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Surgery or Radiation for De-Bulking in Metastatic Situations

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Posted 11/6/2017 7:23 PM (GMT 0)
Hello everyone. My PSA has been creeping up and now stands at 2.3. Latest Scans show no evidence of bone or organ involvement although there is evidence of a small area of activity inside the prostate gland. My MO is now recommending treatment to the primary tumor so I need to make a decision on surgery or radiation.

I'm sure not many of you have faced this decision in the context of a initial metastatic diagnosis. However, many of you have faced the decision of surgery vs. radiation.

Knowing my background and general treatment protocol thus far, I am asking for your thoughts. Knowing the potential side effects, quality of life issues and chance of recurrence in the prostate, what would you recommend and why. No answers are wrong and I just want to get some feedback.

Thanks to everyone who responds.
Posted 11/6/2017 7:54 PM (GMT 0)
I don't have strong feelings about it one way or the other. But since no one really knows if it provides any benefit (all the data is retrospective and there are known selection biases), I think the decision has to be made on the basis of expected side effects.

If cancer in the prostate has started to interfere with urination, I think surgery with ePLND will provide relief of that (albeit with risk of the opposite-- incontinence).

If your urination is OK, I think that whole-pelvic radiation with a brachy boost to the prostate will do a great job with lower risk of incontinence. They can also zap any known bone mets that can be safely treated during the same treatments.

/pcnrv.blogspot.com/2016/08/is-prostate-specific-radiation-still-of.html
Posted 11/7/2017 5:34 PM (GMT 0)
John,

I do not know if you are interested to read studies on this topic. Here are two:

Primary treatment of the prostate improves local palliation in men who ultimately develop castrate-resistant prostate cancer

Does Cytoreductive Prostatectomy Really Have an Impact on Prognosis in Prostate Cancer Patients with Low-volume Bone Metastasis?

You mention: "...chance of recurrence in the prostate" Since you have lymph node and bone mets already the chance of recurrence should be not so much a concern. You will have to continue with systemic therapy after the treatment of the prostate in any case.

George
Posted 11/7/2017 7:04 PM (GMT 0)
John-

There's another option that I mentioned to you in a previous email. UT Southwestern in Dallas runs an SBRT registry. With that, you may be able to get insurance coverage for SBRT monotherapy treatment of the prostate, the pelvic LNs, and any known mets all within the same 5 treatments. Although it might involve staying in Dallas for 10-11 days (treatments are every other day usually), it could cut your treatment time in half compared to brachy boost.
Posted 11/8/2017 4:43 PM (GMT 0)
John,

I think it makes sense to de-bulk (as with many other cancers) but it is not so clear cut with PCa and some insurance won't cover it in situations like yours. I reckon it has a lot to do with the fact that it is only fairly recently (last 10-15 years) that great improvements have been made in metastatic disease longevity given the new drugs introduced in the last 10 years.

However, I have never thought it made sense to use surgery when HDRBT and IMRT/SBRT cover a much greater area for more de-bulking and with less negative side effects. One of our friends, Bryan (Gunner), did have surgery after many other treatments at Mayo under the care of Dr. Eugene Kwan. I suggest you call Bryan and get his take from experience. I communicated with him a month or so ago.

A ll the best,

Jack
Posted 11/8/2017 5:19 PM (GMT 0)
If money is an issue, and with insurance companies it's always an issue, surgery is usually MUCH cheaper than radiation....(not that any cancer treatment is "cheap"....)But things may have changed since SBRT usually only requires 5 treatments as opposed to the old IMRT standard of 40 treatments.....But I agree that attacking the primary tumor is a sound treatment path....
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