Dr. Snuffy Myers offers his thoughts on Prostatepedia’s March issue, to be released this Thursday.
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In March, Prostatepedia focuses on your options when your prostate cancer comes back after initial surgery or radiation. As I reviewed the various conversations, I could not help but note how views have evolved in recent years. Until quite recently, it was widely assumed that men with prostate cancer recurrent after surgery or radiation had widespread metastatic cancer, even if it was not yet apparent on imaging studies. This assumption naturally led researchers to focus on developing systemic treatments capable of attacking the cancer throughout the body.
Today, that assumption is being challenged by the idea that there are men who have metastatic cancer limited in extent and that they might benefit from surgery or radiation focused on the known metastases. This is called oligometastatic prostate cancer.
How did this revolution in our understanding of prostate cancer start? A key scientific paper was published January 1, 2004 by radiation therapists and urologists at University of Rochester (See Radiation Oncology, Biology and Physics 58, 3-10, 2004). It has taken a long time for the implications of this important paper to gain acceptance in the medical community.
One of our conversations this month is with Dr. Piet Ost, who has been involved in randomized clinical trials testing the oligometastatic concept. His interview reviews the major issues facing this line of research.
At this point, we know there are patients who received radiation for oligometastases many years ago who still are free of detectable metastases. We do not have adequate tools to determine who will and who will not benefit from treatment directed at oligometastatic disease. We also do not know the best radiation or surgical approaches to various metastatic sites.
For many years, we depended on bone and CT scans to detect the presence of metastatic prostate cancer. These imaging techniques were known to be relatively insensitive and missed smaller metastases, but were acceptable when the treatment options were only systemic drug treatments palliative in nature.
Once you concede that there are men who might benefit from treatment directed at their oligometastatic disease, it becomes much more important to know exactly where the metastases are so that you avoid treating men with widespread metastases as if they had oligometastatic disease.
This explains why the medical community is so interested in improving our imaging tools to detect prostate cancer metastases. This month, you’ll also read several interviews discussing this line of research, especially those focused on the PSMA scan.
There have also been dramatic improvements in how we treat men with more widespread metastatic disease. Dr. Charles Ryan provides a comprehensive review of the current and likely future options. I would also point out that he has a very interesting new book The Virility Paradox: The Vast Influence of Testosterone on Our Bodies, Minds, and the World We Live In currently available for preorder on Amazon.
Finally, Dr. Eric Rohren reviews the use of Xofigo (radium-223). The appearance of this radioisotope revolutionized the management of metastatic disease in my own clinic. I found his comments very interesting; I’m sure you will as well.