Approaching the oligometastatic state methodically

A valid and well thought out argument. The only thing I would query is your statement that long term ADT shortens life. Yes there is an increased risk of cardiac and stroke events plus some thinking that prolonged ADT might promote genetic changes which result in mets. The numbers involved for the cardiac and stroke are low in patients who do not have a pre existing co morbidity. The numbers for the genetic changes is still being evaluated but more data will become available as more and more men are being kept alive with the new treatments. I think the main issue is the quality of life which ADT can affect. I must admit I am a little biased as hubby has just had SBRT to zap mets and, depending on how that goes, we will be having a conversation about continuing ADT. I do believe that the proposed criteria for stopping ADT is an undetectable PSA. How many will achieve this after zapping is in the lap of the Gods. Should the argument then be extended to the next treatments like Lutetium 177, Immunotherapy, PARP inhibitors, Docetaxel, Cabazitaxel..... if they produce an undetectable PSA with concurrent ADT.

Hi Mascouche,

I also like the Dr Mark Scholz from the Prostate Cancer Research Institute videos, they are incredibly informative. I too like to question the treatment that my partner has and look at alternatives. I think you have a very analytical approach to looking at your own treatment and questioning its validity, but I can't agree with you on the value of ADT and  "shortening" life.  The reason is that there has been extensive research on how ADT can give men with advanced PC extra years, especially if it is given early with a standard hormone therapy just after diagnosis. The "STAMPEDE trial" Using over 10,000 men for research has confirmed this. The results of the trial which investigated new treatment approaches for men affected with high-risk prostate cancers started in 2005 and the results have been  published in the Lancet Oncology in early May 2023. There has been a lot written about how Abiraterone and Enzalutamide are able to extend life. This research has been ground breaking and life changing for many men. 

L

Hi Alwayshope,

When I say that it shortens life, it does not mean that it is not effective against cancer, because when it is effective, then it prolongs life. But if your condition is not a systematic one where cancer is all over the place, then it is worthwhile to se if some radiation could save you from a life on ADT. 

As you mentioned there are increased risk of heart issues, which I believe is the #1 cause of death for people with prostate cancer. But it is more than that. I exercise regularly, eat only unprocessed food (meat and veggies), I sleep between 7 and 9 hours per day, I do not smoke or drink alcohol. Actually I only drink filtered water, tea and coffee. So I am typically on the healthy side for a man in his mid-fifties.

But despite sticking to my healthy habits,  while on ADT I became insulin resistant,  and began having lots of issues with my feet in the evenings where they felt like they were simultaneously on fire and getting lacerated by razors. Granted, maybe that was due to the radiation but my weight also ballooned up from 165 to 212lbs at the end of those 2.5 years. 

Once the ADT treatment was over, it took a few months to get my insulin resistance back in control (through water fasting, intermittent fasting and a low carb) and my weight is presently down to 175lbs. But it still took about 8 months for the brain fog to lift and it took about 11 months before my feet went back to normal.

So when I see in what bad shape my body was after 2.5 years of ADT, I can only imagine that it would not have gotten healthier, hence conducive to a longer life, if I was to be on ADT forever.

When your problem is systemic, ADT might be the best solution. But even then we have to hope that we can at least have periodic ADT vacations in order to repair some of the damage once in a while.

Hi i do agree with you about having vacations from ADT drugs to check where you are, If just to be free of drugs and feel normal again. Intermittent ADT is something I am very interested in for my partner, but it has to be well monitored. There's prostate cancer that can be  watched because it is slow, but there's also prostate cancer in roughly 5% -10%? of men that can't. It needs to be watched like a hawk because it will just run away and take hold. It's important to know what type you have.

L

Hi BarryW,

I agree with you about ADT being useful early on and even more useful when combined with radiation therapy. The CHART and STAMPEDE trials were fairly clear about that. 

And if you are in a polymetastatic phase/state, then there too I believe that ADT plays an important role.

But those were not what my post was about. In the title I did specify oligometastatic. I was talking post the initial phase, when some of us fall into the oligometastatic category AFTER we've already attempted the triplet therapy in the initial phase. That phase fit more with the ORIOLE trial (and maybe the STOMP trial). It is for that phase that I think one should go through a methodic elimination process.

Ok,  If a man was prescribed and advised to take certain medications to bring down his PSA and control his Prostate cancer by a medical professional, and every time he took it his PSA dropped. Then every time  he decided he couldn't take it anymore because of the side effects, he stops taking it he finds his PSA rises, but not only that now metastatic seeds are found in distant places...

Should he- 1).   Take a different ADT drug recommended by a professional in an attempt to find something with which could suit him better with less side effects and then consider having targeted RT to eliminate the new mets?  Or  2).do nothing?

L

In the UK I think there is a limit to the number of subsequent mets that can be treated with SBRT - 5. My husband has a very aggressive form of prostate cancer so it was decided to have a go at zapping all of his distant mets after recurrence as his initial pelvic cancer reacted well to radiotherapy, but not so well to chemotherapy. In total 10 lymph nodes, visceral met and 2 on the adrenal glands were treated with SBRT and we await an MRI in a couple of weeks to see how well it has worked. In Greece we have a choice of where we are treated and by whom so can make sure that the best machines and experts are used for treatment. He has been on Prostap for 4 years now and has not had the side effects that you have experienced, plus he was initially on Bicalutamide for 18 months, then Enzalutamide for 18 months. We were advised that having an aggressive approach with both ways of dealing with the testosterone for 3 years would have the best chance of disrupting the multiplication cycle of the cancer cells.

In the meantime they are doing the genetic testing in preparation for the next treatment if needed.

Hi BarryW My scenario was about oligometastatic, so the patient, me, already has between 1 and 5 distant mets. 

In the scenario you mention, you say that the patient now has metastatic seeds so I assume there was no distant metastasis at diagnosis? I think that patient should take ADT for the duration of his treatment since he never did the full triplet therapy. 

But if after the full triplet therapy has completed and the patient has metastatic in distant places, he should throw radiation at those spots. He can also do some ADT for a while along with the radiation and then stop once the PSA is undetectable for a few months. He should also do Pet PSMA scans to make certain that there is no activity anywhere. 

As you mention, the patient can try different ADT drugs as not everyone reacts the same way to each. Some people has a horrible experience with Abiraterone and it was almost a breeze with Xtandi while some others report the opposite. 

I do not think that doing nothing is ever a good idea.. Unless you are not particularly attached to life and have access to medically assisted suicide so that you do not go through horrible pain from the mets compressing the bones and nerves.

But quite often, it is not a few weeks or months that will make or break everything. If it takes mets up to 8 years before they are big enough to appear on a scan, then it is not something you did or not the month just before your scan that will have cause the metastasis to suddently appear. it was likely already growing for years but was just too small before now.

To be clear, this is my approach for myself. I was diagnosed in 2019 and I opted to try natural approaches for a full year before finally accepting to do the triplet therapy because while I felt healthier than ever, I simply could not get the PSA under control with the high burden of cancer on my prostate and lymph node.  

If I did not rush toward a treatment when I had a PSA of 116, I do not see a need to rush now that I have a PSA of 1.07. I intend to get rid of the metastasis with radiation, and will take ADT during that time if my RO leaves me no choice. But after I've been NADIR for a while, I will take a ADT vacation to see if the PSA rises once again and if it does, I will undergo new scans to see if some met that was previously too small is now visible enough to appear on a scan and be radiated. 

Hope this helps,

Several studies show that going aggressive early is the best approach. That is what I did too, once I had decided to undergo treatment, so about a year after Diagnostic in my case. Luckily I was not worse off for having waited a little, despite having a BRCA2 mutation that is said to make the cancer more aggressive. 

You appear to have a nice health system in Greece. 

Mascouche Yes that's clear.  Have you been diagnosed with Oligometastatic disease? .

L