Article from the Memorial Sloan Kette... - Advanced Prostate...

Advanced Prostate Cancer
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Article from the Memorial Sloan Kettering Cancer Center and Cornell Medical College about multi-modal treatment of advanced disease.

This pilot study may be of interest to most of us since it shows that even with distant metastasis patients can achieve a PSA of 0 (non evidence of disease) if a multi-modal treatment is used.

ncbi.nlm.nih.gov/pmc/articl...

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A Pilot Study of a Multimodal Treatment Paradigm to Accelerate Drug Evaluations in Early-stage Metastatic Prostate Cancer

OBJECTIVE

To evaluate a multimodal strategy aimed at treating all sites of disease that provides a rapid readout of success or failure in men presenting with non-castrate metastatic prostate cancers that are incurable with single modality therapy.

MATERIALS AND METHODS

Twenty selected men with oligometastatic M1a (extrapelvic nodal disease) or M1b (bone disease) at diagnosis were treated using a multimodal approach that included androgen deprivation, radical prostatectomy plus pelvic lymphadenectomy (retroperitoneal lymphadenectomy in the presence of clinically positive retroperitoneal nodes), and stereotactic body radiotherapy to osseous disease or the primary site. Outcomes of each treatment were assessed sequentially. Androgen deprivation was discontinued in responding patients. The primary end point was an undetectable prostate-specific antigen (PSA) after testosterone recovery. The goal was to eliminate all detectable disease.

RESULTS

Each treatment modality contributed to the outcome: 95% of the cohort achieved an undetectable PSA with multimodal treatment, including 25% of patients after androgen deprivation alone and an additional 50% and 20% after surgery and radiotherapy, respectively. Overall, 20% of patients (95% confidence interval: 3%–38%) achieved the primary end point, which persisted for 5, 6, 27+, and 46+ months. All patients meeting the primary end point had been classified with M1b disease at presentation.

CONCLUSION

A sequentially applied multimodal treatment strategy can eliminate detectable disease in selected patients with metastatic spread at diagnosis. The end point of undetectable PSA after testosterone recovery should be considered when evaluating new approaches to rapidly set priorities for large-scale testing in early metastatic disease states and to shift the paradigm from palliation to cure.

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Diagnosed February 2016, 46 years old, Gleason 9 (5+4), PSA 286 with bulky disease in pelvic and abdominal nodes. Immediately placed on Lupron and Casodex and in June did 6 cycles docetaxel while on Lupron. December 2016 prostatectomy (preoperative PSA .51) with extended lymphadenectomy with removal of 42 nodes. Postoperative PSA <0.01 and as of today remains there.

Hitting this cancer hard from every angle while you are strong enough to handle it and while cancer is weak is paramount. Thank God there are doctors willing to break outside of the "safe" barriers and push beyond the way this disease has been treated since the 40's. If you don't have a team willing to try for a durable remission or possibility of a cure it's up to you to find one. I have found a necessary part of fighting this disease is making things happen for yourself. There are far to many hospitals not using these aggressive protocols because they are not backed up with scientific proof. That was the speech I got until I finally found a hospital that would.

Ron

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I agree.

I did something similar, when they refused any therapy for my lymph nodes metastasis in the pelvis and abdomen except for ADT (lupron and casodex) I went to Germany and I got treated with Lutetium 177 PSMA. PSA was 10 when I started the ADT and now is 0.09. Subsequent Gallium 68 PSMA scan showed no metastasis.

Best wishes

Raul

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Hi, Ron -- that is encouraging -- how may nodes were positive of the 42

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Out of the 42 nodes removed one tested positive. The scans showed several large nodes that actually ended up being scar tissue from where cancer was. Both chemo and hormone therapy cleaned up a lot of cancer before the surgery. Doc said the nodes removed looked like raisins because of the scarring. It was an open surgery and had no complications other than ED issues.

Ron

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Would I be correct in thinking my regime of Zoladex, plus Zytiga and Prednisone is considered multimodal? I only ask as it has been incredibly successful for me so far (6 years).

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I have the same question as TommyTV. I'm doing Firmagon plus Zytiga & Prednisone currently. No surgery or radiation at this point (long story). It sounds like a great idea of throwing everything at it in the beginning while you are the most healthy.

If it wasn't for this forum, I wouldn't have even known of the good results with what I'm currently doing. My MO agreed to do it but I'm the 1st one of his patients doing it all at the same time. (Thanks everyone!)

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Reading the posts above, I am wondering the following: If my husband's prostate was removed tomorrow, it would mean that the part of his body which was producing the primary cancer is gone, right? So no new prostate cancer cells could appear, right? And if then the metastases were treated with all the treatment options out there, would my husband be able to be free of cancer in the end?

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The problem with Stage IV prostate cancer is after a localized treatment (prostatectomy or radiation therapy) is done there are still cancer cells left in the system. New cells will appear if prostate cancer cells are left in the body to mutate. They could be hiding in the lymphatic system, blood stream, organs or bone. By using several different modalities it is upping the chances of getting at any cancer existing in those areas. For the best chance for this to happen the cancer should be in its weakest state and before cancer spreads further or becomes resistant to treatment. HT will not kill all the cancer, only suppress it however it does make it weak. There are peaks and valleys with this disease and only so many opportunities will present themselves. I was told the lower the PSA before treatment the better treatment will work. (.50 or lower is ideal)

There are several factors involved. A lot of it is timing, whether or not resistant cells exist, genetics, how much cancer, where it is located, the type and response to treatments. There are guys on here that I'm sure can explain it better but hope this helps.

Ron

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as the saying goes "TIMING IS EVERYTHING"...

Good Luck and Good Health.

j-o-h-n Sunday 02/15/2018 8:32 PM EST

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