My father have PC. Prostatectomy done before 2 and half year. PSA remains stable for 2 year and stared rising since last December 2020. Done PSMA PET yesterday at PSA value 4.1 and report shows bone metastatic at sclerotic lesion in right pubic bone. As per two uro onco it a very small dot and localised. Just started ADT yesterday as per there guideline. They suggested to meet radiation specialist to explore possibility of cure by radiation.
After meeting with Onco Radiation he suggest to go for SBRT on bone to cure it.
Does anyone have experience of sbrt on bone metastasis?
What is your suggestions?
Thank you in advance.
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Brijesh995
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You can remove this met with SBRT but new mets will usually appear within a year. However, the PSA value will be reduced and you can start with ADT later or combine just a short period of ADT now, e.g. six months, with the SBRT radiation.
Realistically, and we have to be realistic, eh?, the data suggest that SBRT alone will not "cure" and that, indeed, metastatic prostate cancer is not curable. However, that doesn't mean that he will not get get a great benefit from SBRT and that he might even be an outlier (20% of men I think) that get a long progression-free survival from the treatment. And being the eternal optimist, I like to think that even if we cannot cure it, we can certainly manage it. As GP24 notes, the standard of care is to add ADT to the SBRT because if there is one visible metastasis you can zap, you must presume there are micro-metastases that you have not detected yet. The ADT will slow them down. In my unprofessional opinion and based on my own experience, I would definitely zap that lesion and continue the ADT for a while (6 months? 12 months?). There is nothing pleasant about ADT, but with only one visible met, early detection, and relatively low PSA, you are staying ahead of it.
It is very popular to zap bone metastases with SBRT. While the radiation will certainly destroy that bone met, there is no evidence that it will cure your father. I think it is important to have reasonable expectations.
It is not a cure but patients who receive stereotactic radiation therapy of the metastases will have a longer median survival than those who receive standard treatment alone.
Ok, it is a hypothese but there have been at least Phase II studies, like the one below. So some data exist that supports it. You certainly know about studies. Have there been studies that rejected the hypothesis?
Purpose: The oligometastatic paradigm hypothesizes that patients with a limited number of metastases may achieve long-term disease control, or even cure, if all sites of disease can be ablated. However, long-term randomized data that test this paradigm are lacking.
Methods: We enrolled patients with a controlled primary malignancy and 1-5 metastatic lesions, with all metastases amenable to stereotactic ablative radiotherapy (SABR). We stratified by the number of metastases (1-3 v 4-5) and randomized in a 1:2 ratio between palliative standard-of-care (SOC) treatments (arm 1) and SOC plus SABR (arm 2). We used a randomized phase II screening design with a primary end point of overall survival (OS), using an α of .20 (wherein P < .20 indicates a positive trial). Secondary end points included progression-free survival (PFS), toxicity, and quality of life (QOL). Herein, we present long-term outcomes from the trial.
Results: Between 2012 and 2016, 99 patients were randomly assigned at 10 centers internationally. The most common primary tumor types were breast (n = 18), lung (n = 18), colorectal (n = 18), and prostate (n = 16). Median follow-up was 51 months. The 5-year OS rate was 17.7% in arm 1 (95% CI, 6% to 34%) versus 42.3% in arm 2 (95% CI, 28% to 56%; stratified log-rank P = .006). The 5-year PFS rate was not reached in arm 1 (3.2%; 95% CI, 0% to 14% at 4 years with last patient censored) and 17.3% in arm 2 (95% CI, 8% to 30%; P = .001). There were no new grade 2-5 adverse events and no differences in QOL between arms.
Conclusion: With extended follow-up, the impact of SABR on OS was larger in magnitude than in the initial analysis and durable over time. There were no new safety signals, and SABR had no detrimental impact on QOL.
I shouldn't say "no data" - there was one very flawed study that suggested that; however, when the sample skews are corrected for, the apparent effect completely disappeared. You can see the math here:
As you see, the apparent effect is completely explained by the fact that colorectal cancer, a cancer with low 2-year survival, was twice as represented in the control group, whereas prostate cancer, a cancer with very high 2-year survival, was more than three times as represented in the treatment group.
There will be two trials that may report results next year - STEREO-OS and FORCE. A retrospective study at Mayo suggested that there was no benefit from zapping bone metastases:
Until we have better data, I think that bone metastases should be zapped but only when it is completely safe to do so. Why not? But I also think it should never be in lieu of systemic therapies (hormonal and chemo) that have proven efficacy.
If there is no proof of benefit to MDT, Why do you suppose insurance companies willingly pay for it? I specifically asked if I needed to say I was doing it for pain relief and I was told by the Ucla doctors that that was not necessary to get approval. PSMA Scans have far more proof of benefit including FDA approval yet my insurance company still will not pay for that. Nor Will insurance companies pay for Provenge for hormone sensitive patients despite some pretty good evidence that it works better earlier. I could go on and in. We all know it’s not cheap and we know insurance companies rarely pay for expensive treatments that are not proven with phase 3 clinical trials. Where’s the disconnect ?
Of course not. Your knowledge base is far more extensive than mine and I have the ultimate respect for you. So I’m not arguing the point. I’m just trying to reconcile two facts that seems highly unlikely to go together. Insurance companies always fight paying for treatments with no proof they work. So why would they so easily pay for something with zero evidence of any efficacy. I can think of no other expensive treatment that has zero evidence of working, that they readily pay for. Can you? Perhaps if you knew of any other expensive treatment they pay for that has zero proof of efficacy or the logic behind their thinking on this subject, it would make more sense to me. Thx TA
Unfortunately that answers my query. Darnnnnnn. I guess I was holding out hope that they (The insurance companies) knew something about SBRT’s efficacy that you did not. Fat chance. Lol
As my father is only 56 year old i don't want to take risk. If there is only 10% chances of cure i don't want to skip that. There may chance from God's blessings it will cure. And as we take three Radiation specialist review and they told there is no side effects of SBRT on that particular location.
We currently know of no way of curing metastatic PC. But why not do it anyway? Many men live many years with it and die of something else, even without a cure.
I agree with your and your father’s decision to have the SBRT to the pubic bone met. It is good that there is just one and it is so small that it took PSMA scan to identify it. So what you/he can and hope for the best. Prolia can also help make getting more bone mets somewhat less likely going forward. I think it is an easy and worthwhile addition for bone protection, even if his bones are otherwise strong. The ADT going forward will weaken them. So this is a way of staying out in front of it for the long term. Best regards, paul 💪💪🙏🏻
Hello. I had two spinal mets and one on my hip. SBRT neutralised the avid PCA on those mets but unfortunately, the radiation weakened my L3 vertibrae to the point where I experienced disintegration of the end cap and compression fracture of the vertibrae. 12 months on, with the help of acupuncture, diet and exercise, I'm back playing golf. The evidence seems to be that the SBRT will slow or stop the localised met but won't cure the disease. And, as I experienced, there are risks. I wish your father all the best. Harry.
Hi, you dad is 56. I was diagnosed at 51. I am now 72. Point is, if you manage the disease you can extend life until something else takes you out, in due course, at your leisure, in the fullness of time. SBRT is a good tool with few side effects. ROs are pretty careful and will say if there is danger at a particular site. I was faced with the same decision when a PSMA scan showed 3-4 small mets, both lymph node and bone - oligometastic. I reckon zap em before they become big mets. Know that it is highly likely that there are micromets floating around. It is unlikely to be curative. But on the other hand, PCa at this stage is incurable. There are a few reasons to suppose it may be beneficial and far fewer that it may be harmful. Since in your father's case it is just one small spot, then yes, there is a possibility of if not cure, remission (kicking the can down the road) for many years. But it is a small (not insignificant) probability.
In my case, PSA went down for a few months, mets were receding nicely then a scan showed a whole lot more new mets, so on to next treatment.
PC is very heterogenous ....nothing one fit all. sure clinical trials CT give overall framework.In may 2019 psa 30.'...T3B..means cancer at least since 5 years as my last psa 2.4 was in 2010
Choline scan showed two mets on pelvic iliac ....So in nov 2019 had SBRT boost on prostate ,two spots and seminal vescicles
Since a year psa <0.006...Who know what it means looking thru glass of CT....
But I have casual rectal bleeding after 18 months...My RO says it is for 5% cases but it becomes 100% for me.....
I wonder if PC cells have different behaviour depending on age bmi race diabetes all that ....and of course then telomere lengths.....with aging
PC cells are pretty smart to trick the shortening of telomere
Most important is nutrition exercicise mind
upbeat and some supplements...along with evolving protocols...
I have had this treatment and it worked well it was done last September and my PSA has dropped from 2.6 to 1 and remained stable now fir last 3 months.It's a easy procedure to have and the theory is by blasting the main site of concern the rest of the cancerous cells are easier to control with the ADT
My husband had SBRT on his very first bone mets almost 7 years ago. This was after a gleason 9/10 at 48, RRP, local radiation, which kept it at bay for 7 years. After his SBRT to clavicle, the bones mets continued to move slowly. He is now on a decline after 14 years and has received SBRT to lower back and skull (palliative). He is considering radium 223. Has gone off of all other meds other than pain right now and making a decision. All in all, I would say SBRT was a good choice for him, slowed it down, he was able to continuing working up until about 4 years ago. And is still fairly mobile even with all the mets to the bones now. Consider it, although not a cure that I'm aware.
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