Survival benefit to debulking the prostate with hypofractionated radiation in men with low metastatic burden

[Tall_Allen]

Findings of the "radiation arm" of the STAMPEDE clinical trial were presented today. They found that irradiating the prostate with hypofractionated radiation significantly extended survival, but only in men with a small number of distant metastases. Otherwise, it had no benefit - but docetaxel does!

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

[DeanNelson]

So this would benefit me as I only had one metz one my spine?

[Tall_Allen in reply to DeanNelson]

All we can say with certainty is there was a benefit in men with few mets. It's nice that it can be done in only 6 treatments.

[DeanNelson in reply to Tall_Allen]

THANK YOU!!!!

[Grace331]

Damn. I wish I'd learned so much before my husband had radiation last year.

[Tall_Allen in reply to Grace331]

It DID improve progression-free survival in everyone, so he may go longer without pain from new metastases even if it doesn't improve survival.

[Grace331 in reply to Tall_Allen]

Thanks Allen. Focus on the benefits since we can't undo what's been done...

[GP24]

Debulking did not provide a survival benefit if the patient presented with four or more bone metastases. So it does provide a survival benefit it you present with any number of lymph node mets or up to three bone metastases.

I guess they determined the number of bone metastases with a bone scan. If you would do a PSMA PET/CT I would expect that you see more bone mets than with a bone scan.

So you still have a survival benefit if the bone scan shows three bone mets and the PSMA PET/CT shows seven bone mets plus five lymph node mets? At least you may debulk the prostate and hope the study's results apply to you.

[Tall_Allen]

Yes - their division of men into low met burden vs high met burden is the definition used in the CHAARTED trial on early docetaxel. It is based on bone scan/CT, and not on any kind of PET scan. Remember, that this was across a population of newly diagnosed men, and there was variance across individuals. If you lit up like a Xmas tree on a PET scan but only 1-3 of them were visible on a bone scan, there MAY still be a benefit to local radiation, but each man must decide if it is worthwhile.

[GP24]

My suggestion in that case is to start with Docetaxel and ADT. After you recovered from the Docetaxel treatment, you can do the debulking and continue with intermittent ADT.

[Tall_Allen in reply to GP24]

CHAARTED showed that docetaxel ONLY increased survival in men with high met burden. STAMPEDE now shows that radiation ONLY increases survival in men with LOW met burden. Different therapies for different kinds of patients.

[teamkv]

By debulking you mean prostate removal right? Or is there a radiation debulking?

[GP24]

Allen writes in his blog:

The term "debulking" denotes the radical treatment (via prostatectomy or radiation) of the cancerous prostate after distant metastases have been discovered.

[Noel91]

Thanks for sharing as always. Would you think this could be applied to cytoredutive Prostatectomy as well? If not, are There any study going on about It?

Thank you!

[Tall_Allen in reply to Noel91]

You mean TURP? That's done for relief of urinary obstruction only as far as I know. I doubt there would be any survival benefit from it.

[Noel91 in reply to Tall_Allen]

Sorry for not have explained It.Cytoreductive prostatectomy is the type of surgery that removes the prostate and as much of the tumor as possible.My Father removal was in all the prostate área(he was T3B and also lymph nodes dissection.

I guess that radiation and Cytoredutive implies the whole pelvic area treatment.

Thank you!

[Tall_Allen in reply to Noel91]

Yes- Debulking is cytoreductive whether it is by surgery or radiation. The idea is to remove the source of the original metastases. In the STAMPEDE trial they did not treat the pelvic lymph nodes as well. The authors speculate that whole pelvic treatment may be curative. The article describes the ongoing clinical trials at the end.

[Noel91 in reply to Tall_Allen]

Thank you very much for explanation!

[henukit]

Thanks. Good and timely info. I'm meeting with MO tomorrow and will discuss panel's recommendations along with this new data. I think I'm on the verge of "low burden" definition: only 2 mets showed on the CT scan, but recent high resolution MRI showed few smaller ones all localized in the pelvic area. The prostate doesn't show any signs of tumor though, so not sure which it's better to go after: mets or prostate.

[Tall_Allen in reply to henukit]

Good luck. Please report back on how it goes.

[snoraste]

I'm surprised this news is not getting a bigger splash. More than 30% risk reduction in Oligo cohort deserves a lot more hurray.

This is the full text:

thelancet.com/journals/lanc...

There are a lot of disclaimers in the report as well - the fact that most of the patients were on single ADT therapy as SOC (82% of patients) may actually UNDERESTIMATE the benefits (there's a discussion by authors that says it did not make any difference, but I see a single Docx vs no-Dpcx chart that shows otherwise - no Abi whatsoever). The authors also realized the poor choice of definition for "low burden". Intuitively, if you have 4mets instead of 3, it is hard to imagine that your risk reduction drops to zero from 32%. There was also mention of combing thru the data and finding the right Mets response curve. I'm definitely looking forward to that analysis.

But at the very least, a new SOC is established for "Oligo" patients.

[MikeDonald]

I am 2 weeks into 4 weeks of radiotherapy - 20 sessions in all, following advice from my consultant. My treatment protocol following diagnosis in 2015 with a PSA of 348 has been

6 rounds of chemo - docetaxel, continuous 3 monthly injections of leuprolide, abiraterone since May 2017 and now the radiotherapy. Kitchen sink approach? Few side effects on any of the treatments so far and those that have materialised have been easily managed.

I guess I'm in a good place right now with PSA being undetectable for 18 months.

[lynnedrum in reply to MikeDonald]

Continued success! How many Mets did you have?

[MikeDonald in reply to lynnedrum]

Just the one in my spine - L3

[EdBar]

And one must keep in mind that they have yet to do a study on RT + ADT + Chemo + Zytiga/Xtandi so there may be a survival benefit when combining all of these early on.

My radiology oncologist was spot on when he recommended RT to my prostate despite being DX with metastatic disease over 4 years ago.

So far so good, PSA remains undetectable when using the combo listed above with Xtandi.

I wonder why FFS isn't considered as important as OS in this study, seems like one would lend itself to the other.

Ed

[Tall_Allen in reply to EdBar]

FFS is a much lower bar. One expects cytoreductive therapy (prostate or metastasis) to lower PSA because that is the source of most of the PSA. But treating PSA is not the same as treating the cancer. Cancer multiplies quickly and undetectable micrometastases will eventually become detectable. FFS is usually necessary condition (immunotherapy may be an exception) but it is not sufficient.

[j-o-h-n]

to TallunderscoreAllen: <===<<< TAKE A BOW!

Good Luck and Good Health.

j-o-h-n Monday 10/22/2018 6:45 PM EDT