Many of us have seen youtube videos making unsubstantiated claims about SBRT (or SABR) for treatment of oligometastases. The actual medical science is quite different - there is as yet no real evidence that an oligometastatic state exists or that SBRT of them extends survival. The one randomized Phase 2 trial with a survival endpoint, called SABR-COMET, was deeply flawed, and adds nothing to our understanding. Here's why:
Again, I will state that I do not know if there is a survival benefit or not - no one does. I urge patients to approach this with caution (people have died from it), and to not put off systemic therapy (which we know has survival benefit).
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Tall_Allen
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Great analysis TA. Hard to imagine why they had such a larger group of prostate cancer patients (slower growing cancer) in one group while having so many more colon cancer patients (faster growing cancer ) in the other group. That’s a real flaw. One question TA. You do not mention the potential abscopal effect that SBRT could have leading to longer survival times. I’ve spoken to a number of MOs that believe that could be a factor in SBRT extending life. Your thoughts ?
The abscopal effect does not depend on there being such a thing as an oligometastatic state. But I do suspect (admittedly based on flimsy evidence) that combining immune amplification (e.g., Provenge) with SBRT, Xofigo, Lu-177-PSMA, or docetaxel (all of which dump a lot of dead cancer cells into circulation) may enhance their effectiveness.
There is no proof - - that is all I hear from physicians - - Mr. Rust, the standard of care is blah, blah, blah in a monotone depressing tone. When I mention that I am still interested in cure no matter what the risk the doc's eyes light up and they get excited and then go on to talk about what could be a chance for cure. Of course then the bridle their enthusiasm with - - the Tumor Board will discuss your case and reach a consensus. Possibility of radiation for oligometastatic disease is a great hope for those of us entering stage IV. Thank you for your diligent advice over these C years.
Thanks Tall Allen
Your in-sight is always so helpful.
I just started Lupron 2 months ago Cassodex before for 6 years.
Psa has dropped from 1.5 to .35
So far hot flashes not bad.
I have heard horror stories about the venlafaxine.
Your initial question/leader says it all, TA. I am an engineer and scientist by education and trade with some medical knowledge gained from 20 years as an emergency medical technician. I used to be only mildly irritated with medical science creating terms that lose cohesion and sense when one really does some research on a specific medical topic. Since I've become seriously interested in medicine via a strong instinct for self-preservation, I now find myself becoming angry..... and there is no better example than "oligometastatic."
On its surface, the term "oligometastatic" is very simple and plausible - it simply references a model theorizing a "parent" tumor that, through the process of metastasis for that cancer, has resulted in a "few" metastatic sites. However, the medical leaps in treatment from this model are largely unsubstantiated.
Oligometastasis fundamentally assumes that the microstate of the cancer (difficult to measure or unmeasurable) is completely captured through the measurement of the cancer macrostate (i.e., a main tumor with several "treatable" satellite tumors). This is not a novel concept - humans have routinely confused the applicability of what seemed logically measurable (think about the Earth-centric universe) to make conclusions about what cannot currently be measured.
I'm not saying that the model is wrong, but it currently has no strong data to support it (hey, I'm still personally waiting on superstring and M-theory to pan out...). Patients need to understand and accept that any treatment based on the oligometastasis model is simply an experiment.
And, can you believe it, 3 surgeons in Bombay actually wanted to operate on my prostate and remove it even though they knew I was metastatic.
They used the term "oligometastatic" to lure me.
With the benefit of hindsight, it is obvious to me that surgery would have been a complete waste. I would have remained incontinent for months, if not longer. I would have spent at least US$ 25,000/- and the pain, blood loss, etc, etc, etc would be unnecessary. Definitely catheters would be shoved up, removed, shoved up, removed. Ugh
I am now beginning to believe many things about medicine, Whatsin. Another poster on this site recently wisely said: "Just randomly poisoning (or operating on) a bunch of men and seeing what happens is evidence-based medicine, not science." In a very real - and unpleasant - way, I've always gotten the feeling that my value is as a medical data point to provide the support for this evidence.
Medicine sells procedures. After radiation and chemo, the body of my C2 vertebra basically collapsed in itself; it looks like a pile of rubble on scans, and medicine calls it a state of "pathological fracture." Of course, I go to see a specialist, and he wants to immediately operate despite the fact that I have no neurological symptoms of spinal cord compression (admittedly, the spinal cord does curve in an abnormal way and the lumen is narrowed).
I have advanced prostate cancer with a median survival of 5 years. I have children. And I was told that 99% of medical experts would advise surgery - a surgery that would carve out the back of C1 to relieve pressure on the spine and fuse the rest of my c-spine down to C7 with a strip of titanium...pretty much all of my usable c-spine. Oh, and recovery would take years, if ever. Years I likely don't have. As you say.... Ugh.
Needless to say, I found the 1%, and I make the most of my time. Cheers. - Joe M.
The problem boiling down to CTC's, micrometastasis, and the immune sytem... and that is the real problem...
I found it interesting you chose SABR-COMET trial as opposed to using some other trials you were aware of--we have discussed Dr Heron's trial at UPMC with no deaths...
But you chose SABR COMET which had less prostate cancer patients than STOMP... Clearly, we disagree on the role/benefits of stereotactic radiation in prostate cancer...
I read that you do not embrace the abscopal effect fully except in combination with Provenge, some other therapies... why would it be of no benefit with say Lupron and Zytiga?
Some other thoughts that occur are in regards to oligometastatic state and new testing like the Axumin and Gallium PSMA scans which detect the cancer at lower PSA and lesser disease progression... Is this not, in effect, getting as close to possible when one utilizes a term like "oligometastatic state", and thus provide additional potential benefits from stereotactic radiation.?? Likely to be less micrometastasis and CTC's...
As you are aware, there are multiple stereotactic radiation trials at NCI listed... If your followers look only at SABR-COMET and not at newer trials since then and read your blog, then ,"Are they getting the whole story." in the words of Paul Harvey...
For the future, using your BlogSpot as proof that you are right....Is it not like running from one hillside to the next screaming..."Look, I am right" and counting it as 2 votes of aye ??...
And, notwithstanding my comment above...full disclosure.... I had what amounted to stereotactic radiation to some really concerning spine tumors: C2 and T4.... although my RO did not call it this (I think for purposes of not completely freaking out a newly-diagnosed APC patient)... I would do it again, but my wife is skeptical. - Joe M.
You may not be aware that the scientific medical community has agreed upon "levels of evidence." The reason I wrote up the SABR-COMET trial as opposed to some of the others you mentioned is because it rises to a level of evidence higher than most of them (see STOMP below). The Phase 3 trials are still higher levels of evidence (Level 1). The reason that the evidence you think is important is actually only suggestive of an association and do not prove causality. Clinical trials that don't have a control group or look at survival (as SABR-COMET did) actually tell us little. What would have happened had those patients not received that treatment? They are only useful for hypothesis generation.
I guess you did not actually look at the citations you provided because the middle two are articles about the SABR-COMET trial, which I reviewed.
As for the abscopal effect, Lupron and Zytiga may kill a lot of cancer cells at the start of therapy, but over time they do more prevention of growth than actual cell kill.
Advanced PET scans increase lead time, but they do not identify an "oligometastatic state."
I am fully aware of ongoing clinical trials, but until we have results, there is no "story." I will certainly write them up as they appear.
In my blogs, I provide links to research in peer reviewed articles. I prefer writing blogs that I can refer patients to than quoting long articles here that no one reads and disappears quickly (just as your post will). If you disagree with any of the points made in my hundreds of blogs, you can comment there and I usually respond. I believe in evidence-based medicine, and recommend patients form opinions based on actual evidence (which I provide) and levels of evidence.
The reality is that the Phase 2 trials coming now with oligometastatic Pca and recurrent oligometastatic PCA trials will provide evidence to evaluate and most likely lead to Phase 3 trials in both...At that point, I guess the proof will be there or not in your mind...
I never said that the newer scans could identify an "oligometastatic state", but are the closest that there has been to getting there--my statement:
Is this not, in effect, getting as close to possible when one utilizes a term like "oligometastatic state", and thus provide additional potential benefits from stereotactic radiation.?? Likely to be less micrometastasis and CTC's...
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