My husband just was offered a similar approach. He has bone mets (ribs + 1 spine), 2 lymph nodes found in PSMA PET CT, T3B N1 M1, he is 60 years old, has atherosclerosis, but is very fit, BMI 21, body fat 12%.
They propose (Zurich Hospital Switzerland) radiation (33 days) + ADT at the same time for at least 18 months.
STAMPEDE showed advantage only for oligometastatic, but radiation was lower dose. This study in finland shows much better results.
Yes in 2011 I had 30 more radiations that was on my hips and prostate gland. In my case the cells in my bones had sunk into the bone leaving a pock mark (like acne). Since my androgens were close to zero these cells could not multiply and form tumors. It's like they were in a coffin. I assume most of them have died off of old age by now (6 1/2 years). I am on active surveillance to make sure I catch any changes from this. My PSA is 0.006 and my Testosterone level is 11 (should be 360). I am on no cancer therapy at this time.
Well everything is not OK, I went to my psychologist because I was depressed and asked him what he would recommend. He suggested that I stay away from mirrors!
Just to be clear...you had lytic bone lesions...prior to radiation...you were on Lupron and something else and your PSA was near zero.... How long were you on Lupron and whatever else before they took you off Lupron and put you on surveillance?? I ask this because after having RP, my PSA rose and at 3, I had axumin scan revealed one bone lytic met ....I got on Lupron and Zytiga within 10 days and had radiation within 2 months when PSA was near undetectable... Gleason 8... Looking for some info...It was Adenocarcinoma Acinar ...
OK I started therapy in 2007 with a raising PSA up to 72. So I started 42 radiations to the prostate area. Then my PSA went down to 0.54, and 1 year later 0.04. However, in 2011 I had increases in my PSA to 25.0. I also had a bone scan that found metastatic cancer in the bone on my hip. So my oncologist recommended 30 more radiations, 4 weeks of Casodex (to prevent a testosterone flair), and every 3 months a shot of Lupron (Eligard - generic). I stayed on Eligard for 6 1/2 years and PSA was 0.005. After 6 1/2 years my oncologist asked me if we could stop the Eligard and I could go on active surveillance. It has been 10 months since my last shot and my PSA is 0.006 now and T is 11.
Eligard stops the production of testosterone and other androgens. Without androgens the prostate cells can not multiply. So I am not on any medications for PCa and my testosterone will slowly come back. I see my oncologist in June and we will discuss this. Each prostate cell has an AR (Androgen receptor) and when an androgen comes near or touches it, cellular division begins. That is why Eligard is effective. Androgens are produced in the adrenal glands above the kidneys as well as the testes. Eligard works on both, unless someone's pituitary is resistant to sending out the hormone that stops androgen production. I have few daily side effects except weight gain and no desire for sex. I can masturbate and have an orgasm, but nothing comes out.
10 - 4 on shooting blanks..... Why do you like eligard rather than Lupron? I am making that decision right now. Now just on Cassodex only for 6 years but now have 6 bone mets. Also talking to a RO tomorrow at Mayo Scottsdale about radiating my mets.
Eligard does the same as Lupron but is less expensive. I used Casodex to stop a Testosterone spike when I started Eligard. Casodex does lower androgens but not as well as Eligard.
That is incorrect that the radiation was a lower dose in STAMPEDE. The biologically effective dose was about the same. The Finnish study does not have anything to compare their results with, so how can anyone determine that results were better? In fact, 3-year overall survival was about the same in both trials.
Commenting on the study, Oliver Sartor, MD, Cancer Research, Department of Medicine and Urology, Tulane University School of Medicine, New Orleans, LA, stated, "The end point deserves special mention, as the end point of undetectable PSA after testosterone recovery has been previously discussed but rarely studied. The authors proposed that this end point may serve as a first step toward establishing a curative paradigm. Many in the field agree, but note that the longevity of effect is essential to prove the point of curability. Regardless, the movement toward a curative paradigm is much needed and the investigators are to be congratulated for setting forth a paradigm that can be used to assess the possibility of cure in a reasonable period of time."
In that study, people received ADT for 6 months... what if it had been a year or two...
"This study has very exciting implications for patients with metastatic disease, in particular for those with only a couple sites of metastases," James B. Yu, of Yale Cancer Center and Smilow Cancer Hospital in New Haven, Connecticut, told MedPage Today in an email.
"I can envision a future where ever more sophisticated molecularly-targeted therapies and immunotherapies in combination with precisely targeted and non-invasive radiosurgery lead to the cure of previously incurable metastatic disease," said Yu, who was not involved in the study. "There will always be a role for locally directed therapy -- and as radiosurgery gets more precise (with improvements in patient tracking and tumor visualization) and easier to plan and deliver (with artificial intelligence-driven improvements in radiation treatment planning), treatment of multiple lesions will become commonplace."
I believe Dr. Yu is correct... the use of targeted therapies, immunotherapies, and radiosurgery...(add in some of the new sensitizer drugs not yet available) may provide an answer for oligometastatic disease.... I know you believe a ten year study is needed for prostate cancer to determine true efficacy... Until that is available, other trials like Dr Heron's at UPMC indicate benefit... Some just don't have time for a 10 year study...
I think you put in the wrong links - it is the same link twice.
I never recommended the SABR-COMET study because it
(1) only included 15 men with prostate cancer, probably none of whom died during the short follow-up. So it would be a mistake to draw any conclusions from it for PC, or to think that the behavior of any of the other cancers from which people died during that follow-up are in any way projectable to prostate cancer.
(2) Over 30% suffered serious treatment-related effects and about 5% died as a direct result of their treatment.
I don't understand what it has to do with PSA and testosterone levels - they didn't even measure those things.
FYI - the CORE study has completed recruitment, so we will get the results earlier than expected. As I've said REPEATEDLY, I have nothing against oligometastasis-directed therapy as long as it is SAFE to do so. I do believe there is a LOT of unsubstantiated hype about it, and patients have unreasonable expectations. In fact, there is currently no evidence that it accomplishes anything. Patients are well-advised to consider that before pressuring their ROs to give them possibly unsafe procedures.
I believe when the phase 2 trials are completed, there will be a much more data supporting what is in hand. As you said, the newer scans provide advanced lead time, which also may help in earlier treatment and extend OS...
As for my PSA, it was near undetectable-post Lupron and zytiga...it would be impossible to determine benefit, but I believe that earlier treatment may enhance OS... just my opinion... and I am betting on it...
Once again - no control group. And treating PSA is not the same as treating the cancer.
Actually - that's not what I said - I said use of better PET scans increases lead time bias - an apparent, but not real, increase in length of survival. This is a problem in trying to determine if earlier detection has any effect on survival. You have to compare apples to apples.
There is data that lower nadir from hormone therapy is prognostic for longer survival.
I get your point on the added lead time from better scans not really resulting in increased OS...took a look at the CORE trial... SOC vs SOC + SBRT--interestingly, they were looking to enroll those with 5-6 cm mets....Of concern is that it seems more about SE and QOL...hopefully, they will look at OS as intently.. Eventually, they will get to studies for people with early detected mets <2 cm... Thanks for the info on this trial...
3 year OS is more than 90% in the Finnish study, not really similar to STAMPEDE.
in the Finnish study they come first to undetectable before doing radiation, and they radiate mets too (also bone mets). A 8.35 year median survival for all metastatic patients (low burden AND high burden) is quite impressive, no?
The 3 yr OS was 81% among those with oligometastases who were debulked with radiation in STAMPEDE. The 5-yr OS in the Finnish study was 81% also - 3 yr was slightly higher, but in a different sample of men from the STAMPEDE trial. Unfortunately, the Finnish study does not break out low volume separately from high volume.
I do think 8.35 year median OS with mets is good but I don't know how impressive it is considering many of the men had their metastases detected with Ga-68-PSMA or other PET scans, which provided significant lead-time bias over the time from detection via bone scan/CT.
The problem with most such studies is their lack of a control group that would tell us what we can expect without the therapy.
The Finnish study says "all patients with high-volume disease", not sure what it means exactly, but radiopharmaceuticals were used to treat about 70% of the patients because they had relatively large and diffuse bone metastases, so high burden.
I agree for the lack of control group, but still... the 3 yr OS of STAMPEDE for all together (low burden and high burden) is far from the Finnish 81% OS at 5 years.
I mean, it goes in the direction that even high burden could have an advantage of a multi approach with radiation.
As I said, it's hard to know what to make of it when they used advanced PET scans to detect mets - how many extra years did it increase apparent survival vs if they used a bone scan/CT only, as in STAMPEDE? Is 8 years from the time of a PET scan/CT equal to 5 years from the time of a bone scan/CT? Who knows?
But I think that is an interesting tactic - using Xofigo, a systemic remedy, first; and then follow up with local radiation therapy to any remaining mets. We know Xofigo increases survival, and it seems to work better if used earlier. Combining Xofigo and Provenge may be a good combination.
Be careful with the cardiac issues...my husband needs a quadruple bypass (can't do it because of bone mets to sternum) after being on STAMPEDE. One shot of firmagon, two of Lupron + Zytiga. He was 62 at DX in late 2017, fit/thin, non-smoker, normal blood presssure, cholesterol, etc. First scan at DX showed mild calcifications that changed to severe after the second shot of Lupron. Firmagon shows less harm to the heart than Lupron, had we known we would have stayed on it, but we were not privy to that convo between the medical professionals at the time. If your husband has atherosclerosis he is "high-risk" for ADT.
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