Non-systemic treatment of low-volume metastatic disease. Gert De Meerleer, M.D., Ph.D. Gent University Hospital om behalf of POMP study group
Background Patients with metastatic prostate cancer are considered palliative 1 st line treatment is androgen deprivation therapy (ADT) Aim ADT: Defer progression (asymptomatic patients) Palliate symptoms (symptomatic patients) Mottet et al., Eur Urol, 2011
Treatment of asymptomatic M+ disease Effect on survival Overall Survival PCa Specific Survival OR 95% CI OR 95% CI 1 year 1,18 0,90 1,49 1,18 0,67 2,08 2 years 1,08 0,89 1,33 1,21 0,93 1,57 5 years 1,19 0,95 1,50 1,54 1,04 2,28 10 years 1,50 1,04 2,16 1,45 1,13 1,87 Wilt T, Nair B, MacDonald R, Rutks I. Early versus deferred androgen suppression in the treatment of advanced prostatic cancer. The Cochrane Database of Systematic Reviews 2001, Issue 4. Art.
At what cost? Impaired physical activity
Sarcopenic obesity
ADT S Impotence Loss of libido
Metabolic Syndrome
Osteoporosis Anxiety / depression
DO METASTASES METASTAZISE? PT N YES? NO? M1 M2
Cross talk between PT, CTC, DTC, LR and DM PRIMARY TUMOR DTC CTC
Localized Oligometastases Polymetastases Hellman, J Clin Oncol, 1995
Localized Oligometastases Polymetastases Hellman, J Clin Oncol, 1995
Which tracers? FDG C11 of F18-Choline
N=72 Mean PSA: 3.7 ng/ml 38% Gleason score 8-10
BRFS
CRFS
ADT: median 12 months plnd: elective RT + boost Others: 5-6 times 5-6 Gy
Median follow-up 31 months
Hypothesis: A new idea?! Early detection and eradication of oligometastases defers initiation of ADT Primary endpoint: Androgen deprivation free survival Initiation of ADT upon one of the following conditions: Diagnosis of polymetastases: (> 3 metastases) PSA: > 50 ng/ml PSA doubling time: < 4 months Symptomatic disease
Clinical Genitourinary Cancer, In Press
10 times 5 Gy, 3 times a week.
AD-FS: 82% at 1 year 57% at 2 years Median ADT deferment: 34 months N=32 Median Follow-up: 24 months (range: 1-81)
AD-FS: 87% at 1 year 65% at 2 years Median ADT deferment: 58 months N=52 30 LNN 20 bone 2 visceral Median Follow-up: 26 months (range: 1-81)
Acute Urinary GI Skin Late Urinary GI Grade 0 Grade 1 Grade 2 Skin 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Repeated salvage SBRT for oligometastatic prostate cancer Feasible Well tolerated Median deferment of ADT: 58 months Basis for current RCT: RT vs. Active Surveillance
Some brand new (unpublished) data Especially for you
Repeated salvage SBRT for oligometastatic prostate cancer
Repeated salvage SBRT for oligometastatic prostate cancer Radiology Radiation Oncology Urology Nuclear Medicine POMP trial Pathology Medical Genetics Experimental Cancerology Infinity lab
Repeated salvage SBRT for oligometastatic prostate cancer piet.ost@ugent.be gert.demeerleer@uzgent.be
Take home message - Low volume metastatic prostate cancer could be a separate entity from polymetastatic disease - Local aggressive treatment seems to at least postpone ADT (early results, to be confirmed in RCT).
Future - extrapolate to postpone e.g. docetaxel? - extrapolate philosophy to RCC. Thank you!
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