Ken Pienta gives his (interesting) 5 cents:
[Kenneth J. Pienta, MD, The Donald S. Coffey Professor of Urology, Professor of Oncology, and Professor of Pharmacology and Molecular Sciences, The Johns Hopkins Hospital, Baltimore, MD]
urotoday.com/video-lectures...
-Patrick
Thank you! Great timing for us to have this information.
My understanding from reading the STAMPEDE, HORRAD, and PEACE1 trials is that RT for mHSPC should be considered only for low burden disease. I didn’t hear that mentioned in the video, but maybe I missed it. I’m high burden and my MO advised against RT and RP, although to her defense I responded really well to ADT and they couldn’t see any spots on my prostate from my MRI. Does anybody have any thoughts about RP for high burden?
Its a great question. High burden is easy to understand when the mets are detectable but if ADT and docetaxel are successful and PSA reduces to well under 0.1 with dormant mets (undetectable but assumed to be there) are you high burden or low burden?
I’m high burden and unfortunately it appears the studies so far have shown high burden doesn’t gain anything with RT, but I don’t think they have completed any studies yet for RP. I guess my MO is thinking that since my MRI showed no spots on my prostate that it’s not kicking out any more Mets but I’ll confirm with her when I see her later in the month.
I'm interested in the differences in treatment between those with high and low burden disease. The division at 5 visible mets is arbitrary. The potential benefit of a treatment must be on a continuum. There cannot be much difference between those with 4 visible mets and those with 6 visible mets. I believe my cancer is considered high burden but not by much.
Good post!
I’m in Canada and coming up to 24 months on Zytiga with current PSA undetectable at 0.01.
I asked my radiation onc a couple of months ago if I could have radiation to my prostate.
The reply came back (after he said he consulted with the team) that I am high burden ( defined at original dx) so my argument did not fly that I am low burden now as my Mets have been dealt with eg Mets in spine radiated after surgery due to spine compression and SBRT in a neck met due to a 2cm mass causing some pain.
SOC (standard of care ) in Canada stops out of box ( out of SOC) treatment.
However I still think that I should do RP or preferably radiation ( presumably with brachytherapy boost ) to my prostate as even though there is no data supporting longer overall survival, there is not a lot of data on this subject currently so why not do it. My thinking is do what is logical and has potential to stop new Mets forming from blood circulating through a diseased prostate. So should I do this privately and if so where would be a good choice at reasonable cost?
I think the issue is that new mets can form from any other met, so removing or radiating the prostate brings diminishing benefits with more or larger metastases. In exchange, you get all the side effects of treating the prostate.
I myself have many mets and a good response to treatment, so I've spent some time contemplating this. It's nice to have full urinary control.
Hi Tom67
Sounds good ( but how good??!!) and this is what RO’s working under SOC will say as to do more radiation they need data that shows a benefit or met pain that is significant....otherwise with no benefit from data how is cost of radiation justified.
However the lack of data and low burden/ high burden classification at dx instead of after Mets have been wiped out by stereotactic radiation/ Lu177 etc is disappointing.
Has not RP and debulking prostate reached the point where with an excellent surgeon/ radiologist the % of urinary issues are now very low?
Isn’t it logical for me to assume that when ( as opposed to if) my prostate cancer cells become Zytiga resistant, the more Mets I have , including the mothership, the more chance of new Mets forming from both Mets outside the prostate and the prostate itself?
One thing about treatment I find frustrating is that it's based on population studies and doctors are very reluctant to tailor treatment to an individual. Ugh!
I work with a guy who had an RP a few years ago. He told me he still has a bit of control problems and will use a pad in his underwear when on a long flight or other circumstances where he might have to hold it for a while.
So I finally took the time to watch the video in the original post, and what I found interesting is how much we still don't know. We have excellent evidence for early use of docetaxel and/or abiraterone, but the studies I've seen don't show such a striking benefit for treating the prostate, intermittent vs continuous ADT, etc.
I'm in the camp that believes it's the total tumor burden that matters, and if the prostate only has 10% of the cancer, then you only get maybe a 10% benefit from treating it and 100% of the risks and side effects. And of course, I could be completely wrong.
It seems no matter what choices we make, 10 years from now doctors will look back and say "we were so stupid in 2019". 
Patrick, thank you for this excellent link. Are there any other similar links to interviews/presentations from this conference/retreat?
Marnie,
Here are two:
Mary-Ellen Taplin on germline testing:
urotoday.com/video-lectures...
Joaquin Mateo on integrating PARP inhibitors into SoC:
urotoday.com/video-lectures...
-Patrick
Good vid, thanks.
I had my prostate debulked with IMRT back in 2014 even though I was Stage 4. It was done by a forward thinking RO who said there was a benefit to it and I could get more mileage out of ADT by doing it.
When I started seeing Snuffy Myers he said it was “one of the best things I could’ve done - kill the mothership “.
So far so good, been undetectable for about 5 years now.
Ed
There is some thinking that the oldest and most mutated cells are in the prostate where the disease originates. Another more likely advantage is that as disease progresses, those with a treated (or removed) prostate are much less likely to have urinary strictures and bladder problems, nephrosis, which is urine forced into the kidneys due to tumor closing the ureters, and such effects. For these "side" effects such treatment can be valuable in reducing problems in the future when the disease progresses and the cascade of events creates problems for the treatment team juggling issues simultaneously.
Thanks for sharing Patrick, an interesting interview, cheers 😎DD.
On treating micro-metastatic disease 
Erleada in the EU for metastatic prostate cancer
