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Radiation For Metastatic Prostate Cancer

What Should Patients Know About Msks Approach To Treating Prostate Cancer

Dr. Parker on Radiotherapy in Metastatic Prostate Cancer

At MSK, we manage prostate cancer in a very comprehensive way, tailored to each patients disease and to the individual person. There is no one specific therapy that is best for everyone.

Our initial assessment includes a carefully evaluated biopsy and a very detailed MRI to show the location of the disease, the integrity or soundness of the capsule surrounding the prostate, and the amount of disease. Then, based on that information and with input from the urologist, the radiation oncologist, and the medical oncologist we can provide a comprehensive recommendation.

The radiotherapy we do here at MSK is state-of-the-art and unparalleled. We are the only center in the world to do MRI-based treatment planning. When we give brachytherapy, we use computer software that provides us with real-time information about the quality and accuracy of the seed implant during the procedure. This allows us to make adjustments while the patient is still under anesthesia, so that when the procedure is completed, we have been able to achieve ideal placement of the radiation seeds. This translates into improved outcomes.

For more advanced disease, we have ongoing studies in which we combine novel hormonal therapy agents with radiation to achieve better results. Even the way we follow our patients after treatment is unique, with carefully sequenced MRI checks that give us opportunities to monitor patients extremely closely.

What Is Intermittent Adt

Researchers have investigated whether a technique called intermittent androgen deprivation can delay the development of hormone resistance. With intermittent androgen deprivation, hormone therapy is given in cycles with breaks between drug administrations, rather than continuously. An additional potential benefit of this approach is that the temporary break from the side effects of hormone therapy may improve a mans quality of life.

Randomized clinical trials have shown similar overall survival with continuous ADT or intermittent ADT among men with metastatic or recurrent prostate cancer, with a reduction in some side effects for intermittent ADT .

Epidemiology Of Advanced Prostate Cancer

Approximately 11.6% of men will develop prostate cancer in their lifetime, with the likelihood increasing with age prostate cancer is most often diagnosed in men age 55 to 74 years, and the median age at diagnosis is 66 years. Since the advent of prostate-specific antigen screening, prostate cancer is being detected and treated earlier.

Overall, incidence rates of prostate cancer began declining in 2000. Acceleration in the decline began in 2008, when organizations began recommending against routine PSA screening From 2011 to 2015, the rate decreased by about 7% per year.

A review of almost 800,000 cases of prostate cancer diagnosed from 20042013 found that although the incidence of low-risk prostate cancer decreased from 2007-2013 to 37% less than that of 2004, the annual incidence of metastatic prostate cancer during those years increased to 72% more than that of 2004. The increase in metastatic prostate cancer was greatest in men aged 5569 years.

At diagnosis, 77% of prostate cancer cases are localized in 13%, the cancer has spread to regional lymph nodes, and 6% have distant metastasis. The 5-year relative survival rate for localized and regional prostate cancer is 100%, compared with 30.5% for metastatic cases.

The mortality rate associated with prostate cancer continues to increase in Europe and in countries such as Australia, Japan, and Russia.

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Ongoing Studies And Future Directions

As investigation into the curative potential of MDT in OMPC continues, several major questions remain unanswered. Can MDT alone produce durable clinical benefits and, if so, how can patients be most appropriately selected? Does MDT provide additive benefit when combined with ADT and other systemic therapies? Does MDT have clinical benefit in oligoprogressive CRPC? Can MDT be combined with immunotherapy to encourage a systemic antitumor response?

Multiple prospective randomized clinical trials are ongoing to answer these first two questions. Similar to STOMP, the Baltimore ORIOLE trial is evaluating progression, ADT-free survival, and immunologic correlates in men with OMPC randomized to receive observation or SABR. PCS IX is investigating the clinical benefit of adding SABR to systemic treatment with ADT and enzalutamide in patients with CRPC. CORE and STEREO-OS are randomizing patients with prostate, breast, or lung cancers with 1-3 oligometastases to standard of care systemic therapy with or without SABR. STORM is randomizing patients with oligorecurrent prostate cancer confined to the lymph nodes to MDT with six months of ADT ± whole pelvic radiotherapy. Finally, the Movember GAP6 international initiative is pooling tissue samples from clinical trials such as these in order to promote collaborative efforts to facilitate further biologic understanding of the oligometastatic state in prostate cancer.

Defining The Oligometastatic State

Prostate

Although the definition of oligometastatic disease varies considerably in the literature, most definitions limit the maximum number of metastatic sites to between 3 to 5.8 Furthermore, a major challenge in synthesizing the available literature is the wide array of clinical scenarios represented. In the landmark paper by Hellman and Weicheslbaum, the authors described two scenarios that both fell under the umbrella of oligometastatic disease, but likely have different clinical courses. The first are tumors early in the chain of progression with metastases limited in number and location and another group of patients with oligometastases who had widespread metastases that were mostly eradicated by systemic agents, the chemotherapy having failed to destroy those remaining because of the number of tumor cells, the presence of drug-resistant cells, or the tumor foci being located in some pharmacologically privileged site. Consequently, more granularity is needed when describing oligometastatic disease. One such effort is the European Society for Radiotherapy and Oncology and European Organization for Research and Treatment of Cancer consensus recommendations for characterization and classification of oligometastatic disease, which identified 9 distinct states of oligometastatic disease.9 Standardized definitions of oligometastatic disease will lead to a more uniform understanding of study results and allow for cross-study comparisons.

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Radiation Therapy For Prostate Cancer

Radiation therapy uses high-energy rays or particles to kill cancer cells. Depending on the stage of the prostate cancer and other factors, radiation therapy might be used:

  • As the first treatment for cancer that is still just in the prostate gland and is low grade. Cure rates for men with these types of cancers are about the same as those for men treated with radical prostatectomy.
  • As part of the first treatment for cancers that have grown outside the prostate gland and into nearby tissues.
  • If the cancer is not removed completely or comes back in the area of the prostate after surgery.
  • If the cancer is advanced, to help keep the cancer under control for as long as possible and to help prevent or relieve symptoms.

How Does Radiotherapy Treat Advanced Prostate Cancer

Radiotherapy can be used in different ways to treat advanced prostate cancer:

  • As part of your first treatment for advanced prostate cancer If youre offered radiotherapy as part of your first treatment, youll have a type called external beam radiotherapy.
  • To improve symptoms in areas where the cancer has spread You may have external beam radiotherapy to the part of the body where the cancer is causing problems.
  • To help some men with bone pain live longer If your cancer is causing bone pain, you may be offered a type of internal radiotherapy called radium-223 to help you live longer and to treat the bone pain.

A clinical oncologist or radiographer will plan your radiotherapy with you. They will explain which type of radiotherapy you will have, how long the treatment could take and the possible side effects. This could depend on where your cancer has spread to, any symptoms youre having, and your general health and fitness.

A team of treatment radiographers will give you the treatment. They’ll also give you support and information during your treatment.

The information on this page is for men with advanced prostate cancer. If your cancer hasn’t spread to other parts of the body, read our information on external beam radiotherapy for localised or locally advanced prostate cancer instead.

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Demographics And Pathological Characteristics

A total of 22,604 mPCa patients who met the inclusion criteria were identified from the SEER database. There were 5,505 patients in the radiotherapy group and 17,099 participants in the control group. Patient characteristics are shown in Table 1.

Table 1 Clinicopathological characteristics of the cohort by treatment groups.

New Radiation Therapy For Prostate Cancer Reduces Deaths Study Shows

STAMPEDE: Radiotherapy for men with newly diagnosed metastatic prostate cancer

By the time Michael Rosenblums prostate cancer was discovered, it was already at a late stage. Hed initially sought medical help because of excruciating back pain, but, during an exam, doctors found a tumor on his spine and tests revealed a skyrocketing prostate-specific antigen, or PSA, score. Chemotherapy didnt help much, so when doctors offered the opportunity to be in a clinical trial for a new experimental treatment, Rosenblum jumped at it.

The trial was investigating a new, potentially groundbreaking type of treatment for prostate cancer, a therapy that specifically targets a protein on the cancer cells. The treatment, part of a new class of liquid radiation drugs, obliterates most prostate cancer cells without hurting the surrounding tissue.

Its wonderful. I have no symptoms or anything, said Rosenblum, a 75-year-old retiree, who was diagnosed four years ago. He participated in the clinical trial at Memorial Sloan Kettering Cancer Center in New York. “My PSA went from 100 … to zero.

Higher PSA levels suggest that prostate cells are growing, which may indicate cancer.

Results from the trial Rosenblum participated in were released Thursday ahead of the annual meeting of the American Society of Clinical Oncology. The study finds that the new drug reduced the risk of death by 38 percent in patients with advanced prostate cancer. Progression of the disease was reduced by 60 percent.

The patients who received the new drug got it intravenously once every six weeks.

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New Radiation Therapies Keep Advanced Prostate Cancer In Check

  • By Charlie Schmidt, Editor, Harvard Medical School Annual Report on Prostate Diseases

Treatments for prostate cancer are always evolving, and now research is pointing to new ways of treating a cancer that has just begun to spread, or metastasize, after initial surgery or radiation. Doctors usually give hormonal therapies in these cases to block testosterone, which is a hormone that makes the cancer grow faster. But newer evidence shows that treating the metastatic tumors directly with radiation can produce better results.

In March, researchers published the latest study that supports this approach. Based at Johns Hopkins University School of Medicine in Baltimore, the team used a method for delivering powerful beams of high-dose radiation to very small cancers in the body. This approach is called stereotactic ablative radiotherapy , and it can spare healthy tissues with remarkable precision. Doctors map out where to pinpoint the radiation in advance by putting patients into a computed tomography scanner that takes x-rays of the body from many different angles.

Then the men were followed for six months and monitored for changes such as PSA increases, tumor growth, worsening symptoms, or how many men wound up on hormonal therapy.

What Is Advanced Prostate Cancer

When prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer.

Prostate cancer is often grouped into four stages.

  • Stages I & II: The tumor has not spread beyond the prostate. This is often called early stage or localized prostate cancer.
  • Stage III: Cancer has spread outside the prostate, but only to nearby tissues. This is often called locally advanced prostate cancer.
  • Stage IV: Cancer has spread outside the prostate to other parts such as the lymph nodes, bones, liver or lungs. This stage is often called advanced prostate cancer.

When an early stage prostate cancer is found, it may be treated or placed on surveillance . If prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer. Stage IV prostate cancer is not curable, but there are many ways to control it. Treatment can stop advanced prostate cancer from growing and causing symptoms.

There are several types of advanced prostate cancer, including:

Biochemical Recurrence

If your Prostate Specific Antigen level has risen after the first treatment but you have no other signs of cancer, you have “biochemical recurrence.”

Castration-Resistant Prostate Cancer

Non-Metastatic Castration-Resistant Prostate Cancer

Metastatic Prostate Cancer

  • Lymph nodes outside the pelvis
  • Bones
  • Other organs

Metastatic Hormone-Sensitive Prostate Cancer

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Site Of Oligometastasis: Bone Versus Lymph Node

The sites of treated metastases in the studies were mostly bone or lymph node. In the present review, twelve, seven and 37 studies with treatment of exclusively nodal metastases, bone metastases or both were included and investigated. In most studies including patients with nodal and bone metastases, the site of metastasis was not a predictive factor for the respective clinical outcomes . In contrast, Fodor et al. reported a higher risk for clinical relapse in patients with extra-pelvic lymph nodes metastases compared with pelvic lymph node lesions and in the studies of Schick et al. and Deek et al. a trend for better biochemical progression-free survival was shown in patients with lymph node metastases compared with those with bone metastases . In addition, the largest study to date based on prospectively collected data based on patients treated on clinical trials, demonstrated that the presence of bone metastases was associated with a worse survival compared to lymph node metastases in MPC . Hence, it is not surprising that in the recently published APCCC report, the majority of experts voted for the distinction of these two kinds of metastatic patterns . However, since encouraging clinical outcomes of studies with exclusively bone metastases were reported, with 2-year LC and PFS rates of 76100% and 2738%, respectively, these patients may benefit from MDT and should not be excluded .

Survival In Patients With Metastatic Prostate Cancer Undergoing Radiotherapy: The Importance Of Prostate

How Radiation Therapy is Used to Treat Cancer
  • 1Department of Urology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
  • 2Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China

Objectives: To explore the effectiveness of radiotherapy in mPCa patients with different PSA stratifications based on the cancer database of a large population.

Background: Screening criteria for patients with metastatic prostate cancer, who are candidates for radiotherapy, are rarely reported.

Patients and Methods: We identified 22,604 patients with metastatic prostate cancer in the Surveillance, Epidemiology, and End Results database and divided them into a radiotherapy group and a control group. Patients with metastatic prostate cancer were divided into subgroups according to their levels of prostate-specific antigen to evaluate the efficacy of radiotherapy. They were also divided into six subgroups according to their prostate-specific antigen levels. We used multivariate Cox analysis to evaluate overall survival and cancer-specific survival. After 1:1 propensity score matching, Kaplan-Meier analysis was used to explore the difference in overall survival and cancer-specific survival in the radiotherapy and control group.

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Why Treat Prostate Cancer Metastases With Ablative Radiation

Rationale for Metastasis-Directed Therapy in Prostate Cancer

Traditionally, the management of metastatic cancer has been chiefly through systemic treatments while local therapies such as radiation have been used primarily for palliation of symptomatic lesions. Prostate cancer commonly spreads to the bones, causing pain and potentially leading to fractures at weight-bearing sites such as the femoral neck, acetabulum, or vertebral bodies. Radiation is highly effective at reducing pain caused by osseous metastases and can be delivered in one or multiple fractions of external beam radiotherapy or with the systemic radiopharmaceutical radium-223.

External Beam Radiotherapy For Advanced Prostate Cancer

You can have external beam radiotherapy as an outpatient in the radiotherapy department. Some people may need to stay in hospital while they have it. Radiotherapy is given using a machine that is like a big x-ray machine. This is called a linear accelerator .

You may have external beam radiotherapy as a single treatment or as a few sessions over a few weeks.

At the beginning of a treatment session , the radiographer will make sure you are in the correct position on the couch and that you are comfortable. Radiotherapy is not painful. But you have to lie still during the treatment. You may want to take your painkillers before you have it.

When everything is ready, the radiographer leaves the room so you can have radiotherapy. The treatment only takes a few minutes. You can talk to the radiographers through an intercom or signal to them during the treatment. They can see and hear you from the next room.

Your cancer doctor, nurse, or radiographer will explain your treatment and its possible side effects. They can give you advice to help you cope with any side effects. They can also help answer any questions you may have.

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What Is Stereotactic Body Radiation Therapy And What Advantages Does It Offer

Traditionally, we deliver external beam radiation in 45 to 48 sessions over a span of ten weeks, using very sophisticated computer-based planning and enhanced imaging techniques and tumor tracking during the treatment. This is called image-guided IMRT and it is the current standard of care.

But there is increasing interest in giving this radiation in shorter courses of treatment. Many of the people we care for have a type of radiation therapy called MSK PreciseTM. MSK Precise is a form of SBRT that can be given in five sessions instead of the usual 45 to 50. MSK has been doing this for the past nine years, and the results in the several hundred people whove been treated have been excellent so far. The treatment is very well tolerated, with outcomes that are at least equivalent to and possibly better than the standard ten weeks of treatment. Because of its superior precision, MSK Precise has less side effects than more conventional radiation techniques, with extremely low rates of incontinence and rectal problems. The sexual side effects are low and similar to what is experienced with conventional external radiation techniques. And of course, its much more convenient for patients.

For patients with more-advanced tumors, we are completing a phase II trial in which were combining sophisticated brachytherapy approaches with MSK Precise. This kind of combination of dose-intense or escalated radiation may end up being a very effective regimen.

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