Is "de-bulking" the original prostate tumor a good idea for men with metastases?

The answer is: "it depends."

No two cases are identical. One of the most common reasons for de-bulking a tumor-laden organ is because it is pressing into and interfering with the function of an adjacent organ. It's major surgery, and it's not going to offer a cure, so one would go hesitantly into it. Needs to be assessed on a case-by-case basis. One size does not fit all.

As you say, it's not that simple. Some cancer cells (like some advanced metastatic ones) multiply a lot faster than others, and some have the ability to travel and clump, whereas others don't. As I wrote, the cells in the prostate may actually slow down the growth of cancer cells in the bone - no one knows for sure. Tissue effects and signalling are very important with cancers. Remember, these are men with distant mets, so there are a whole lot of cancer cells in systemic circulation. A few million cells more or less in the prostate may not make a bit of difference because it's only a drop in the bucket. I'm not saying it's futile, I'm just saying that we just don't know. It's a lot to go through if there is no benefit.

- Allen

I won't vouch for the accuracy of this or if it still stands up to scrutiny based on newer knowledge, but David Servan-Schreiber, MD, PhD in his book Anticancer says this about surgeon Judah Folkman's experiments relating to the inability of tumors to grow to significant size without first developing an adequate circulatory system:
"large primary tumors send out metastases. But as in any colonial empire, they prevent these distant territories from becoming too important by producing another chemical substance that blocks the growth of new blood vessels–angiostatin.(This explains why metastases sometimes suddenly grow once the principal tumor has been surgically removed.)". (From the book anticancer by David Servan-Schreiber Page 52.)

So I used to feel a little bit better about the surgery that I've volunteered for by telling myself that maybe there was a benefit to the debulking, even though I had a positive margin and seminal vesicle involvement, so they did not "get it all". And if primary tumors send out mets, then debulking is probably a good thing, right? But reading the above- that it also sends out a met limiting factor- has thrown some doubt on that.

But on the other hand, I have read of a couple of different large studies on high risk PC patients – where surgery was the primary treatment–indeed the majority had no adjuvant or salvage RT– where both the overall survival and prostate cancer specific survival were quite excellent all the way out to 20 to 25 years. I was always quite surprised at those results, and the only thing I could pin it on what is the debulking. But I certainly have no idea. I would certainly like to believe that is the case, considering I was debulked.

Gunner34 said...
Yes, it's a lot to go through if there is no benefit. But if it helps get PSA to 0 when other approaches don't, it may be worth a try.

I had a tumor and mets that were pressing into my rectum, invaded my bladder, was throughout my prostate bed, in my lymph nodes, several bones in my pubic area, legs, sternum and clavicle, and other areas including my lungs. After about a year of ADT2 and chemo, most of these areas were "resolved" with the exception of the prostate area, which was still showing up as fiery. We concluded that my PSA which had come down to 0.18 and then went quickly to 0.36 (about a month) was coming mostly from the prostate.

I had to consider the risks of debulking. My surgeon could not confirm that my survival would be extended by any more than 12-18 months by going ahead with the RP. However with a rising PSA and a C-11 Choline scan that identified the prostate and local lymph nodes as the primary suspects, I went ahead with the procedure - an open RP. I was undetectable for 6 months after surgery and without any changes we went ahead with 36 treatments of radiation to all of the area of original metastases.

Fast forward to today -- I am doing very well. PSA remains undetectable as it has been since my debulking surgery. I felt like I was carved out like a pumpkin but after 2 years of slow recovery I have to say that it was worth it.

This path may not be for everyone. I was 46 when I started and very fit even though I was a few pounds overweight.

My story is by no means a scientific statistic. But it is a success story and debulking seems to have provided an excellent chance at sustained survival. Unfortunately, I know too many men whose diagnosis was not as severe, and because they had mets they were not debulked. Some of these men are no longer with us.

Thanks Allen for posting this discussion.

Gunner, thanks for that post. Your study of 1 makes me feel a little more confident that there was a benefit to my own debulking during my RP, even though I was in a category (G9, PSA a bit over 10) that a few very smart folks feel would be much better served with something other than surgery. Most of the time I agree with them, but sometimes I think there might have been a benefit. Your story, and the studies I mentioned of surgery only high risk guys who did much better than I would have guessed, make me feel there may well be a benefit to getting that main tumor out of there with or without other treatments. Maybe. Hopefully.

Of course I am talking about surgery, the OP is about RT. But both are considered debulking apparently.

Post Edited (BillyBob@388) : 1/31/2016 9:23:53 PM (GMT-7)

Thanks Allen.
Yes, the bone mets were treated as well. Only 12 treatments up in my shoulder area but the full 36 in my pubic/pelvic area. The illiac, ischium, and pubic areas as well as the upper leg bones (femur?) were included in the radiation that was also targeting the entire prostate bed.
I'm feeling pretty lucky so far and happy to share that all this can work towards a durable outcome, even with a 5+4 Gleason.

Allen
Yes, my blood cells were affected. Red counts had already been low since chemo but the radiation stalled that recovery. I'm finally just barely in the low range of normal.
Other blood #'s are also surprisingly normal.

If the gentleman that you mentioned has any questions about my experience I'm happy to discuss with him. I can send an email with my contact info if it would help. I agree that being young helped with recovery but I don't think that anyone shouldn't at least consider all the treatment options, regardless of age. Taxotere wasn't fun but it was easier than the Etoposide/Cisplatin cycles. I saw some guys in their 70's during my treatment and they were walking to and from the treatment center on their own. One of them didn't even lose his hair.

Gunner you have always been a source of inspiration for me through your story. Yours is one of the stories I bring up to my Med Onc as a possible path for me if/when necessary. Thanks for what you've gone through and your leading by example. Best of luck to your continued great results!!!

Jordan

Post Edited (jpenn44) : 2/1/2016 5:39:22 PM (GMT-7)

Dear Gunner34,

You've always been a loyal battle brother of mine on this forum, and I appreciate the details you have shared. I know that we both have had positive experiences at Mayo Clinic in Rochester, Minnesota --- certainly a "medical mecca" for those of us who live here in the Midwestern region. I've always appreciated your insight and support.

It sounds like de-bulking the original prostate cancer tumor in your case has led to some VERY favorable outcomes for you. You've traveled down some rough roads in your recovery, but you have lived to tell the tale and you are doing remarkably well. I always follow your posts, I know we've crossed paths many times here over time, and know we have some common threads in our story ...

I have the strong hope that SOMEDAY, perhaps in combination with other treatments, studies will show that de-bulking the primary prostate tumor surgically WILL be proven to have some survival benefits for those of us with metastatic prostate cancer at diagnosis.

When I visited with Dr. Eugene KWON at Mayo Clinic last fall, surgery was briefly mentioned as an outside possibility, if it was determined at some point that this might help in my particular case. It was the first time I had ever heard a doctor say those words to me, even as a faint possibility. It was our initial consultation and we spoke of many topics together that day, and I would like to know more about that possibility for myself and others in my situation. Yeah ... I've got friends in my same boat ... same diagnosis ... so we keep tabs on each other, for sure ... always hoping to hear something new that will help one of my friends ...

Honestly, I guess if I was ever given the option, I would strongly consider surgery for myself. There is that innate instinct that says, "Slay this dragon and cut it out of me right now!" I realize with metastatic prostate cancer, the situation is more complex than that ... but that thought is still there. I'm thankful for EVERY battle brother who can successfully pursue SURGERY and hear the word "CURE" ...

In the case of advanced prostate cancer, I know most doctors shake their heads and say, "I'm sorry --- surgery isn't an option for you --- you have metastatic prostate cancer --- it's already spread --- there isn't any merit in considering surgery --- we will pursue treatments with you --- we'll work hard to control your cancer, but there is no cure right now."

Those diagnosed with advanced prostate cancer have to quickly learn the difference between TREATMENTS vs. CURE ... I'm just thankful that the arsenal of treatment weapons has increased so much, in just the past few years ! It's exciting to think about which treatment will emerge next on the scene ... and I admire those researchers and scientists who are devoting their lives in the pursuit of the next breakthrough ...

I'm thankful EVERY day for the treatments that have been used in my case. Each form of treatment has shown positive benefits in my case ... ADT hormone shots, Taxotere chemotherapy treatments, and now ZYTIGA. I have a lot of gratitude for having 100% of my drive and energy each day. Recently, my oncologist and I "mapped out" which treatments he envisions for my future treatments, just as a way of planning for the future --- that was a very meaningful topic of conversation for me, at my latest consultation. Meanwhile, I'm very mindful of every single one of us involved together in this battle that we share ...

Some time back, I read an inspiring article that described this era as the "Golden Era Of Prostate Cancer Research" --- with new treatments emerging, new medical protocols being introduced, clinical trials being conducted across the globe, and new discoveries happening in laboratories, as we speak. Those who have been involved in this battle for longer periods of time than me have CERTAINLY seen quite a change in the options that are being offered to advanced prostate cancer patients ... and the miraculous effects of medications like XTANDI, ZYTIGA, XOFIGO ... to name just a few. Some of these new breakthroughs are helping friends of mine right now ... and also helping me, as well ... I'm thankful for every one of these breakthroughs that are helping prostate cancer patients across the globe. Thousands of prostate cancer patients being helped in ways that were not even imagined ten or even five years ago ...

I wished I had saved one article that I read some time back ... I loved its inspiring message ... it said that in this current era, things are evolving quickly in the landscape of prostate cancer treatments, compared to decades ago ... and that the treatment landscape for prostate cancer changes as quickly now as perhaps every six months, in terms of what doctors can now offer to their prostate cancer patients ... a new medication, a new treatment option, the completion of a clinical trial, a new discovery in the lab, a new sequencing of treatment options that improves survival for patients ...

Thank you, Gunner34, for sharing your story --- and I appreciate all the keen insight and positive support you share with ALL of us here ---

My best to you, looking forward,

"Cyclone" From Iowa State University

Tony,
Why can't you disclose the NCT# of the ongoing trial? That's public information, isn't it? Members may want to look into it.

Allen,

As you may have read in my other posts, this was a decision that I thought long and hard about. I was given the option by my radonc who explained that he did not recommend surgery due to the possibility of serious complications and felt that he could do it safely using IMRT. The benefits of debulking were palliative - it would stop the spread to nearby organs which are very difficult to treat and he thought that it could extend the length of time that first line HT would remain effective. He also mentioned that my prostate could be the source of additional mets if left untreated. I also had a medonc that concurred with the palliative reasons for having my prostrate radiated. Meanwhile my uro was entirely against it thinking it was too risky and could cause serious urinary issues.

So I did a lot of research on it. Debulking as you know is used in the treatment of many other cancers and eliminating a large amount of cancer in my body made sense to me. I also wanted to take an aggressive approach to treat my G9 cancer. I'll also cite pages 50-51 in Snuffy Myers HT therapy book that discusses an MD Anderson study in 1994 that in more than half the cases they looked at in men with metastatic PCa that had become castrate resistant that more than half of the cases that hormone resistance first emerged in the prostate gland, followed by the bones and then lymph nodes. Snuffy explains that hormone resistance is a product of cancer cell mutation and so it makes sense that one would expect it to emerge in an area that contained a large amount of cancer cells.

I decided to go ahead and have my prostrate radiated along with several pelvic nodes in the fall of 2014. So far so good, no noticeable SE's. I became a patient of Snuffy's in July of this year and he said that having my prostate radiated was one of the best moves that I made among my aggressive treatment decisions. He said that there are theories that the primary tumor may send signals to other tumors in the body and that eliminating it in a case like mine was a wise move.

In the end I wanted to make sure that I'm doing all I can to take aggressive action against an aggressive G9 cancer and debulking was part of that process, given the choice I'd do it again in a heart beat.

Ed

A bit of a general question on metastatic cancer cells. Is it correct to say that not all metastatic PC cells multiply aggressively?

In other words, is it possible for someone with bone mets to experience moderate/slow PSA doubling times during ADT holidays? Or is it usually the case that bone mets always tend to aggressively grow when not treated?

Arthur

Allen,

Does make sense. It's good to hear that at this stage of the disease, random events could occur in our favor.