MDA Trial-Surgery versus Radiation for high risk PCA

My Gleason score was not as high as yours (8=4+4), but it is a rare form Ductal) that had spread to my lymph nodes. Had DaVinci surgery last April, Lupron stating last June and I am getting close to being done with s. radiation (11 left out of 38). Even though my prostate was large at about 75 grams, they were able to save my nerves. Got bladder control back after about three months. Was able to be romantic - until I started hormonal. Not having any major side effects from radiation. In addition to everything down there being asleep, the side effects from hormonal are hot flashes, slight weight gain and muscle loss. I am having a harder time concentrating, but that may just be me dealing with the whole situation.

For me having surgery followed by hormonal and radiation was worth it. Please not that a lot of very wise people here may not agree with that.

I agree with Michael-T that there should be no concerns about salvage in your case. Salvage refers to a second attempt at a cure. You are considering de-bulking (not cure) as a way to reduce your current tumor load and perhaps slow down, but not stop the spread. They are not trying to completely eliminate cancer from your body, just reducing the amount coming from the primary source. This is based on the theory (from lab studies) that a lot of metastases continue to be spawned from the original source. No one really knows for sure if it will even slow it down, although some retrospective analyses lead some doctors, like yours, to theorize that it might. While it is preferable to take out as much as they can (via surgery with ePLND or whole pelvic radiation) the first time, there is no point to going back to take out more.

My opinion is that the data is good enough to start a clinical trial on. Also, it may be tried outside of a clinical trial if you and your doctor think that the potential benefit in lengthening survival outweighs the more certain risks of side effects from treatments. There are many considerations. If the cancer in the prostate has become so bulky that it is interfering with urine flow, surgery may relieve that, but then you may suffer the opposite problem - incontinence. Radiation, on the other hand, may, at first, make any blockage worse because of the inflammation. That should go away with time as the swelling subsides and much of the cancerous tissue is ablated. Also, conventional IMRT is an ordeal - 40-44 treatments usually over about 8 weeks. I like the idea of using SBRT instead because it is only 5 treatments during which they can treat the whole pelvic area and zap any convenient known metastases as well.

Hello John16,

Glad to see you are exploring the options, my friend. We've both got the "advanced case scenario" in this card game, and those of us here who have drawn those cards are always waiting for news of the new breakthroughs ...

When I first got diagnosed, my local doctors ALWAYS said ... "No surgery options for you ... advanced case ... no benefit to surgery ... not a possibility ... not a consideration ... not an option ... case closed."

At Mayo Clinic, Dr. Kwon has said that surgery COULD be an option for me, at some point down the road, if the situation warrants it ... it's the first time I've heard any doctor even say that it MIGHT be considered ... sometime, someday ... he's watching my situation closely ...

I have several close friends with the same diagnosis that I have ... in every single case, each one of them always says, "Why ? Why can't they do surgery on me ? They do surgery on everyone else ! They do surgery for almost every other kind of cancer ! Why do I have to be sent home, with the surgery option not even being CONSIDERED ?"

It's hard to hear those words, expressed by friends of mine who have now received the news of their own diagnosis ... friends who have now become like brothers, in every sense of the word ...

You go home from your initial diagnosis, feeling like you've got a ticking "time bomb" implanted in your body ... and then they start rolling out the other options ... and you wrap your mind around the difference between "treatment" vs. "cure" ... it's an uneasy pathway that we walk upon ...

We work our P.S.A. levels down with chemo treatments & A.D.T. hormone shots ... we're thankful for the meaningful successes along the way ... but, I think we STILL wish that surgery could at least be a viable option ... every fellow wishes for his own shot at a cure ... but we forge ahead, and keep facing forward ...

Let us know what you decide, as you continue to explore these new options and new possibilities, John16 ... you might end up being a trailblazer for others to follow ...

You have my loyal support, every step of the way, in all of this ...

Handshake of friendship,
"Cyclone Fan" ~ Iowa State University

My read on the trial is that it is examining only the issue of de-bulking the primary tumor, by surgery OR radiation, and comparing outcomes against a group that had no de-bulking. both groups get best systemic treatment for metastatic PCa, so the plan for lymph nodes is chemo + ADT.

My big question: EPE in primary cancer is most usually found in the apex I believe- and this then means that nerve-sparing is complicated by nearby tumor mass (nerve bundles are close to the apex IIRC- I could be wrong, I am working from ADT memory and what was a distant conversation with my uro)- my uro stated that tissue changes in nerve bundle due to nearby tumor make it hard for a clean dissection --> no nerve-sparing. SO... can ADT/chemo reduce primary tumor in a way that nerve-sparing is feasible when it was not on first diagnosis?

good luck john- I follow your story with great interest since we walk the same path

rf

TA-

here is link to the trial I believe;

NCT01751438

My read is that the study looks exclusively at debulking of primary tumor in a setting of likely chemo/ADT for best systemic therapy for newly diagnosed metastatic patients.
Maybe going after pelvic nodes too with surgery or RT will improve outcome, but SE from these more aggressive therapies could cloud the data for the main study question I am thinking.

Study is offered at four sites (one in CA), 120 enrollment, started March 2013

I am starting to realize what rare birds in the PCa aviary are those of us diagnosed as metastatic right out of the chute- here's to prostate surveillance!

My question on ADT and later surgery was whether ADT/chemo can change a surgery from non-nerve sparing to possibly nerve sparing. If I understood my uro correctly, tumor tissue near a nerve bundle often results in a more friable tissue around the bundle, making it very difficult to achieve nerve-sparing (but not impossible- this talk was pre-scans and relevant to my mpMRI/biopsy results).

De-bulking sure makes sense especially to avoid severe urinary symptoms down the road- would be great if it gives more.

just crossed my fingers for ya john16

rf

My understanding is that the chemo/HT has greatly reduced the primary tumor mass such that nerve sparing now looks very possible. The surgeon said he has seen much more difficult tumors to remove and believes nerve sparing is very likely in my case.

I think, but will confirm, that the surgeon will also remove the lymph nodes that can be removed.

I will be interested to hear what the RO thinks. I go back and forth on surgery vs. radiation. I have to say that, like a lot of folks, my gut tells me to "get it out". But I will try to stay objective in the decision making process. TA's radiation data and information are compelling regarding SE's. To some extent, I feel like you are gambling on a very skilled surgeon doing his job well. By the way, the surgery would be robotic.

Of course, I could lose the coin flip and all of this would be moot. Don't you love the decision tree process?

Thanks to everyone for the input.

Regarding the debulking of the principal source of the PCa, I think it makes very good sense. But debulking isn't done only by surgery. Most anyway you treat the principle source will work. Thus the various radiation treatments will be just as effective if not more so for the debulking.

You know you are high risk and that lowers the success rate for surgery. That then leads to a greater probability of needing salvage radiation. The combination of the two consistently produce the worst outcomes of side effects and risks. Radiation as a primary treatment for you as it was with my high risk dx, can be very effective and present less side effects and risks.

Hi John,
I have a lot of details about the MDACC efforts looking at specifically this trial and also about the pending Phase III version coming next year. Dr. Brian Chapin is the primary investigator and I know him and have worked with him on research.

Last week while I was in Chicago I attended a "Cytoreductive" symposium hosted by MDACC. It looked at three genitourinary cancers ~ bladder, renal, and prostate. Some call this "debunking". They say all three offer survival benefits but to what degree requires the phase III trials.

I'll talk specifically on the MDACC trial for prostate cancer that you are qualified for. For two years now MDACC has been presenting to us at SWOG the trial design, findings, and results. The belief is that there will be a role in standard of care in tumor debunking for stage 4 patients. And seeing the Phase III trial design there is a strong belief is is true in prostate cancer patients. The phase III version will not be out for some time. But the fact that it's moving to that phase is encouraging.

Phase III Primary end point: overall survival.
Secondary end Points include comparing RT v. RP in randomization, genetic tissue banking and analysis, and more that can't be stated.

I believe that anyone that will be doing debunking or radiation to the primary tumor should do so in a trial if one is available. It will give us substantive information that all can use moving forward.

Just a note on that Phase II. MDACC is reporting that SE's from the RP are not significantly worse than men with RP in earlier Dx's. But in fact for men that were experiencing blockage they were to some degree no longer self catheterizing. And if the overall survival has in fact improved, that too is valuable information.