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Radiotherapy breakthrough for Advanced Prostate Cancer?

User
Posted 22 Oct 2018 at 15:43

Today's Times (22nd Oct 2018) contains the following about a trial that gave Radiotherapy to men with advanced PCa.  The results give an increase in 3 and 5 year survival times stated as 'monumental' in the article but seeming more modest in my opinion.   Also in my opinion it's seemed obvious that treating the main growth should slow the disease although more expert professionals say it doesn't or at least that the saving isn't worthwhile for perhaps the cost or quality of life for a short while. Whereas for the patient I'm sure a chance of more time is worth the treatment.

I'm not qualified to comment really, does anyone want to add more, express how much of a breakthrough they think this is and if it can be easily implemented.

Regards

 

Extract from the Times 22nd Oct 2018:

Thousands of men with advanced prostate cancer could have their lives extended thanks to a “monumental” breakthrough in treatment.

One of the largest clinical trials for the disease found that radiotherapy boosted survival rates by 11 per cent for men whose cancer had spread to nearby lymph nodes or bones.

 

The result is likely to change the care given to about 3,000 men every year in England alone and could benefit many more around the world.

Researchers found that treating the prostate with radiotherapy in men whose cancer was locally advanced boosted three-year survival rates to 81 per cent, compared with 73 per cent among those receiving standard care.

 

Chris Parker, lead researcher of the study based at the Royal Marsden Hospital, London, said: “Our results show a powerful effect for certain men with advanced prostate cancer. These findings could and should change the standard of care worldwide.

 

“Until now, it was thought that there was no point in treating the prostate itself if the cancer had already spread, because it would be like shutting the stable door after the horse had bolted.

 

“However, this study proves the benefit of prostate radiotherapy for these men. Unlike many new drugs for cancer, radiotherapy is a simple, relatively cheap treatment that is readily available in most parts of the world.”

 

Radiotherapy to the primary tumour did not appear to help men whose cancer had spread further. Experts said the technique’s use would not need to go through the National Institute for Health and Care Excellence (Nice), but would require approval from NHS England.

The trial, funded by Cancer Research UK, involved about 2,000 men with prostate cancer that had spread. Half were given standard treatment, typically hormone therapy, and half also received radiotherapy to the prostate.

 

The results were published yesterday in The Lancet, and presented at the Munich congress of the European Society for Medical Oncology.

Nicholas James, chief investigator of the trial from the University of Birmingham, said: “Although survival times are improving, no one with advanced prostate cancer is cured of their disease by hormone therapy alone.

 

“These important results move the dial significantly further in terms of what we can do for this large group of men. These results should change the standard of care for certain men with advanced prostate cancer — and could be implemented tomorrow.”

About 47,000 men a year in Britain are found to have prostate cancer; more than 11,500 die from the disease.

 

Charles Swanton, Cancer Research UK’s chief clinician, said: “This is a monumental finding that could help thousands of men worldwide.”

Simon Grieveson, acting deputy director of research at Prostate Cancer UK, said: “We now want to see the use of radiotherapy extended to this group of men without delay.”

 

From <https://www.thetimes.co.uk/article/monumental-prostate-cancer-breakthrough-g5xtjd25g>

User
Posted 22 Oct 2018 at 15:43

Today's Times (22nd Oct 2018) contains the following about a trial that gave Radiotherapy to men with advanced PCa.  The results give an increase in 3 and 5 year survival times stated as 'monumental' in the article but seeming more modest in my opinion.   Also in my opinion it's seemed obvious that treating the main growth should slow the disease although more expert professionals say it doesn't or at least that the saving isn't worthwhile for perhaps the cost or quality of life for a short while. Whereas for the patient I'm sure a chance of more time is worth the treatment.

I'm not qualified to comment really, does anyone want to add more, express how much of a breakthrough they think this is and if it can be easily implemented.

Regards

 

Extract from the Times 22nd Oct 2018:

Thousands of men with advanced prostate cancer could have their lives extended thanks to a “monumental” breakthrough in treatment.

One of the largest clinical trials for the disease found that radiotherapy boosted survival rates by 11 per cent for men whose cancer had spread to nearby lymph nodes or bones.

 

The result is likely to change the care given to about 3,000 men every year in England alone and could benefit many more around the world.

Researchers found that treating the prostate with radiotherapy in men whose cancer was locally advanced boosted three-year survival rates to 81 per cent, compared with 73 per cent among those receiving standard care.

 

Chris Parker, lead researcher of the study based at the Royal Marsden Hospital, London, said: “Our results show a powerful effect for certain men with advanced prostate cancer. These findings could and should change the standard of care worldwide.

 

“Until now, it was thought that there was no point in treating the prostate itself if the cancer had already spread, because it would be like shutting the stable door after the horse had bolted.

 

“However, this study proves the benefit of prostate radiotherapy for these men. Unlike many new drugs for cancer, radiotherapy is a simple, relatively cheap treatment that is readily available in most parts of the world.”

 

Radiotherapy to the primary tumour did not appear to help men whose cancer had spread further. Experts said the technique’s use would not need to go through the National Institute for Health and Care Excellence (Nice), but would require approval from NHS England.

The trial, funded by Cancer Research UK, involved about 2,000 men with prostate cancer that had spread. Half were given standard treatment, typically hormone therapy, and half also received radiotherapy to the prostate.

 

The results were published yesterday in The Lancet, and presented at the Munich congress of the European Society for Medical Oncology.

Nicholas James, chief investigator of the trial from the University of Birmingham, said: “Although survival times are improving, no one with advanced prostate cancer is cured of their disease by hormone therapy alone.

 

“These important results move the dial significantly further in terms of what we can do for this large group of men. These results should change the standard of care for certain men with advanced prostate cancer — and could be implemented tomorrow.”

About 47,000 men a year in Britain are found to have prostate cancer; more than 11,500 die from the disease.

 

Charles Swanton, Cancer Research UK’s chief clinician, said: “This is a monumental finding that could help thousands of men worldwide.”

Simon Grieveson, acting deputy director of research at Prostate Cancer UK, said: “We now want to see the use of radiotherapy extended to this group of men without delay.”

 

From <https://www.thetimes.co.uk/article/monumental-prostate-cancer-breakthrough-g5xtjd25g>

User
Posted 14 Feb 2019 at 18:09

In hindsight i was very lucky.

diagnosed in nov 2014, spread to 3 lymph sites, neck, aorta and pelvis.

i was never on a trial but i had early chemo jan 2015 6 lots of docetaxl and then 6 fractions of rt in may 2015.

i asked the onco at the time and he said that there was some evidence that blasting the mother ship was good even for advanced pca and early chemo looked positive.

since then early chemo is the norm and rt appears to have benefits but only if the spread is to 4 sites or less. any more and the evidence shows no benefit.

over 4 years on, psa yesterday 0.05, lowest ever, over 3 years on abiraterone, still running crazy races ( off to the arctic in 16 days for a non stop 380 mile race pulling a sledge, self supported), i am one lucky guy i know. i have raised over £100,000 for pcuk personally in those 4 years too. https://www.justgiving.com/fundraising/Kevin-Webber7

Never give up. make the most of it.

kev 

Dream like you have forever, live like you only have today Avatar is me doing the 600 mile Camino de Santiago May 2019

User
Posted 07 Jan 2019 at 12:05

Hi Peter's Place

The Times report seems to be for the STAMPEDE trial and the results are in the Lancet Oncology journal (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32486-3/fulltext ) I can't get past the Times's paywall but the dates are right and they have the same lead investigator.  

The interpretation for the Lancet report is "Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer." which seems at odds with the Times headline.  Also in the summary is this "Radiotherapy improved failure-free survival (HR 0·76, 95% CI 0·68–0·84; p<0·0001) but not overall survival (0·92, 0·80–1·06; p=0·266)." But that doesn't explain the headline still.

Digging deeper into the report there's a table for subgroups of patients by high and low metastatic burden: for low burden there is a difference between control and radiotherapy (73% overall survival v 81%) and for high burden it is 54% overall survival for control and 53% for radiotherapy.  So this explains the Times's headline - they are talking about low burden patients (low burden defined as T<any> N<any> M1).

The report goes on to say that RT should be a standard treatment for low metastatic burden patients.

RT is comparatively cheap so this looks like it has a good chance of becoming "standard of care" for such patients.

Hope this helps and interested to hear what you think.

User
Posted 11 Feb 2019 at 11:56

Thanks chaps.

Simplest stuff (for thickies like me) is on the Stampede trial web site: http://www.stampedetrial.org/media-section/news/

Won't repeat what you've already clarified except to say I think anyone on this forum who has Stage 4 metastatic disease should be asking for this. Particularly if you are "low burden" which the diagram on the link above pictures quite well. It's generally thought to be most effective at the start of treatment alongside other therapies (chemo, HT etc.) but the team at the Marsden seemed to think a bit of a gap isn't an issue.

I've just finished the RT based on this and found it fairly manageable.

The oncologist gave me a choice based on the recommendation from my second opinion team at the Marsden.

1) 6 fractions, 1 weekly of a reasonably high dose - 36GY/6# over 6 weeks the one commonly used in the Stampede trial

2) "more sophisticated" 20 fractions over 4 weeks - 60GY/20# over 4 weeks - which she recommended. 

I did comment that I've not had years of experience and medical school she had so I was hoping for a firm "you should do this one" but in the end I'm glad I was given a choice.

I did get the speak with one of the doctors who ran the trial and he told me that they don't know why it works. But they think that the RT boosts your immune system to fight the cancer, one of the reasons it is more effective with lower burden disease.

In my (un medically trained but we all become mini doctors through this process dont' we :-) ) mind this meant that the 6 fractions higher dose treatment gave a bigger ZAP BOOST and a week for my body to get over it.

At the start of our conversation the clinical onco (our first meeting) was of the opinion I should go with option 2 - in her experience pre-Stampede this is what she gave to PCa people, but at the end she agreed that I hadmade the right choice. Not really what I wanted, as I am a bit of a thickie as I said, particularly still suffering from Chemo brain (the ammount of times I get to the top of the stairs wondering why I made the trip....)

My regular onco agreed with me when we met a week later. He's very very good and he said that high dose less frequent RT was proving to be effective in other cancers based on the same logic so I left feeling very comfortable with my choice.

So the weekly treatments were very manageable -  tiredness (this built up over the weeks - I'd generally sleep following treatment on the day and last two treatments the following day) and feeling very odd on the day (the RT team said the larger dose can do that) but otherwise OK to work, exercise and generally live OK. Your wees and your bits go funny but I know that we're all used to that anyway this forum. "Numb knob then" was how my wife sweetly put it when I tried to describe it.

I would say, if you fit the profile speak to your onco about this ASAP. I don't think they can refuse following the Stampede trial.

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User
Posted 07 Jan 2019 at 12:05

Hi Peter's Place

The Times report seems to be for the STAMPEDE trial and the results are in the Lancet Oncology journal (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32486-3/fulltext ) I can't get past the Times's paywall but the dates are right and they have the same lead investigator.  

The interpretation for the Lancet report is "Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer." which seems at odds with the Times headline.  Also in the summary is this "Radiotherapy improved failure-free survival (HR 0·76, 95% CI 0·68–0·84; p<0·0001) but not overall survival (0·92, 0·80–1·06; p=0·266)." But that doesn't explain the headline still.

Digging deeper into the report there's a table for subgroups of patients by high and low metastatic burden: for low burden there is a difference between control and radiotherapy (73% overall survival v 81%) and for high burden it is 54% overall survival for control and 53% for radiotherapy.  So this explains the Times's headline - they are talking about low burden patients (low burden defined as T<any> N<any> M1).

The report goes on to say that RT should be a standard treatment for low metastatic burden patients.

RT is comparatively cheap so this looks like it has a good chance of becoming "standard of care" for such patients.

Hope this helps and interested to hear what you think.

User
Posted 09 Jan 2019 at 08:48

I couldn't access the Times article either, but the Lancet does supply a PDF (all ten pages!).

I can't claim to have understood the whole thing, but a few of points stand out:

1. All the subjects were diagnosed at stage IV; this isn't about a recovery/salvage treatment.

2. Those who gained most were early stage IV ('light metastatic load').

3. The study didn't (and couldn't) include a 'chemo comparison', as the key chemo meds weren't available when it started.

4. The study does appear to confirm the once-controversial notion that prostate cancer metastases continue to be influenced by the primary tumour, and that influence diminishes as the cancer becomes more advance and the cells more undifferentiated.

Having said all that, it certainly offers a solid treatment option for men with early stage IV disease: Good News.

Sure, the authors main conclusion is that "Radiotherapy to the prostate did not improve overall survival for unselected patients with newly diagnosed metastatic prostate cancer" - but that rather misses the point; those diagnosed at Stage IV have a three-year survival rate of 29% (cf SI - SIII almost 100% at three years), and those three years are typically dominated by often ineffectual treatment regimes, ensuring a pretty low quality of life. The study established that radiotherapy improved failure-free survival, offering an improved quality of life.

And, of course, the subgroup with a light metastatic load did show improved survival.

 

Edited by member 09 Jan 2019 at 09:03  | Reason: Not specified

.

-- Andrew --

"I intend to live forever, or die trying" - Groucho Marx

User
Posted 11 Feb 2019 at 11:56

Thanks chaps.

Simplest stuff (for thickies like me) is on the Stampede trial web site: http://www.stampedetrial.org/media-section/news/

Won't repeat what you've already clarified except to say I think anyone on this forum who has Stage 4 metastatic disease should be asking for this. Particularly if you are "low burden" which the diagram on the link above pictures quite well. It's generally thought to be most effective at the start of treatment alongside other therapies (chemo, HT etc.) but the team at the Marsden seemed to think a bit of a gap isn't an issue.

I've just finished the RT based on this and found it fairly manageable.

The oncologist gave me a choice based on the recommendation from my second opinion team at the Marsden.

1) 6 fractions, 1 weekly of a reasonably high dose - 36GY/6# over 6 weeks the one commonly used in the Stampede trial

2) "more sophisticated" 20 fractions over 4 weeks - 60GY/20# over 4 weeks - which she recommended. 

I did comment that I've not had years of experience and medical school she had so I was hoping for a firm "you should do this one" but in the end I'm glad I was given a choice.

I did get the speak with one of the doctors who ran the trial and he told me that they don't know why it works. But they think that the RT boosts your immune system to fight the cancer, one of the reasons it is more effective with lower burden disease.

In my (un medically trained but we all become mini doctors through this process dont' we :-) ) mind this meant that the 6 fractions higher dose treatment gave a bigger ZAP BOOST and a week for my body to get over it.

At the start of our conversation the clinical onco (our first meeting) was of the opinion I should go with option 2 - in her experience pre-Stampede this is what she gave to PCa people, but at the end she agreed that I hadmade the right choice. Not really what I wanted, as I am a bit of a thickie as I said, particularly still suffering from Chemo brain (the ammount of times I get to the top of the stairs wondering why I made the trip....)

My regular onco agreed with me when we met a week later. He's very very good and he said that high dose less frequent RT was proving to be effective in other cancers based on the same logic so I left feeling very comfortable with my choice.

So the weekly treatments were very manageable -  tiredness (this built up over the weeks - I'd generally sleep following treatment on the day and last two treatments the following day) and feeling very odd on the day (the RT team said the larger dose can do that) but otherwise OK to work, exercise and generally live OK. Your wees and your bits go funny but I know that we're all used to that anyway this forum. "Numb knob then" was how my wife sweetly put it when I tried to describe it.

I would say, if you fit the profile speak to your onco about this ASAP. I don't think they can refuse following the Stampede trial.

User
Posted 11 Feb 2019 at 12:41
Unfortunately, Stampede are no longer recruiting to that arm and as it hasn’t been approved by NICE it will not be available as an option on the NHS to most men yet. No harm anyone asking their onco but don’t build your hopes up just to be crushed.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 11 Feb 2019 at 13:44
You could get the RT privately. Cost would be around 5k I think.
User
Posted 11 Feb 2019 at 14:24

I didn't realise re the NHS, bearing in mind it was them who ran the trial.

As you say, you can ask, interested in anyone who has experience having applied pressure on this one in the NHS.

 

User
Posted 11 Feb 2019 at 15:17
The NHS doesn't run Stampede - it is funded by organisations such as Cancer Research UK and some universities, I think PCUK also put in a bit of money? It has been running since 2005 and has had a number of different arms over the years. If results are very persuasive there is a good chance of NICE being influenced but it takes quite a long time to get from trial data to new clinical practice.

They have just published the findings of the trial that your onco had access to. Looks great so we are likely to see some pressure on NICE although they will have to be persuaded that the benefit outweighs the additional costs.

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 11 Feb 2019 at 15:31
Hi Matt

I'm a Stage 4 knacker and signed a consent form which was pushed in front of me by my Onco this morning to embark on 20 Radiotherapy sessions starting provisionally next month. I had my last of six chemo sessions on 14 January, feeling good now, ready for a holiday and back to walking 4 miles a day like I used to in the good old days before I picked up this crappy disease.

John (Jasper)

User
Posted 13 Feb 2019 at 15:19

Good luck with your RT John. The holiday is that bit nearer :-) - Seriously the best thing you can do after treatment. I did and it was by far the best holiday I've ever had.

I will never know if the best choice or RT was - 6 or 20 fractions - as unfortunately this crappy disease as you rightly call it doesn't seem to want to let me know its plans, if it did it would have been nice if it let me know it was there somewhat earlier.

However I am interested in if there was any discussion on options or they just said it should be a 20 fractions one and that's it?

User
Posted 13 Feb 2019 at 19:21
when Tony was first diagnosed in 2006 locally advanced he was offered HT on its own Radiotherapy or both or the trial, he asked his oncologist what he would do if it was him and his reply was "well if it was me I would throw everything at it, you are young and fit so I would have the RT and HT, if you go on the trial you moght only get one or the other, Tony threw everything at it and it is only in the last 18 months it has relapsed so obviously the right decision.

User
Posted 13 Feb 2019 at 20:04

Originally Posted by: Online Community Member

I will never know if the best choice or RT was - 6 or 20 fractions

However I am interested in if there was any discussion on options or they just said it should be a 20 fractions one and that's it?

As far as I can recall, you are the only member here that has had the 6 fractions option 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 14 Feb 2019 at 16:05

My husband was offered  six weekly sessions of rt at a routine appt the week it was published in the Lancet about benefit for those with low burden met spread. Consultant said he may be able to get approval from his team to go ahead if he didnt mention "cure". This was at a routine 3 month appt on a Wednesday and on that Friday got a call for first appointment to start with an info session.

Husband now completed 2 of 6 sessions. No side effects so far.

 

 

User
Posted 14 Feb 2019 at 16:11

Sorry Suelor, I forgot about your OH.

For others' interest, here is Sue's post on that discussion:-
https://community.prostatecanceruk.org/default.aspx?g=posts&m=205379#post205379 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 14 Feb 2019 at 18:09

In hindsight i was very lucky.

diagnosed in nov 2014, spread to 3 lymph sites, neck, aorta and pelvis.

i was never on a trial but i had early chemo jan 2015 6 lots of docetaxl and then 6 fractions of rt in may 2015.

i asked the onco at the time and he said that there was some evidence that blasting the mother ship was good even for advanced pca and early chemo looked positive.

since then early chemo is the norm and rt appears to have benefits but only if the spread is to 4 sites or less. any more and the evidence shows no benefit.

over 4 years on, psa yesterday 0.05, lowest ever, over 3 years on abiraterone, still running crazy races ( off to the arctic in 16 days for a non stop 380 mile race pulling a sledge, self supported), i am one lucky guy i know. i have raised over £100,000 for pcuk personally in those 4 years too. https://www.justgiving.com/fundraising/Kevin-Webber7

Never give up. make the most of it.

kev 

Dream like you have forever, live like you only have today Avatar is me doing the 600 mile Camino de Santiago May 2019

User
Posted 29 Apr 2019 at 19:25

Hi all, A quick update.

First PSA test following the 6 fractions and my PSA has gone down from 0.5 to 0.07

I'm really pleased, makes the RT worth the effort. 

Hopefully this means its had the right effect and keeping things at bay for a while longer 🙂

Matt

 
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