SIU 2017: Local Treatment for Metastatic Prostate Cancer

Lisbon, Portugal (UroToday.com) Dr. Tilki presented today on the status of local treatment for metastatic prostate cancer (mPCa), an increasingly exciting field with potential for lots of change in the near future. 

First, she focused on the oligometastatic PCa disease space. Initially described as an intermediate state between localized disease and widespread systematic metastases, the definition now varies by the number and location of metastases, with no consistency in the literature. There are numerous ongoing clinical trials, which have yet to report data, but the definitions vary across the board – anywhere from 3-10 lymph nodes, +/- visceral mets, or not-specified. 

What is the rationale for surgical treatment of oligometastatic disease?

  1. Improved local control
  2. Removal of the primary tumor as a potential source for further metastases
  3. Improved response to systemic therapy
  4. Delayed progression to systemic therapy

There are NO prospective or randomized data in this area. Only retrospective data available – 16 Original articles (12 full articles), including primarily large database analyses. 
  • 4 SEER papers
           o   Culp Eur Urol 2014 – RP and brachy patients had much better OS, but the numbers were very small (highly selected group)
           o   Leyh-Bannurah Eur Urol 2017 – when propensity score matched, RP and RT yielded lower CSM rates
                - Also lower in Gleason 7, cM1a, and married men
                - RP was better than RT in terms of CSM
           o   However, SEER database limitations make it difficult to make any strong conclusions
           o   Dr. Tilki recently did a subgroup analysis of patients with cM1a-c PCa from 2004-2014 with newly available PSA data – compared RP, RT and - no local treatment (NLT) in ~14,000 patients
                - M1a and M1b patients benefitted from local treatment
                - Lower baseline PSA resulted in survival benefit up to threshold of 60 ng/mL
            o   All these studies highlight the highly selective nature of the patients who received LT, which calls into question the outcomes
                -
  • Institutional case series and Munich cancer registry
            o   RP was associated with better outcomes, but many had very low sample size and lacked MV analysis
                - Only study that did not confirm survival benefit came from Dr. Tilki’s center – 83 patients with <=3 bone mets, PSA <= 151, and <cT3 and asymptomatic
            o   RP vs. best standard care (43 and 40, respectively)
            o   Patients who did not receive RP were older, higher PSA, higher cT stage, more Gleason 9-10 – select group!
            o   Despite that, there was no difference in survival outcomes (Castration resistance free survival and OS)

Randomized controlled trials are needed to better answer this question. 

  1. gRAMPP study – RP + neoadjuvant hormones vs. ADT alone in men with pauci-metastatic PC:
            - German, initiated 2015
            - Primary outcome: 5-year CSS
            - Recruited 79 patients so far (of 500)

       2. This is just one of many trials that have been initiated, but data will take some time to obtain (see below for full list)




Presented by: Derya Tilki 

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal
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