Recently discussed here was whether low volume metastatic state was a thing, and whether metastatic directed treatment is proven science yet and this interview just came out highlighting a meta analysis that concluded standard of care (adt alone) seems to be markedly inferior to treatments that add pathway inhibitor AND zap the prostate as well. The interview pointed out this challenges the “dogma” that “once the cancer has escaped” there is no longer any use treating the prostate.
Interesting. Basically the interview concludes in new cases of low volume metastatic cancer, the data suggests throwing the kitchen sink at it, including attacking the original tumor, and not just going onto adt. I think that is a fair summary. someone can correct me if I had misread it.
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probabilities, that’s all….if it just became metastatic you have a batter chance to hit all the visible and invisible metastasis, if like in my case you are diagnosed with high burden then there is a fair chance that zapping would do nothing (or almost) but add adverse effects. But to my knowledge SOC is triplet therapy in case is metastatic cancer or at least doublet, not adt alone.
As I share, I used a very uncommon kitchen sink to go after my perceived 'low volume metastatic condition'. IMO, well within SOC as SOC is a very broad range of treatment.
After my unsuccessful salvage RT (without ADT), over six years ago, at usPSA 0.11, I went for imaging trial in Europe. Five suspicious pelvic lymph nodes identified.
Instead of STAMPEDE protocol I went after remaining tumor burden with salvage extended pelvic lymph node surgery using frozen section pathology method.
Six cancerous nodes confirmed including para-aortic. Then did one year only of ADT for added insurance.
Post surgery pre-ADT nadir was usPSA <0.010. After slight rise been holding 0.03X range past three years, no further ADT; bimonthly testing . Annual imaging and blood biopsy indicate NED.
1. Treatment of the prostate when there are low volume metastases. This is called "debulking." If there are 3 or fewer metastases on a bone scan/CT, it slows progression and increases survival.
2. Treatment of metastases with metastasis-directed therapy when there are few metastases. It usually lowers PSA, but whether there is any net benefit is unknown.
so when he says “For many, this was a surprising finding, and it sort of challenged the dogma that local therapy to the primary tumor had no impact on survival in patients whose cancers had spread elsewhere”
That is the situation described in #1 above, not #2. The "primary" means the prostate, not metastases. Before 2018 there was a question about whether treating the prostate could slow progression after oligometastases had been discovered. That's what he means by "dogma."
I am wondering if you could help me understand something. Like many in North-America, when my cancer was diagnosed I was offered the following treatment based on STAMPEDE (or is it CHART?) of Lupron + Abiraterone + Radiation to the prostate and pelvic lymph nodes.
But if it is better to throw everything at the cancer early on while it is still hormone sensitive, I am wondering why chemo like Docetaxel was not also part of this toolset?
Since it is Cytotoxic and kills cancer cells instead of just putting them to sleep, would that not be safer to include it in the mix while the body is still strong and before cancer mutates from a long exposure to ADT?
"Thanks but why not use it even if metastases were not distant?" Because docetaxel only acts on actively growing distant metastases. It has no effect on pelvic lymph node metastases.
"And now that I do have one, assuming the shoulder blade is considered distant, is adding Docetaxel to Regulovix+Xtandi of no benefit?" Hormone therapy drives prostate cancer cells into a senescent state in which docetaxel is no longer effective. That's why it's only used in newly diagnosed patients.
We synthesized the available evidence from clinical trials conducted in patients with newly diagnosed low-volume metastatic prostate cancer to compare the outcomes of four treatment approaches. A strategy that consists of androgen deprivation therapy, an androgen receptor pathway inhibitor, and prostate radiotherapy appeared to be most effective in terms of overall survival.
I'm in the EXTEND trial at MD Anderson, low mets, only 1 T7 site outside pelvis. I had whole pelvis radiation after chemotherapy. I'm a firm believer in killing the mother ship.
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Interesting paper summarising state of art (2022) for ADT
Digging into STAMPEDE data fir SBRT
Updates to de novo metastatic prostate cancer treatment 
