No survival benefit to debulking the ... - Advanced Prostate...

Advanced Prostate Cancer

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No survival benefit to debulking the prostate with radiation in first randomized clinical trial

Tall_Allen profile image
24 Replies

This is very disappointing. It did not make any difference whether the patients were oligometastatic or polymetastatic or how high their initial PSA was. But there are some caveats:

• The radiation dose was low (70 Gy)

• Whole pelvic radiation was not allowed

• Brachy boost therapy was not allowed

• They did not include the systemic therapies (Taxotere and Zytiga) proven to increase survival when used at the time of diagnosis

Here's a discussion:

pcnrv.blogspot.com/2018/09/...

24 Replies
cesanon profile image
cesanon

Allen, thanks for the article.

Noel91 profile image
Noel91

Thanks for sharing Tall Allen, It is very dissapointed for those Who chose debulking like we did. Let's wait for the new clinical trials stil going on to see how new meds help in survival.

in reply to Noel91

ar.iiarjournals.org/content...

Look at this study, quite good results!! But they did also ADT (even before radiation)

Noel91 profile image
Noel91 in reply to

Didn't see that before thank you!

Dayatatime profile image
Dayatatime

All had bone mets, all went into it with PSA >20 and no specific age other than younger than 80. Targeted localized therapies have a best result when PSA .50 or less. Might be very possible debulking works in a patient of a different prognosis such as nodes or limited bone mets. This wasn't a huge trial and the amount of men with limited mets would not be a significant number. This is only 432 of thousands with this disease most of whom never received aggressive multi-modal therapy. Could have made a difference with early chemo or HT given for a duration before radiation treatment.

Tall_Allen profile image
Tall_Allen in reply to Dayatatime

This WAS sufficiently powered to detect a difference if there was one. You can read about how they determined the sample size, and they are right. I don't think anyone presenting with detectable bone mets has a PSA of 0.5 or less. It only apples to men with the most common kind of metastatic spread, which is to the bone.

Dayatatime profile image
Dayatatime in reply to Tall_Allen

I understand a PSA of 0.5 is not common among anyone with detectable bone mets. My point is any localized treatment is going to work better with a lower PSA. That's where a good Oncologist comes in to hopefully get it as low as possible before administering. It is not unheard of to bring it down to a much lower point than 20. I only wanted to point out the nodes because the title can be misleading when first looking at it. There are so many variables with treatment that I think it's important to point that out. I wouldn't rule anything out with mets because one trial shows no benefit. I'm sure it wouldn't take much research showing the opposite is true as well.

Tall_Allen profile image
Tall_Allen in reply to Dayatatime

That's why I provide a link to my article about it. Men starting with lower PSA did no better with prostate radiation in this study. Of course, their PSA usually got below 20 when they started on ADT. There has never been a trial of this quality before, only observational studies.

in reply to Dayatatime

I was wondering why in the finnish study they did first HT (and if necessary chemo) before radiation to get to a very low PSA if possible under 1. ar.iiarjournals.org/content...

From where do you have the notion that "Targeted localized therapies have a best result when PSA .50 or less"?

Dayatatime profile image
Dayatatime in reply to

I consulted with a Possessor of Radiation Oncology from MD Anderson named Deborah Kuban. She stated the lower the PSA before any primary treatment the better. The weaker the cancer the better the effect localized treatment will have. She told me .50 or less is ideal. This would hold true for both radiation and surgery. Think of it as kicking it while it's down.

in reply to Dayatatime

Makes sense..

henukit profile image
henukit

Timely info. I'm just at this stage freshly treated per CHAARTED with excellent response and thinking about what's next. MO is pitching multi-modal de-bulking, but looking at this trial I have so many doubts.

in reply to henukit

ar.iiarjournals.org/content...

henukit profile image
henukit in reply to

Thanks!

Tall_Allen profile image
Tall_Allen

This trial just came out. You might want to email your MO the link to the research and ask for his opinion. There are several important caveats that are being investigated in ongoing clinical trials. With docetaxel pre-treatment, Zytiga along with Lupron, multimodal radiation including whole pelvic radiation (or surgery + ePLND), and SBRT to known mets, there may be some benefit. It's very much a judgment call.

henukit profile image
henukit in reply to Tall_Allen

Ok forwarded. They are going to present my case on the next panel, so all staff physicians will be present: MOs, RTs, surgeons etc. We'll see what they say.

Thanks for posting this.

patandemma profile image
patandemma

maybe the followup period is too short to demonstrate a difference in survival b/c you're dealing with prostate cancer as opposed to,for example, pancreatic cancer (a far more rapidly lethal disease)

In other words,the shorter the followup,the less likely a difference in mortality would show up.

Tall_Allen profile image
Tall_Allen in reply to patandemma

The median f/u period here was 4 years among men who were metastatic on a bone scan. More than half the men in both arms had died during that time, so it was long enough.

gourd_dancer profile image
gourd_dancer

Everybody is different, but 15 years ago I fried mine with seeds and IMRT, killing a lot of cancer cells along the way. As soon as it turn systemic with a year, I poisoned the cancer. Along with Lupron for an additional five years, I seem to be ok. Undetectable.

My only comment is that with a lot of restrictions in an incremental trial, sometimes, one gets the answer they were expecting. That said, my six month hormone-chemotherapy, did well for me.

GD

Tall_Allen profile image
Tall_Allen in reply to gourd_dancer

You don't understand what "debulking" means. I guess you did not read the article where it was explained. It means treating the prostate AFTER metastases have been discovered. They were expecting the answer to be the opposite, based on earlier observational studies.

gourd_dancer profile image
gourd_dancer in reply to Tall_Allen

Allen, I read it. The reason, my PSA never came down is that I well on the road to metastatic PCa with micro-metastates. I mattered not which primary treatment I chose, it was too late. Borderline yes, but screwed none the less.

GD

in reply to gourd_dancer

I am new here!!! Please explain to me your treatment!!!... My love has was diagnosed with advantages stage prostate cancer in August 2018. He is 51 years young. His is on lupton and zytiga, and zymita for the bones. Cancer has spread to spine, lymphnodes, and small shots on his lungs... Please help!!!

gourd_dancer profile image
gourd_dancer in reply to

It was a six month trial. The protocols are posting under my previous posts. Or google, Gourd Dancer Advanced Prostate Cancer

Crabcrushe profile image
Crabcrushe in reply to

How is he?

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