Metastatic PCa [mPCa] & Radical Prostatectomy [RP].

[pjoshea13]

New meta-analysis below.

The old view is that mPCa requires systemic treatment, & that a RP adds no value & simply increases morbidity.

The new view is that cancer debulking can make the disease more manageable. If so, there should be a survival advantage.

From the new paper:

"The recommended therapy ... for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without chemotherapy. The role of radical prostatectomy (RP) in the treatment of mPCa is still controversial."

"Our results successfully shed light on the relationship that RP for mPCa was associated with decreased cancer-specific mortality ... and enhanced overall survival ..."

"In addition, patients with less aggressive tumors and good general health seemed to benefit the most. Moreover, no matter compared with {no local therapy} or {radiation therapy}, RP showed significant superiority in {overall survival} or {cancer-specific mortality}."

I don't suppose that Mark Scholz ("Invasion of the Prostate Snatchers") would be happy with that finding.

-Patrick

ncbi.nlm.nih.gov/pubmed/292...

Biosci Rep. 2017 Dec 20. pii: BSR20171379. doi: 10.1042/BSR20171379. [Epub ahead of print]

The role of radical prostatectomy for the treatment of metastatic prostate cancer: a systematic review and meta-analysis.

Wang Y1, Qin Z2, Wang Y3, Chen C3, Wang Y3, Meng X3, Song N4.

Author information

Abstract

The recommended therapy by EAU guidelines for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without chemotherapy. The role of radical prostatectomy (RP) in the treatment of mPCa is still controversial. Hence, a meta-analysis was conducted by comprehensively searching the databases PubMed, EMBASE and Web of Science for the relevant studies published before September 1st, 2017. Our results successfully shed light on the relationship that RP for mPCa was associated with decreased cancer-specific mortality (CSM) (pooled HR=0.41, 95%CI=0.36 to 0.47) and enhanced overall survival (OS) (pooled HR=0.49, 95%CI=0.44 to 0.55). Subsequent stratified analysis demonstrated that no matter how RP compared with no local therapy (NLT) or radiation therapy (RT), it was linked to a lower CSM (pooled HR=0.36, 95%CI=0.30 to 0.43 and pooled HR=0.56, 95%CI 0.43 to 0.73, respectively) and a higher OS (pooled HR=0.49, 95%CI=0.44 to 0.56 and pooled HR=0.46, 95%CI 0.33 to 0.65, separately). When comparing different levels of Gleason score , M-stage or N-stage , our results indicated that high level of Gleason score, M-stage or N-stage was associated with increased CSM. In summary, the outcomes of the present meta-analysis demonstrated that RP for mPCa was correlated with decreased CSM and enhanced OS in eligible patients of involved studies. In addition, patients with less aggressive tumors and good general health seemed to benefit the most. Moreover, no matter compared with NLT or RT, RP showed significant superiority in OS or CSM. Upcoming prospective randomized controlled trials were warranted to provide more high-quality data.

KEYWORDS:

cytoreductive prostatectomy; meta-analysis; metastatic prostate cancer; radical prostatectomy

PMID: 29263146 DOI: 10.1042/BSR20171379

[BigRich]

I debulked my tumor in 2003. I believe it bought me many additional years.

Rich

[E2-Guy in reply to BigRich]

I second 'BigRich's'post...RP in 2004, 4+4 GL, pre-op PSA 5.5, post-op PSA 0.03. It took 13 years for my PSA to climb to 1.1. Still no ADT. Should have had the culprit taken out many years before; just extra weight on the drag strip! My older brother was diagnosed with PCa when his PSA was 2.2; had an RP 17 years ago (no adjuvant therapy) and his PSA is undetectable today.

[BigRich in reply to E2-Guy]

I used to run C Gas at the drag strip, what did you run?

Rich

[E2-Guy in reply to BigRich]

Rich,

I was just joking; however, I did run my Triumph 650 Bonneville motorcycles back in the 60s. Best times were in the low 13s...nothing today, but back then even most of the really hot stock cars were in that range. My 62' Chevy 409 would do about the same. Hope you enjoy the holidays and wishes for a good 2018 plus many more years to boot! Cheers, Ron

[BigRich in reply to E2-Guy]

I am not playing can you top this; however, I had a 327 with solid lifters -, corvete cam and a possi 456 rear end and I blew away a 409 in a street drag. Should not have happen, but I could power shift, no clutch, did it by ear, did not blow the flywheel. While he was clutching, gave me almost a car length.

Rich

[BigRich in reply to BigRich]

PS the engine was stock before I did some minor changes, it stayed in a Bel Air 4dr sedan.

Rich

[Dr_WHO]

Thank you for the reference.

We must get out the word about the value of surgery even when the cancer has spread along with the results from the Stampede and Latitude trials. I am a perfect example. I have Ductal, rare form of prostate cancer that migrated to the pelvic area. Back in February 2016 I had to argue with the surgeon to operate even though it had spread. Had the surgery where they removed 14 lymph nodes in addition to the prostate (one node was totally transformed into cancer). That was followed by 38 rounds of radiation and Lupron with Zytiga added to the mix when the Stampede and Latitude trials were published. So far I am going strong.

I wish that everyone newly diagnosed with cancer knows about these updates!

[Break60]

I can see why this is controversial since mets are already evident. I was stage ptc1 at bx so had RP. Then I was staged pt3b ..not good. So I questioned my decision to have RP. But 4 1/2 years later I’ve only had 3 visible mets which I’ve treated with RT and ADT and my Psa is <.1.

So I can’t help but believe that debulking was helpful in slowing progression.

Has debulking in this setting been studied?

Bob

[pjoshea13 in reply to Break60]

Bob,

It's a relatively new idea in PCa. & with a new label: "Cytoreductive prostatectomy".

My own RP of 13 years ago failed immediately, so became, essentially, cytoreductive rather than curative. I'm glad to be rid of it, but I do miss the sex.

-Patrick

[Break60 in reply to pjoshea13]

Patrick

I miss it too but I only think about when dreaming.

Bob

[E2-Guy in reply to Break60]

I guess I'm lucky that along with losing that nasty prostate gland, I've also lost much of my libido! Now I'm better able to concentrate on what's really important without being interrupted by visions engendered by that stupid 'little head'. I find myself far more productive and also content with less. Instead of the need for fancy cars, a large boat and a big house, I derive satisfaction from living in my small condo, driving a five year old pickup truck, and playing with my cacti. When my buddies ask me if I miss the sex, I tell them it's like loving a scrumptious steak; however, if you've just had a nice chicken dinner, you really don't need the steak.

[Break60 in reply to E2-Guy]

To Ron

I too was overly focused on having orgasms to the point where I was losing my soul. So in a strange way PCa has saved my life. In may not end up being as long a life but it surely will have been a less guilty one with a better chance of entering the pearly gates 😇!

[BillNIttles in reply to Break60]

I consider the loss of my libido a huge positive advantage of being on Lupron. The other parts suck though, so I am taking a break. It will be interesting to see if my old distraction return.

[Dayatatime]

When I was first diagnosed I went with a rural upstate NY hospital and general oncologist. I was told the "once outside of barn door" BS and not knowing much myself trusted and listened to them. The more I educated myself and read I started seeing its just not the case anymore. My local docs were always telling me not enough science based evidence. I went to Roswell Park in Buffalo NY for another opinion, talked to their head Urologist and he basically told me I was a dead man walking. BTW after that experience I wouldn't send my dog there.

On this site I found a video posted of Mayo's Dr. Kwon at a 2014 conference talking about treating oligometastatic disease. I couldn't believe what I was seeing. I started digging and found even more about the benefits of localized treatment with metastatic disease mostly in European Urology.

I was diagnosed 2 years ago and the very FIRST doctor I consulted with said "only HT". I said what about early chemo and he replied "why would you want to do that to yourself". SECOND doctor "not enough fact based evidence to support benefits of surgery however made right move with chemo." THIRD doctor "Only radiation, quality of life issue if surgery" FOURTH doctor "Only HT, to much bulky disease in my nodes." FIFTH doctor "same as fourth, only HT."

After watching the video I had to give it one more try and purchased a plane ticket to Mayo in Minnesota. They offered me surgery to debulk the disease and fortunately there wasn't as much cancer as initially thought because early chemo and HT did some major damage to it. A lot of what was in scans was scar tissue where cancer was. Another benefit of surgery is to see what is actually going on in there. 1 year out from surgery I have no evidence of disease and 2 years ago I carried a Gleason 9 tumor and bulky nodal disease. Absolutely no way that could've happened without surgery.

I read a Go Fund Me Story about a man in Kentucky only last year that was opened up for a prostatectomy and surgery was stopped after finding it in his nodes. It actually made me angry to hear that happened to him. I agree with Dr. Who and word needs to spread. Its not always a cure but can add years to a mans life. If the procedure didn't work the major hospitals wouldn't offer it.

Ron

[Hidden in reply to Dayatatime]

Who was the doctor at Roswell? Mohlar, Trump, Guru, ... ???

I go there, and scouting info would be helpful.

[Dayatatime in reply to Hidden]

Guru. I mailed my records and scans to his office weeks before going and they were never looked at until I was in his office. The first words that came out of his mouth in a very agitated manor were "why are you here and who sent you". The man would barely let me get a word in when I tried to answer him. He then poked me in the prostate area and said "I operate here not here" as he poked me in affected lymph node areas. He then said he had to take a phone call leaving me with an intern fully knowing he wasn't coming back in.

I drove almost 5 hours for a visit that took 10 minutes with him and a half hour with an intern. The man didn't even have the courtesy to answer questions or look at my scans. His intern did all the talking, telling me HT was my only option and how bad my outlook was.

Guru is a robotic surgeon and considering the cancer I had in my nodes I understand an open surgery was needed. He still could have showed some compassion instead of making it very clear I was wasting his time.

I wouldn't change a thing because if anything he pissed me off enough to give me that much more drive. As a result I ended up with the best care I could ever ask for. As it is often said, everything happens for a reason.

Ron

[Break60]

I was fortunate to hear about Dr Dattoli from guys on the HealingWell site. He broke away from MSKCC in the 80’s because they were overly conservative. He set up his own prostatecancer center in Sarasota and treats only PCa with RT and Brachytherapy as well as HT. He treated Snuffy Myers and subscribes to Myers treatment theories. Outside the box treatment of all PCa including oligomets.

Bob

[Hidden in reply to Break60]

Good to know!

eMailed him regarding HDR. Do you know if he does HDR seeds?

[Break60 in reply to Hidden]

Not sure but his office is very responsive. He’ll do a free one hour phone consult.

[BillNIttles]

Hey Nal

I've been psa and tumor free for 17+ mos. and I am also taking a Lupron break. Had my last shot Dec. 8, hoping everything stays that way.

Take care

Bill

[snoraste]

It is astonishing the level of disagreement on this approach even within the same practice. My MO believes there's no survival benefits at all, but after doing some research, I insisted on having a urology consult. The urologist (from the same practice, mind you) suggested I should definitely do it, despite the fact that there has not been a clinical trial to establish the benefits.

His point was that setting up a randomized clinical trial in surgery is far more difficult than the medicinal ones. We may never get the comfort and rigor of a randomized clinical trial in this case.

Another point is that these observational data are mostly prior to the more aggressive treatments that are now the standard of care. Combining the local therapy with the new and more aggressive systemic therapy should deliver an even stronger punch.

So, I have put my money where my mouth is and

scheduled my RT surgery for April -

[Dayatatime in reply to snoraste]

Snoraste,

A few things I recommend are to get your PSA as low as possible before your surgery. Studies have shown the lower it is the better the outcome. .50 or lower is ideal. The lower the PSA the weaker the cancer. This is where you need a specialist to help make that happen for you. I actually did it by just adding Casodex to the Lupron I was already taking.

Not sure who you are seeing but make sure your going with a surgeon that is very experienced in this game. Look at it like a carpenter building your dream house. Would you choose one that only built a few or many. There can be some pretty serious side effects if not done properly.

Your only going to get one shot at this so make it count. Good luck and hope all goes well for you. Feel free to email me with any questions and Ill help best that I can. Lots of guys on here that have great advice on what to expect after surgery.

Ron

[snoraste in reply to Dayatatime]

Points well taken Ron. I’ll be doing this at MSK. The surgeon was of your opinion: continue for 3-4 months on ADT+Zytiga and then do the surgery. My PSA dropped to 1.5 last week, so planning to keep it there.

I’d appreciate to hear about your experiences - the surgeon tells me 2-8 months incontinence (depending on person) and ED which I’m already addressing, knowing what’s coming ahead.

-Shayan

[Beermaker]

I have been disappointed about the lack of people with APCa doing a debulk. Before my radical prostatectomy I had a PSA of only 6.2, but showed 4 lymph nodes that were suspicious on my CT scan. My PSA fell to 0.19 after the RP, but based on everything that was remove being cancerous with positive margins, I was put on Elligar (Lupron.) PSA fell to <0.01.

One year later, my my urosurgeon / oncologist put me on a ADT vacation. It failed within a year with PSA hitting 10.2, They put me on Trelstar, which is another ADT drug. I have been undetectable for about 4 years since. Those four nodes are still there, but latest scans have not shown them. I will have another CT scan in 6 months which is supposed to show more mets if the they are there.

At the RP debrief I was told my PCa was "particularly aggressive" and needed close attention. After 6 years with PCa after the RP, I firmly believe the debulking has kept me where I am today. More studies need to be done, but I would push for debulking. Every patient is different and it might not help the next one. More studies are needed for sure.

~ Marshall

[4tran4]

I am newly diagnosed, 68, Gleason 9, stage 2n1b0. PSA 55. CT and Axumin scans show only one lymph node positive. Bone scan negative. At first I thought radiation might be better based on QOL considerations but my doctor (Martin Sanda of Winship Cancer Instiute at Emory) convinced me the surgery would give me more options:

1) he believes in the debulking theory although he concedes the jury is still out.

2) during surgery they will do a super extended lymph node dissection (about 40) hoping to get it out of me or at least know precisely how far it has spread. You really don’t know anything after radiation because they can’t do biopsies of the lymph nodes.

3) he’s candid that radiation sometime afterwards is likely.

4) I asked about drugs before surgery but he didn’t believe that had been shown to be effective yet.

5) if I’m lucky, surgery will forstall the day I have to start ADT, which I am dreading.

Surgery is scheduled for next month.

[pjoshea13]

Although, when there is any degree of metastasis, surgery is not considered to be performed with 'curative' intent, it seems to me that you have a good chance of a durable remission. I doubt that I could have found a doctor such as Martin Sanda 14 years ago. Good for him

IMO, ADT is always best deferred. Too many men have been rushed into it in the past, only to have it fail within 2 years. There is a case for short-term ADT while waiting for surgery, however.

Best, -Patrick