It is the general consensus that prostate cancer when still confined to the prostate gland is gland curable, but when it has left the prostate gland and becoming metastatic it is no longer curable.
But evidence now says there might be an intermediate stage where the cancer has spread outside the prostate gland but is still in small numbers and is a confined to a limited area. This intermediate stage is called oligometastatic.
Oligometastatic disease was first described in a paper written in 1995 by Samuel Hellman and Ralph Weichsel¬baum (Hellman, S & Weichselbaum, RR J. Clin. Oncol 12:8, 1995). This paper was not written about prostate cancer, but its relevance to prostate cancer might be significant.
The paper as well as another follow up they wrote stated that some patients with oligometastatic cancer can have their survival markedly prolonged when the metastatic lesions are targeted surgically or treated with radiation, however the authors did not look at prostate cancer. They evaluated patients with liver metastases removed by surgery who have now survived long enough that they are very likely cured and among patients with lung metastases removed by surgery (between 20-30% were still alive at 15 years).
Many people in the prostate cancer community are aware of Dr. Snuffy Myers who was diagnosed with oligometastatic prostate cancer in the lymph nodes. At the time of his diagnosis statistics showed that at best he could have expected only 10 years of survival before he would succumb to the prostate cancer.
Dr. Meyers, with the help of Dr. Michael Dattoli was treated with radiation to the prostate gland and lymph nodes in the pel¬vis. Additionally, surgery was used to eliminate the lymph nodes in the lower abdomen that might be involved. All of this was done after hormonal therapy had been used to reduce the total volume of cancer. As of this date, Dr. Meyers has long survived his 10-year date with death.
One person exceeding the 10-year date is not scientific proof, but Dr. Meyers and Dr.Dattoli continue to use this treatment with great success.
When Dr. Meyers was treated it was very difficult to visualize these metastatic lesions, but since then our scanning abilities have greatly improved. Not only are the scanners become more sensitive, but also we now have new contrast agents that enhance the ability to visualize these lesions.
In 2004 at the Uni¬versity of Rochester in New York, the existence of oligometa¬static disease in prostate cancer metastatic to bone was finally documented (Singh, D, et al O Int J Rad Onc Biol Phys 58: 3, 2004). The first observation was that men with five or fewer bone lesions had nearly the same 5-year survival as those with PSA-only recurrences (no visible metastases).
They found that in men with five or fewer bone lesions (versus more than 5) remained stable for up to several years before the cancer started to spread widely. Those with more than five bone lesions were much more likely to spread widely.
It was proposed that stereotactic radia¬tion to bone metastases in those with five or fewer lesions may eliminate the bone metastatic cancer and make the patients disease-free for a pro¬longed period of time. After the publication of this paper there were several other papers that hinted that radiation could control individual bone lesions. However, because of small patient numbers and limited follow-up, these papers cannot be considered as proof.
Currently, there is one clinical trial looking at oligometastatic prostate cancer. It is entitled: Non-systemic Treatment for Patients With Low-volume Metastatic Prostate Cancer. On the web page www.clinicaltrials.com, its Identifier is NCT01558427.
I have heard of another study being conducted by Dr. Patrick Cheung at Sunnybrook Health Sciences Center in Toronto, Canada (www.sunnybrook.ca) where this therapy is being evaluated. However, I have not been able to locate the actual information about this study.
Joel T. Nowak, M.A., M.S.W.
Aloha Joel:
Greetings from Jesse who you met at the PCRI Conference. She referred me to your article.
In reading the Study you refer to that is being conducted in Belgium, it appears that this Phase II Study is directed to postponing ADT by either active surveillance or salvage therapy to the limited metastases (no more than 3).
In contrast, the Study being conducted by Dr. Patrick Cheung at Sunnybrook in Toronto is more directed to preventing or slowing the spread of cancer by applying Stereotatic Radiation at curative doses to the sites of metastases (no more than 5).
I understand that this therapy is being used in clinical practice in various centers in the US, e.g., by the Mayo Clinic in Rochester, and by Dr. Snuffy Myers to whom you refer.
Let’s keep our fingers crossed for a successful outcome!
Houseboy
Thanks once again joel for a very timely article. I have been wondering for some time why it would not be wise to attack mets if they can be seen and are few in number before they become castrate resitant. I had surgery 7 plus years ago and have a couple very small spots in the lung which have beem receptive to intermittent ADT. All the scans since these were discovered 4 years ago have showed no other mets anywhere. I know there are no guarantees, but, common sense tells me go after these while they are still small. I am going to ask my docs about this article and see what they say, but, the logic of this makes perfect sense to me. I am not kidding myself about what I am facing down the road.
I seem to fit into this category. I was diagnosed with a 4.4 PSA & a Gleason 6 in 12/07. Cancer in 5 to 10% of the Prostate, including on a nerve. Prostatectomy 2/28/08, with a 3+4 Gleason 7. There was one nodule in the left nerve bundle. Subsequently I had a rising PSA, with a 3 month doubling time to 0.7 in 11/08. I had a spot on my sternum, which was radiated (as was the pelvis) along with Lupron therapy for 6 months. My PSA began to rise again in 5/10. Doubling time 4 & a half months. A 2nd metastasis was found in 7/11 at T2 on my spine. This was radiated in 8/11. I was again given Lupron at half the original dosage. It was replaced by Elegard. The last shot was in 11/12. My PSA has remained at <0.13. My next blood work is in 2 weeks. Both my local Oncologist & my Urologist at Mayo told me the 2nd metastases was not a daughter of the first, but grew from a 2nd independent seed. Both seem confident that they will continue to deal successfully with a future recurrence. I'm now at 5 year survival.
Roger – Glad that you have been able to maintain control of the cancer. I am curious how the doctors can determine if the two mets are related or not.
– Joel