Anyone have a RP with metastatic prostate cancer?

[BarronS]

I've been reading some exciting things cryoreductive surgery in people with metastatic prostate cancer - even hormone resistant. It seems that people who have lower tumor burden (most defined by <5 bone mets. Although a few studies are indicating lower tumor burden as <10) and see a reduction of their PSA to <4 at 7 months are seeing the most benefit.

I was wondering if anyone on this message board has had their prostate removed after the detection of metastasis. What has been your journey? Has this seem to made things better for you?

Everything I have been reading is very promising and suggests that removing the prostate, even after metastasis, is extremely beneficial.

[BarronS]

I've read a lot of your posts and I saw that you had it done with a gleason score of 9. I'm not a research scientist, so I'm probably way out of my league with what I'm going to say.

But I would think that if you had a gleason score of 9 in the prostate, that doesn't necessarily mean that the prostate cancer that has spread to the bone would be a gleason 9 cancer. Maybe it's a lower grade cancer and would not spread quickly and could be put into remission longer. I would think that getting rid of the primary tumor would help stop the seeding of G9 disease into the rest of the body.

It seems that some clinical sites have seen an overall survival at 5 years between 49 to 70 percent. This is compared to an overall survival of 29 percent for those who have not had the prostate removed. I'm surprised that this isn't game changing yet. I know that more studies need to be done, but it just seems obvious that removing the primary tumor would be beneficial.

[Tall_Allen]

We only have reliable data on radiation of the prostate. (Although results aren't likely to be much different with surgery.) STAMPEDE showed a survival benefit when there were 3 or fewer (not 5) distant metastases. None of the studies used 10 as the number of metastases. I should mention too that Dr James (one of the study authors) cautioned me that the subgroup analysis was underpowered to detect the relatively small difference (not "extremely beneficial"). PSA will certainly decrease from such treatment (because most of the PSA comes from the largest tumors), but fiddling with a biomarker is not the same as increasing survival.

[BarronS in reply to Tall_Allen]

I wasn't going off the stampede trial. I was going off other research that indicated 5 year survival rates of up to 70 percent in some clinical settings. Selection bias could have accounted for some, but it seems that much of the research is pointing it to be very beneficial.

When dealing with oligo metastatic disease, many of the new studies are now defining it as 5 or less bony mets. I believe I saw around 10 new research studies that are recruiting and the majority of their criteria to define oligo disease was 5 or less mets. Two of the recruitment studies had it as 10 or less mets.

[Tall_Allen in reply to BarronS]

There have been only two randomized clinical trials of debulking - STAMPEDE and HORRADS - both showed no overall benefit. STAMPEDE suggested there may be a benefit in men with 3 or fewer mets.

Here are the randomized clinical trials on de-bulking in the works for prostate cancer, which is what we care about. If you know of any others, please let me know:

no met limit: clinicaltrials.gov/ct2/show...

≤5 mets: clinicaltrials.gov/ct2/show...

≤5 mets: clinicaltrials.gov/ct2/show...

extra-pelvic mets: clinicaltrials.gov/ct2/show...

[BarronS in reply to Tall_Allen]

urotoday.com/conference-hig...

ncbi.nlm.nih.gov/pmc/articl... ascopubs.org/doi/abs/10.120...

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

[BarronS in reply to Tall_Allen]

Ongoing clinical trials with their definition of "Oligometastatic".

cancernetwork.com/prostate-...

Table 1 and 2.

[Tall_Allen in reply to BarronS]

You have to pay attention to dates and the levels of evidence. The two randomized clinical trials (STAMPEDE and HORRAD) replace all prior observational trials that you listed. I too was optimistic until I saw the results of HORRAD and STAMPEDE. Until the Dall'Era study (review below), observational studies showed a benefit to debulking:

pcnrv.blogspot.com/2016/08/...

Now we understand why those studies suggested the wrong answer- the men who were debulked were less progressed and in better health than the men who weren't. This once again shows why we can only put faith in large randomized clinical trials.

You are also getting two different situations confused (Tables 1 & 2). These two are different:

(1) Oligometastatic when the prostate has already been treated (metastasis-directed therapy -MDT)

(2) Oligometastatic when the prostate has not yet been treated (debulking of the primary prostate tumor)

The reason they are different is because the prostate is known to be the primary source of metastases, whereas metastasis-to-metastasis seeding is a secondary source. If getting rid of the motherlode does not improve survival, it is unlikely that getting rid of sporadic metastases will have much of a benefit. In the case of prostate treatment, there are serious side effects to be considered. In the case of MDT, there is usually little toxicity when it is in a safe place to be irradiated.

[cesanon]

RP is a major procedure with major potential side effects.

You should be dubious about doing RP if you have clear evidence of metastasis outside the pelvic area.

[HB1966]

Hi,

in 12/2015 I had my initial diagnose with a PSA of 1016 and multiple mets in bones and lymphs.

I startet with lupron and had 6 cycles of taxotere. That decreased the size of the tumor and made it easier to operate. In 1/2017 I had my RP.

The (maybe) benefits are: reducing of tumor-load. If in the future the available medicines do not work so well, it can reduce local complications (e.g. urinary retention). According to my uro, there are studies that show that the formation of new metastases exclusively from the primary tumor emanates. And last: it is a very good feeling to know, that the source of all evil is not longer in my body ,-)

After RP I was 2 years on ZYTIGA. In dec 2018 I switched to XTANDI. Unfortunately XTANDI is not working very well. Next (systemic) options are chemo, XOFIGO, LU-177 and DNA-Mapping. In my opinion RP is a good choice espeacially in younger years. I am 52 y.o. and live in germany.

Best wishes !

[Garbonzeaux]

Yes, I had RP 8 months after diagnosis with some mets and 3 months after completing 6 rounds of taxotere, see my profile for further details. PSA has been undetectable for 13 months now. Don't yet know what the long-term benefit will be, but it made sense to me at the time to shoot down the mothership, and at the moment, I'm very happy I did so.

[MiRob]

I too had it done with a gleason score of 9 and Mets to 2 of 32 nodes an possible micro metastasis.

I have no regrets having it done.