"To the best of our knowledge, our study represents the first randomized effort to report the superiority, in terms of clinical progression-free survival, of SBRT and a [short course of ADT] compared with SBRT alone in metachronous oligorecurrent hormone-sensitive prostate cancer," wrote Jereczek-Fossa and co-authors."
Comments? (I'm heading to Dr Google to figure out what "metachronous oligorecurrent" actually is..
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Don_1213
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It proves that ADT should not be omitted with MDT (metastasis-directed therapy using SBRT).
Arguably, they found that delayed recovery of T may explain the difference. "The results of this analysis showed that, in our cohort, the advantage of the combined treatment group was no longer [statistically] significant when considering eugonadal progression-free survival for the SBRT with ADT group, " The ongoing PROMETHEAN trial is powered to correct for that.
"Metachronous oligorecurrent" means that patients recurred after initial definitive treatment (RP, EBRT, or RP+SRT) with up to 3 metastases that weren't detected at initial diagnosis
This study seems to start with the premise that MDT with. SBRT, delay systemic treatment implying it extends lives. In fact it says:
“..the new RADIOSA trial reinforces the role of metastasis-directed therapy in delaying systemic treatment escalation.”
Based upon your previous posts, I’ve always thought you had your doubts as to the efficacy of MDT, yet generally were in favor of it based upon the premise that it might work and it was generally safe. Is there anything in this or other recent studies that has made you more optimistic on MDT VIA SBRT?
I will take that as a ‘no’. You are clearly in the minority with that opinion now. Even AI, when asked the question says:
“AI Overview
Yes, studies suggest that metastasis-directed therapy (MDT), especially when combined with intermittent hormone therapy, can improve progression-free survival (PFS) and potentially extend life in men with oligometastatic prostate cancer. “
Interestingly, Dr. Scholz says the use of MDT (via SBRT) has transformed his practice and resulted in significant extensions in survival. Obviously that’s not ‘level 1” evidence but his clinical practice is pretty large. UCLA has a very large contingent of MDT via SBRT and from what I am told, they get very little pushback from the insurance industry. You would think insurance companies would fight paying for this relatively expensive treatment if there was no substantive evidence of efficacy.
I have great respect for you TA, so let me ask you the question in another way. Given all you know on the subject and if you were a betting man, would you bet that when all the final analysis is in, that MDT does in fact extend life? Or that it’s all a mirage?
"You are clearly in the minority with that opinion now. " LOL. Is science a popularity contest? I think if you asked most people and even some doctors questions like: are measles vaccines needed? Is gravity a force? Can diet cure cancer?, you would get the wrong answers, as far as we now know.
Putting aside the agnorance that AI causes, I don't disagree that MDT+ADT "can improve progression-free survival (PFS)." Progression is initially almost entirely PSA progression, and since MDT certainly treats PSA, short-term progression (as defined in all trials so far) certainly slowed.
" and potentially extend life " That is certainly a question worth investigating - whether it does or not.
One doctor's practice cannot possibly decide the question. Insurance companies have always approved MDT because it is palliative (which is why NCCN also lists it as a therapy that can be offered). They don't know something the rest of us don't.
I have equipoise. I have always said that lacking evidence, if safe, why not. It certainly makes patients and doctors (like your Dr. Scholz, who also is seeing the effect of lead-time bias of prevalent PSMA PET scans) feel like they are accomplishing something.
I am skeptical, but hopeful. The reason for my skepticism is the STOMP trial, which IMO is the best so far. The authors pre-specified an 80% confidence interval for this pilot study. This is unusual (it is usually a 95% confidence interval). Ostensibly, this was because they knew they would be implementing an expanded Phase 3 study (which was never done)and only wanted to check for gross differences in this Phase 2 pilot study. In a more conventional statistical analysis, the hypothesis that MDT affected ADT-free survival would have been rejected. Also, at 80% confidence, they should have accepted the hypothesis that the higher number of metastases in the Surveillance group made a difference - but the authors seem to ignore the inconsistency. Because of this, patients and clinicians are cautioned to not make changes in treatment decisions based on this.
Because "polymetastatic progression" was the endpoint used to determine whether ADT was indicated for treatment, and 39% of the Surveillance group were already starting with 3 metastases at baseline, it is surprising that it took 13 months for a single new metastasis to become detectable in that group, and that for 19% of the Surveillance group, a fourth metastasis never became detectable throughout the 3 years of follow up. In the MDT group, four new metastases had to become detectable after the first ones were eradicated by treatment. 31% (11 of 31) had a second round of treatments, and 6% had a third round of treatments before the sudden appearance of four or more detectable metastases all at once. By setting "ADT-free survival" as the endpoint and making it conditional upon the simultaneous detection of four metastases, they guaranteed that the endpoint would be reached earlier in the Surveillance group.
What is surprising is that even with that built-in bias, the difference was not significant with 95% confidence. It is also worth noting that in a pre-planned subgroup analysis, there was no significant difference in ADT-free survival (even at 80% confidence) among those who had a PSA doubling time at baseline of >3 months. Patients with "indolent" metastases did not benefit from MDT. This study does not show that metastatic progression was slowed by MDT. Only an improvement in overall survival time can show that.
It's also worth mentioning that among the top doctors, there is no consensus on MDT.
Q77: In patients with synchronous low-burden mHSPC on next-generation imaging and negative on conventional imaging, do you recommend additional MDT (if technically feasible) of all lesions?
• Yes, in the majority of patients: 45% (47 votes)
• Yes, but only in selected patients: 39% (40 votes)
• No: 16% (17 votes)
• Abstain/unqualified to answer (2 votes)
NO CONSENSUS
(There is also no consensus for metachronous low-burden mHSPC Q83, oligoprogressive mCRPC Q133 & Q134)
One thing you said previously is difficult to reconcile with real world activity. You said that insurance companies allow MDT for ‘palliative’ purposes only. If that’s the case, does that mean doctors who prescribe MDT for multiple mets must do so under the guise of current or future pain relief, resulting from each and every met being treated? And if they indicated it was only for curative or delay of progression purposes, the treatment would likely be denied?
I only know that insurance routinely approves MDT and has always done so. I don't think justification is required, although the ins-and-outs of insurance never makes sense to me.
Well, in hindsight I had (unknown) metastatic pelvic lymph nodes at the time of my RP and subsequent RT to prostate bed. Seven years ago yesterday, 06 March, I had metastasis-directed extended pelvic lymph node surgery, no ADT. Six pelvic nodes nodes including para-aortic confirmed cancerous. (Yes, I know, anecdotal).
Yesterday, I had latest uPSA draw - result 0.029. Previous two were 0.028 and another 0.029, respectively. Been holding 0.03X range since June 2021, no ADT. (Yes, I know, many do not support use of ultrasensitive PSA testing).
Had I done ADT with ePLND it seems logical I would have same result; would my treatment method and outcome still be anecdotal? All the best to all of us!
Hi Nano, So glad you are doing well. My husband had radical prostatectomy - Gleason 7 - initially no lymph node involvement noted at time of surgery and psa of 9. Three months later, psa of 5 - looks like we are going the triplet route - your story gives me hope. I want him around for years. He has five nodes that show on psma pet scan.
Hi Luv your man ;). All the best with your husband's treatments. I am currently experience success with my metastatic melanoma - so good outcomes can and do happen. Best! Murray
so delay T return with a period of adt, and then delay progression (big surprise /sarcasm) but also perhaps use up some of the valuable time the cancer will spend before it becomes fully castrate resistant? is this just re-arranging the chairs on a titanic?
It is couched as an great result but what is missed at least for me in these studies that only follow patients for five years or eight years is whether a change in a milestone has added years of quality lifespan, or just shuffled the deck of symptoms, side effects and so on.
some think delaying horrible metastatic growth, broken bones, etc is worth it compared to perhaps additional side effects of teatment...what is rarely spoken about here is the final uncontrolled metastaic devastation of the patient....instead we often see "he died peacefuly" !!! Well, maybe drugged out in the very final last days!!!
Loved the analogy! However do not forget you get to hear the band. Kind of ironic also that all the women and kids have already left the ship and us men are waiting to die. 🪑
No longer Uncle Google, now we ask our cousin A.I.
What is metachronous oligorecurrent"
ChatGPT said:
Metachronous oligorecurrent refers to a specific pattern of cancer recurrence. Let’s break it down:
Metachronous: This means that the recurrence happens at a different time than the initial cancer diagnosis, usually after a period of remission. It contrasts with synchronous, where multiple tumors appear at the same time.
Oligorecurrent: This refers to a recurrence of cancer that is limited in number and location, typically meaning a few (usually up to 3-5) metastatic lesions.
So, metachronous oligorecurrent cancer describes a situation where a patient experiences a limited number of cancer recurrences after a disease-free period. This term is often used in the context of metastatic cancers where treatment options like surgery, radiation, or systemic therapies might still offer good control of the disease.
Just don't make any decisions based on general AI....perhaps specialized(trained?) AI will make that possible in the future. The AI quotes I see hear generally demands that I look further into stduues that may or may not be in accord with the AI answer!!
It depends on the type of decision you're making. General AI (AGI) doesn’t exist yet, but if you mean AI systems available today (like machine learning models, ChatGPT, or predictive algorithms), here are some considerations:
When AI Can Help:
✅ Data-Driven Decisions – AI can analyze large datasets and recognize patterns humans might miss.
✅ Automation – AI can handle repetitive tasks efficiently, freeing up time for more strategic thinking.
✅ Recommendations – AI can suggest options based on probabilities, like in finance, healthcare, and logistics.
✅ Predictive Analysis – AI models can help forecast trends in business, marketing, and economics.
When You Should Be Cautious:
⚠️ Ethical Concerns – AI can have biases, so always check for fairness.
⚠️ Lack of Human Judgment – AI lacks intuition, creativity, and moral reasoning.
⚠️ Incomplete Data – AI predictions are only as good as the data they’re trained on.
⚠️ Accountability – If something goes wrong, you are responsible, not the AI.
Best Practice:
🔹 Use AI as a decision-support tool, not as the sole decision-maker.
🔹 Verify AI-generated insights with human expertise.
🔹 Be aware of potential biases in AI models.
🔹 Stay updated on regulations regarding AI use in your industry.
Splashy headline but note they emphasized the importance of patient selection:
"...significant PFS advantage with ADT was not observed in those with a prostate-specific membrane antigen (PSA) concentration of 0-2 ng/mL, a PSA doubling time of more than 3 months, and M1a disease stage at baseline, along with patients whose time from first curative treatment to SBRT was more than 43 months."
It sounds to me like ADT tended to help only the more advanced cases, which intuitively makes sense.
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Statins and prostate cancer
With or without ADT?
Any chance of weight loss??
Hormone therapy can make prostate cancer worse, study finds
