart, brain, liver, or other vital organ that are going to kill you, why would cutting out the prostate (which won't kill you) help?

There certainly seems to be no medical consensus on debulking, though I think most docs oppose it. I don't know that we have enough empirical evidence for or against it yet.

[Dan59 in reply to AlanMeyer]

I guess I was just thinking of the importance in every study I have seen of achieving undetectable psa, a complete remission as soon as possible, in regards to survival. Dr Myers speaks of the importance of achieving a complete remission in all cancers in his book. I myself never did achieve undetectable psa, as it nadired at 3. 9 years ago.

[Blair77 in reply to Dan59]

Dan59 I think your results are amazing!

[Dan59 in reply to Blair77]

Thanks Blair

[AlanMeyer in reply to Dan59]

I agree. Complete remissions are what everyone wants. I also think the techniques that Memorial Sloan Kettering was reporting in this paper constitute progress. It used to be thought that only men with organ confined (i.e., all inside the prostate gland) cancer could be completely cured. MSK and others are showing that some men with metastases, but not too many, too large, or too inaccessible, can also be cured or at least put into long lasting remission.

That's not the end of prostate cancer, but it is progress.

And by the way, I think Blair is right. Your own results are pretty amazing.

Alan

[Dan59 in reply to AlanMeyer]

Thanks Alan

[Hidden in reply to Dan59]

I myself have no visible signs and -a negative PSA for 1 yr now .That is short time in my saga.No one has even mentioned those words, ""Complete remission"" to me..I'm scared of using those terms for myself...maybe if I had no signs for 7 or more yrs Id feel differently.I believe everything hinges on how advanced and how aggressive your disease is when you find out of course.My gut tells me however, that this is a lifetime project ,and I can never stop and return to my old ways and sugar habits..As P. C. Contenders we can never stop striving for better health.

[Dan59 in reply to Hidden]

The National Cancer institute definition of complete response is : "The disappearance of all signs of cancer in response to treatment. This does not always mean the cancer has been cured. Also called complete remission. "

[Hidden in reply to Dan59]

Cure is a big word

[AlanMeyer]

I think this study is easy to misinterpret.

A key point in this study is that the men were "oligometastatic". What that means is that they had a very small number of metastases (like 1 or a few). I think that ALL of the cancer sites were treated with surgery or radiation. 95% of the patients achieved an undetectable PSA, but, so far, 16 are still undetectable. Four have had a rising PSA, at months 5, 6, 27+ and 46+ months.

Is this a good outcome? Yes, I think it's great. It's the same thing that Mayo Clinic has been reporting in connection with their C-11 choline scans.

Only a minority of metastatic patients are "oligometastatic". For those, the work at Mayo, MSK, and some other hospitals where they do these kinds of treatments, can be effective.

It's progress, but it's not a cure for everyone, or even for most metastatic patients.

Alan

[leswell in reply to AlanMeyer]

Thank you for removing the guilt for not banging on Mayo’s door when you know you’re not oligometastatic.

Question, Alan. Why isn’t everyone with numerous bone metastases taking Cabozantinib? Scans in the NYTimes picture some scans with total removal.

[AlanMeyer in reply to leswell]

I don't really know anything about cabozantinib, so I looked it up and found this Phase III trial result:

ascopubs.org/doi/abs/10.120...

It looks like many other cancer drugs in producing a relatively small average gain (1.2 months in this study) in overall survival and a relatively large risk of serious side effects (71% in this study, 33% causing people to drop out.)

However, you never know. Sometimes a drug that provides a small average benefit provides a big benefit to some patients. What we need with all of these kinds of drugs is a better understanding of how to tell who will benefit and who won't before we administer the drug.

Alan

[leswell in reply to AlanMeyer]

Since we are both 78 this year, 71% of the participants having serious side effects is a bigger risk than we would take. Chalk my cavalier question up to wishful thinking about eliminating bone mets. (It’s something I should have looked up myself.) Down Les’s PCa road it’s more likely to be cabazitaxel than cabozantinib! Thanks for the Phase III trial link. “Amen” to your last sentence. The day will come when liquid biopsies will be routine and inexpensive.

Mrs. S