I've heard of a couple of institutions doing this in the setting of oligometastatic disease to bone. Does anyone know of any trials showing its efficacy?
Treatment of prostate to therapeutic doses in the setting of bone metastases
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Not curative efficacy no. People do it but off protocol and they give LT ADT. It will be years before anyone knows if that works.
If they have a big tumor and might live a while curative ish dosing (66-72) makes sense for palliative reasons.
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People certainly treat these patients "curatively", and not sure if that is the right thing to do in the absence of obstructive symptoms.
Median survival for patients with bone only metastatic cancer is generously a few years, let's just say 3. We know from the "treatment vs no treatment" for all prostate cancers that the survival benefit doesn't show up until about the 12-15 year mark. So.. Most of these guys are dead after 3-5 years, and very few are alive at ten. Plus, they are older patients to begin with, so they will die of other things, too.
I think of radiation and surgery for prostate cancer as equally curative, with a different menu of side effects. And, if I saw a urologist perform a prostatectomy on a dude with prostate cancer with a bone metastasis but no prostate obstructive symptoms, I would mock him/her mercilessly at tumor board (urologists are so dumb, and get so mad when you taunt them with mere facts, it's hilarious).
Sounds like something you'd see being done at CTCA or something.
Vote Trump!
DD
Median survival for patients with bone only metastatic cancer is generously a few years, let's just say 3. We know from the "treatment vs no treatment" for all prostate cancers that the survival benefit doesn't show up until about the 12-15 year mark. So.. Most of these guys are dead after 3-5 years, and very few are alive at ten. Plus, they are older patients to begin with, so they will die of other things, too.
I think of radiation and surgery for prostate cancer as equally curative, with a different menu of side effects. And, if I saw a urologist perform a prostatectomy on a dude with prostate cancer with a bone metastasis but no prostate obstructive symptoms, I would mock him/her mercilessly at tumor board (urologists are so dumb, and get so mad when you taunt them with mere facts, it's hilarious).
Sounds like something you'd see being done at CTCA or something.
Vote Trump!
DD
LOL. They're my referring physicians so I can't call them dumb to their face. Unfortunately very big named institutions are doing it too...
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They refer??
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Any data from said institutions published in a decent journal?
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The CHAARTED trial (NEJM 2015) illustrates that median survival in men with hormone naive metastatic prostate cancer is nearly 5 years (57.6 months to be precise) in men treated with ADT and docetaxel...it is longer in men with low volume metastasis. There is evidence in kidney, breast, colon and ovarian cancers that cytoreductive surgery with or without radiation is associated with improved survival and response to systemic therapy. Several laboratory models suggest that treating the primary tumor can influence metastases. The current best evidence for an effect in prostate cancer is a SEER-based study published in 2014 (Culp SH, Schellhammer PF, Williams MB. Might men diagnosed with metastatic prostate cancer benefit from definitive treatment of the primary tumor? A SEER-based study. Eur Urol. 2014;65:1058–1066). Of course this is not definitive and prospective trials are required. The NCI has specifically asked for studies in this scenario (does local therapy influence survival in the setting of metastasis.
To the original question go to clinicaltrials.gov and search NCT01751438 or go to https://clinicaltrials.gov/ct2/show/NCT01751438
Mock away if you wish...
The chemotherapy arm of the recently published CHAARTED study shows median survival of 57 months in metastatic hormone-sensitive prostate cancer. 2/3 of the patients this trial had "high volume" metastatic disease ( with high volume defined as the presence of visceral metastases or ≥4 bone lesions with ≥1 beyond the vertebral bodies and pelvis). This trial was initiated in 2006 before the approval of next-generation antiandrogens, Radium-223, etc (all of which demonstrate improvement in survival in the castrate resistant, post chemo setting). It may be reasonable to imagine there are not an insignificant number of pts getting closer to that decade mark for survival. In addition, a number of academic centers are doing "debulking" surgery for oligometastatic prostate cancer. As a precedent, in renal cell cancer, there is evidence of survival benefit for primary tumor resection in the setting of metastatic disease.
http://www.nejm.org/doi/full/10.1056/NEJMoa1503747
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I knooooooow, wombat, but everybody was dead on that trial after 80 months. Or has my Dirty South friends say "urry-one". They all were gonezo. Not even one left.
That's not even 7 years. So, until the systemic therapy gets better, I don't see where the local treatment is going to change things. If the benefit of local treatment (not PSA control, but avoiding death) doesn't show up until 10-15 years, and everyone currently is dying at 7 years or earlier, I don't know if it would help. Maybe you're right. But the math doesn't seem to work. It took years and years to show that anything that changes survival in even localized prostate cancer. For metastatic...
That's not even 7 years. So, until the systemic therapy gets better, I don't see where the local treatment is going to change things. If the benefit of local treatment (not PSA control, but avoiding death) doesn't show up until 10-15 years, and everyone currently is dying at 7 years or earlier, I don't know if it would help. Maybe you're right. But the math doesn't seem to work. It took years and years to show that anything that changes survival in even localized prostate cancer. For metastatic...
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Ah yes..therapeutic nihilism.
As JM Keynes stated years ago "In the long run we are all dead".
I don't think your analogy with localized disease is apt. In low risk disease competing risks for mortality are likely to blur any effect of local therapy. Radical prostatectomy (PIVOT and Holmberg) improves survival in men with intermediate/high risk disease and radiotherapy (when added to androgen deprivation) improves survival in men with locally advance disease (NCI Canada and Widmark). In both cases the improvement is evident within the first decade. In men with metastatic disease the major cause of death is prostate cancer (competing risks are much less important) and it is reasonable to conclude that a local therapy may move the curve.
If you are only interested in cure then maybe you should focus your practice on keloids, low risk prostate cancer and seminoma.
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I concede. You're much smarter than me (no sarcasm). Maybe people should be treating these folks.
As a Third Rate Doctor at a Third Rate Institution, I end up following NCCN Guidelines, UpToDate, and AUA, none of which currently recommend local treatment. If I was a First Rate Doctor, I could consider going rogue. At this point, due to limited intellect, I'll probably not treat that aggressively and send to First Rate institutions for 2nd opinions.
Luckily keloids make up a vast part of my practice, so I'm not insulted. I make people feel prettier.
As a Third Rate Doctor at a Third Rate Institution, I end up following NCCN Guidelines, UpToDate, and AUA, none of which currently recommend local treatment. If I was a First Rate Doctor, I could consider going rogue. At this point, due to limited intellect, I'll probably not treat that aggressively and send to First Rate institutions for 2nd opinions.
Luckily keloids make up a vast part of my practice, so I'm not insulted. I make people feel prettier.
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I can relate... I can only shoot for the fairway in my practice!
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Stampede is already adding some interesting (albeit nonrandomized) data for clinically lymph node positive patients. This study:
http://oncology.jamanetwork.com/article.aspx?articleid=2470990
showed significant improvement with the use of XRT in clinically node positive patients. Not randomized, but left to treating physician discretion. The Lancet Stampede manuscript (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01037-5/abstract) also showed that chemo seems to be helpful in N+ patients. Unfortunately in that study they did not show a forest plot for N+M0 patients. I look forward to seeing the results for the randomized use of XRT with bone mets down the road (gotta love 8 arm trials...)
http://oncology.jamanetwork.com/article.aspx?articleid=2470990
showed significant improvement with the use of XRT in clinically node positive patients. Not randomized, but left to treating physician discretion. The Lancet Stampede manuscript (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01037-5/abstract) also showed that chemo seems to be helpful in N+ patients. Unfortunately in that study they did not show a forest plot for N+M0 patients. I look forward to seeing the results for the randomized use of XRT with bone mets down the road (gotta love 8 arm trials...)
