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  • Jul 30, 2018
    Surveillance or Metastasis-Directed Therapy for Oligometastatic Prostate Cancer Recurrence: A Prospective, Randomized, Multicenter Phase II Trial

    The question of how aggressively to treat oligometastatic disease, and whether or not there is a benefit to doing so, is an evolving paradigm in multiple disease sites. This is of particular importance in primary histologies with a long natural history, such as breast and prostate cancer, where patients may live for years with a diagnosis of metastatic disease. These authors report on the results of a Phase II, multi-center study in which patients with asymptomatic patients with prostate cancer and fewer than 4 extracranial metastases were randomized to either surveillance or metastasis-directed therapy (MDT) at all detected lesions (using either surgery or stereotactic body radiotherapy). The primary endoint was androgen-deprivation free survival, and ADT was started at symptomatic progression, progression to more than 3 metastases, or local progression of known metastases. This study enrolled 62 patients, with 31 patients in each arm. The median ADT-free survival time was 13 months for patients in the surveillance arm and 21 months in the MDT arm (HR 0.60, 80% CI 0.40 –0.90). There were no symptomatic or local progression events observed in the MDT group, whereas 3 and 6 events occurred in the surveillance arm, respectively. The authors conclude that MDT is safe and effective compared to surveillance.
    This is an important study that provides support of metastasis-directed therapy for oligometastatic disease. Metastasis-directed therapy has become more common in recent years, particularly as SBRT becomes more widely used and available. 

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    Journal & Date: Journal of Clinical Oncology 36, no. 5 (February 2018) 446-453.
    Key Institution: Ghent University Hospital, Ghent, Belgium
    Keywords: Oligometastatic disease, prostate cancer, metastasis-directed therapy

  • Jul 30, 2018
    EBRT with brachytherapy boost improves survival over prostatectomy or EBRT in Gleason 9 and 10 prostate cancer

    High risk prostate cancer, particularly with high Gleason score (9-10) has high risk of distant metastasis and prostate cancer-related death. Due to inherent challenges in participant accrual, there are no prospective randomized trials comparing prostatectomy (RP), external beam radiotherapy with androgen deprivation (EBRT), and external beam radiotherapy with brachytherapy boost and androgen deprivation (EBRT+BT). The current study performed a multi-institutional consortium retrospective review of 1809 men across 12 institutions who underwent RP (n=639), EBRT(n=734), or EBRT+BT(n=436) in order to identify any prostate-cancer specific survival (PCSS) benefit using this larger dataset. EBRT+BT had a significantly lower PCSS than RP (HR=0.38) or EBRT (HR=0.41).

    5-year PCSS was 12%, 13%, and 3% for RP, EBRT, and EBRT+BT respectively.

    Distant metastasis rate was significantly lower with EBRT+BT as compared to RP (HR=0.27) or EBRT (HR=0.30). There was an overall survival benefit in the first 7.5 years of follow-up with EBRT+BT versus RP (HR=0.66) or EBRT (HR=0.61). Of note, 43% of patients undergoing RP required post-operative radiotherapy. This study presents novel findings to suggest both a distant metastasis and prostate-cancer specific survival benefit from EBRT+BT. Strengths of the study include large statistical power, generalizability, and robust statistical methods including propensity score matching. Limitations include those inherent to the retrospective study design. Overall, these are valuable and statistically powerful data suggesting that patients with Gleason score 9-10 prostate cancer should be treated with extremely dose-escalated radiotherapy, including external beam radiotherapy and brachytherapy boost along with androgen deprivation too optimize clinical outcomes.

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    Journal & Date: JAMA. 2018 Mar 6;319(9):896-905
    Key Institution: Multi-institutional: 11 in the US and 1 in Norway; first author from UCLA
    Keywords: Prostate cancer, Gleason score 9-10, retrospective review, prostatectomy, external beam radiotherapy, brachytherapy boost, androgen deprivation

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