It would seem this procedure is not recommended as it is also for radical.
Is there any reason a doctor would recommend this?
Seems the horse is out of the barn.
radiotherapy to the prostate if metas... - Advanced Prostate...
radiotherapy to the prostate if metastasized out side of the prostate.
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totom
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Totom,
In my opinion it is valuable to irradiate the prostate, even if you have high metastatic burden. This is actually backed up by the STAMPEDE trail data, that is cited as a reason not to irradiate with high metastatic burden.
Since prostate cancer is heterogeneous, there are difference forms of the cancer within a tumor and throughout the body. Once it is metastatic, an array of treatments are needed. I noticed that my Alkaline Phosphatase (ALP) was going down with androgen therapy, while my PSA continued to rise. This indicated to me that the cancer in my prostate was more castration resistant than the metastatic lesions in my bones.
I wrote a paper to explain why I thought I should get a radical prostatectomy. My medical oncologist (MO) said that the trial data showed it wouldn't be effective for met. The urologist said the surgery wouldn't be effective, and would would reduce my quality of life.
My MO referred me to a Radiation Oncologist (RO) for another opinion. He read my paper and agreed with my reasoning that the "local" tumor in the prostate could continue to seed new metastatic lesions that would be castration resistant. He told me that the Standard of Care (SOC) was to not treat the local tumor, but was willing to treat me anyway. He referred me to the STAMPEDE trail to understand why the standard of care was to not irradiate.
thelancet.com/journals/lanc...
I read the report carefully and noticed something that isn't reflected in the conclusions. If you look at the last line of Figure 3, you see that there is a reduced hazard of dying from prostate cancer if you receive radiotherapy in addition to docetaxel treatment. The line above shows no improvement if you use radiotherapy without docetaxel treatment. There are two categories, because docetacel wasn't approved for use until 2015. 90% of the patients were treated with radiation before docetaxel was approved, which heavily skews the overall results, and leads to the wrong conclusion.
The proper conclusion from the trial data, is that radiation therapy provides a benefit when combined with chemotherapy. Without chemotherapy, radiation doesn't help patients with metastatic disease.
Thanks and I agree.The RO in my opinion is not at the highest level .
First he allows me to decide if I should do ADT . He suggested doing it for five months.
There was no mention of doing docetaxel at the same time. I went to see him for the gland and spot outside of the gland to be treated with a proton beam. Instead he moves on to photon and maybe some proton. So far it appears to be not a total job. As you know I have received AC-225 and LU-177 in Heidelberg. PSA is <0.08 and I have been off ADT now for thirteen months. My decision at this time is to go back on ADT ( preferable ORGOVYX ) proton or high testosterone injections without ADT. My present T is 10.
Being eighty years old I understand the cancer usually is not to aggressive.
Fortunately I have this forum to talk to . Many good signs my T is returning naturally and this then causes concern for the PSA to rise also. Testing in two weeks. My OC is prepared to give me the T shot.
Here is an interview with Dr. Koontz of Duke University, that discusses this question.
hematologyandoncology.net/a...
She doesn't come to the same conclusion as I do about irradiation in the presence of high metastatic burden. However, with the stakes high, I decided to err on the side of over-treating rather than under-treating. Especially, in light of the relatively low side effects of Stereotactic Beam Radiation Therapy (SBRT) . I think my Urologist was correct in recommending against Radical Prostatectomy.
"I decided to err on the side of over-treating rather than under-treating."
That's also my philosophy.
But anything powerful enough to do good is generally powerful enough to cause problems.
In this case you expose yourself to secondary cancers 15 to 20 years later.
Never a free lunch it seems. Lol
I’ll trade remission now , for cancer 20 years from years from now, any day of the week.
When I told my sister I was getting a PET scan. She asked if I was worried about getting cancer. Yeah, she actually said that. I told her when a train is headed for you, you jump off the tracks, and you don’t worry you might sprain your ankle in the process.
It is only recommended if there are fewer than 4 distant metastases on a bone scan/ CT:
prostatecancer.news/2018/09...
If the metastatic burden is higher, there is no benefit. This has been proved in two major randomized clinical trials. There are ongoing trials to see if the same conclusions are true for radical prostatectomy.
Another complication is if the metastases have been detected with a PET scan.
The justification for this is that initially metastases come from the prostate, but very soon afterwards, metastasis-to-metastasis spread is the principal source of new metastases. Unfortunately, much of such spread occurs while metastases are too small to be detected.
In my reading if the STAMPEDE trial, it didn’t prove that. I realize my interpretation of the trial results is different than most people”s. The subclass that was treated with docetaxel and radiation was small enough to not be statistically significant, so I could have confirmation bias.
When I was discussing this with my care team. I saw another current trial of radiation treatment for high metastatic burden, that noted the flaws in STAMPEDE. When I went to look for it on clinical trials , I got 300 hits for my search string. I’ll check again, and see if it has completed.
There were two trials-HORRAD and STAMPEDE. They both found the same thing. All trials test the intervention+the standard-of-care (SOC) against the SOC (otherwise it wouldn't be ethical). It's true that the SOC changed in 2016 to include docetaxel for mHSPC and 18% of the men in the STAMPEDE debulking trial received docetaxel too. But that was true in both the treatment and control group, and neither group benefited from debulking (fig 3b). I'm not sure what your concern is.
BTW- HORRAD randomized before docetaxel became SOC, so no one got docetaxel in that trial.
Radiation without systemic treatment would be useless. Any trial that doesn’t include systemic treatment would be useless in answering whether adding radiation to systemic treatment is effective. The majority of the STAMPEDE patients and all the HORAD patients didn’t receive chemotherapy, so their results can’t be used to judge the efficacy of chemotherapy combined with radiation.
In both HORRAD and STAMPEDE, ALL patients did receive systemic treatment with ADT, which was the SOC before ADT+docetaxel.
When docetaxel was added to ADT+RT for high risk PCa, it failed to improve results meaningfully enough to warrant the additional toxicity.
Preliminary reports from PEACE1 (in which most received docetaxel+ADT as the SOC) confirm that prostate debulking had no effect when patients were additionally treated with abiraterone. Abiraterone works equally well regardless of tumor burden.
Thanks, it was the PEACE1 trial I was remembering. I’ll take a look at the results
I looked at the PEACE-1 results reported at ASCO 2021. This trial will directly assess the usefulness of adding radiation to SOC for mCRPC. It hasn’t gathered enough data in the radiation plus SOC arm to present results yet. I think the question won’t be fully answered until those results are available.
Does the radiation debulk the prostate gland? How does that affect the Urethral.
No, "Debulk" means it gets rid of the tumors within the prostate.
Thanks. May do radiation to knock out what is left. On vacation now but soon back on ADT. ORGOVYX I think
That only delays progression if you've only had 3 or fewer distant metastases.
Prior to going to University of Heidelberg and getting AC-225 and LU-177 (four trips) I had cancer in my lymph nodes in the groin and cancer on spine. All is gone except the small amount on the prostate and a spot outside of the prostate. I suppose that spot would get the proton. This then changes and suggests no reason to debulk.
There is sometimes another reason to debulk. As the cancer grows in the prostate, it can clog things up there, causing urinary problems. A TURP is sometimes used palliatively. It may be reasonable to debulk the prostate with radiation prophylactically.
That makes sense. Should do this just for that.
" Another complication is if the metastases have been detected with a PET scan."
Yes, what to do then? Without a clear answer, should men have PET when conventional imaging ..... CT, bone scan, MRI, are all negative for spread ?
The OP was wondering if debulking was useful. I said, yes, if fewer than 4 distant metastases were detected on a bone scan/CT. But what if, say, 5 distant metastases are detected with a PSMA PET/CT scan, but say, only one with a bone scan/CT? Is it still useful to debulk? I don't know the answer, but I would certainly recommend debulking in that case. That's why it's important to always have a bone scan/CT even if one is getting a PSMA/CT scan.
I thought it was now standard of care in low volume newly diagnosed metastatic cancer after the stampede trial results;
clinicaloncologyonline.net/...
I believe it is standard for oligometastic disease
MD Anderson had planned for pelvic/prostate IMRT after my chemo, and I enrolled in their EXTEND trial, and was randomized to their "upfront local consolidative therapy (LCT)", which then included a 10-7 met. I only had 1 other bony met and that was sacrum, (done with the pelvis), so I had low mets, but they would have done the prostate/pelvis regardless.
If you have 5 sites or less it might make sense.
I was dx with stage 4 Gleason 9 disease with numerous mets throughout my skeleton and nodes back in March of 2014. A well respected RO in my area recommended treating the prostate and as many affected nodes as he can do safely. He said it would help avoid cancer from my prostate spreading to nearby, hard to treat organs and also increase the effectiveness of ADT. After reading Snuffy Myers book which discusses how the prostate remains the main source for additional mets when left to fester (I paraphrase) I decided to have it done.In 2015 Snuffy became one of my MO’s, during a visit he mentioned that having my prostate radiated was one of the best things I could have done early in my treatment. I’m still here, outliving my original expiration date, I’ll go with that. Having my prostate radiated early on was part of the “kitchen sink” approach I implemented, hitting it hard, hitting it early with a multidimensional approach has worked for me so far.
Ed
I agree with his thinking and yours. If cancer is heterogeneous, then you have to attack it in multiple ways. If there’s a low risk localized procedure that produces good results, then do it in addition to the systemic treatment
My Dr. at Duke (Armstrong) said "we still need to burn the barn down" even though the horses have left the barn. I had 3 distant spots showing as well as one near my prostate that were treated with radiation along with my prostate. I have since had one spot on my tailbone also treated with radiation. My PSA is rising again, was 1.05 a few weeks ago. PSMA scan scheduled in a few weeks.
Kill the host. I like the "burn the barn down even though the horses have left".
Burn down the Ranch.....
Good Luck, Good Health and Good Humor.
j-o-h-n Monday 11/29/2021 6:31 PM EST
I have been dealing with metastatic prostate cancer since 2008. I was told in 2015 to prepare for end of life. I ended up Reading an article by Dr. Kwon at the mayo clinic.Well then he will tell you that you're wasting your time with radiation I did not feel that way. I came back to Baltimore where I went to the proton Center and they removed all tumors in my lymph nodes. At the time I did not have any tumors on the bone. That being said it has moved over to the phone and I'm having to fight it with numerous clinical trials that are somewhat effective like lutetium. The point is that you can roll up into a ball and say this is it or you can keep trying to find a Plan B. Right now I am in HAT trial add Maryland but I do not have results as of yet. Remember this started in 2008 and my Gleason was 8.It's 2021 and I'm still standing. Best of luck to you! I've gone through every traditional therapy you might expect so I'm OK with searching for a Plan B's. Best of luck to you!
Thanks. It seems so far most men agree that radiation is the way to go.
What is the HAT trial?Thanks
NCT02566772
Thank you.
FT-7051 Is the name of the drug that I am on right now for the clinical trial. The information I gave you earlier was incorrect. I apologize
Not a problem.
I was treated with ADT + Docetaxel + Radiation to the prostate as SOC for stage 4 metastatic prostate cancer in 2017/2018. I had 6 metastatic spots on skeleton and very large prostate. I believe one of the reasons for radiation to the prostate was to relieve any problems with urinating like TA mentioned and to ensure that the prostate didn’t spread any more cancerous cells. To be honest the radiation was the easiest treatment and I felt at ease knowing I was killing the host. I remember when first diagnosed and being told that the prostate wouldn’t be removed, I didn’t understand why because I only new of other men with prostate cancer that had there prostate removed. I didn’t understand the situation and still don’t. I am trying to learn by being on this site. The Oncologist is just waiting for the cancer to spread then we can add more treatments.
One reason to not remove the prostate is that with advanced cancer it is just about impossible to surgically remove all of the cancer around the edges of the prostate. Radiation can safely treat a wider margin around the prostate and that’s why it’s preferred. That said, some oligometastatic patients treated at Ucsf do receive prostatectomies, in part because the prostate tissue can be analyzed in detail after RP. They generally need radiation afterwards.
My husband's diagnosis in July 2020 was with bone mets. Nobody ever told us how many but I assume that there were more than 4 spots. Surgery was not offered but after ADT for 9 months or so, he underwent SBRT. 5 sessions to the prostate. The two weeks after that were terrible for radiation proctitis side effects. The treatment itself was pretty much a walk in the park compared to the after effects. Hopefully, there would be some benefits in the mothership not sending any more mets out and also perhaps other long term benefits of the urinary type as T_A mentions. After that my husband still had to go onto Enzalutamide to see PSA reduction.
Javelin18 is spot on when he reminds us that prostate cancer is a poster child for the heterogenous nature of prostate cancer. It is this very reason that trials are often flawed and also why many people drop out when they read of other treatments available. Earlier this year I did a zoom visit with Dr Agarwal at UCSF about his on-going trial of cyberknife with apalutamide versus apalutamide alone in mCRPC. During this conversation I specifically asked him how he got funding given the general view that "whack a mole" did not work. HIs response was to basically say the data against this approach was so poor in both design of studi3w and group selection that funding was easy because in fact the question was unanswered.
The conversation reminded me of a resent statement by Marcia Angell, MD, Former Editor in Chief of the New England Journal of medicine where she said:
"It is no longer possible to believe much of the the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as the editor of The New England Journal of Medicine."
Her observations and conclusions have certainly been validated by the whole "scientific process" surrounding Covid-19!
We all may have the same disease but our tumors are all too often different even the various tumors in our bodies. We, our treating physicians, and our health insurers need to realize and respect that.
I was diagnosed in January 2020 (gleason 9, 4 small bone mets and lymph nodes). Started ADT (firmagon) immediately, docetaxel started 6 weeks later. After advise from my urologist, supported by my oncologist, decided to have radiation a few months after the chemo was finished (6 high dose treatments using MR-Linac).
Although I don't know precisely what has been most effective, my PSA has continued to drop to this day and my scans show stability or shrinkage across all mets.
Greg
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