Whole-pelvic radiation therapy for high-risk patients

The decision about whether or not to treat the entire pelvic lymph node area along with the prostate (called whole pelvic radiation therapy or WPRT) or to treat just the prostate with a margin around it (called prostate-only radiation therapy or PORT) has long been a matter of judgment. … READ MORE …

Timing of initiation of ADT for men with biochemical progression after first-line surgery

For many years your sitemaster has been advising patients that overly early use of androgen deprivation therapy (ADT) in many men with progressive prostate cancer is not necessarily the best decision (for a number of possible reasons). … READ MORE …

Rethinking risk stratification for radiation therapy

In 2016, we looked at the Candiolo risk stratification system for radiation therapy. To our knowledge, it has not been prospectively validated or widely adopted. … READ MORE …

Extending OS on initial ADT for men with mHSPC

Back in 1989, the SWOG 8494 trial first showed that adding an antiandrogen (flutamide) to bilateral medical orchiectomy with an LHRH agonist (leuprolide acetate) extended median overall survival (OS) by 7 months in newly diagnosed men with metastatic, hormone-sensitive prostate cancer (mHSPC). … READ MORE …

Lower salvage radiation dose — are outcomes the same?

A large randomized clinical trial, SAKK 09/10, found that a salvage radiation dose of 64 Gy over 32 treatments had equivalent biochemical outcomes compared to 70 Gy over 35 treatments. … READ MORE …

Brief, intense radiation and hormone therapy for very high-risk prostate cancer

As we’ve seen, brachy boost therapy seems to have the best oncological results for men with very high-risk prostate cancer. … READ MORE …

Early data from the PEACE-1 trial

The so-called PEACE-1 trial is an ongoing Phase III trial among men diagnosed with de novo metastatic castration-sensitive prostate cancer (mCSPC). … READ MORE …

First clinical trial of Lu-177-PSMA-617 in recurrent, hormone-sensitive men

While we expect only a few months of extra survival from the VISION trial of Lu-177-PSMA-617 in heavily pretreated, metastatic, castration-resistant men (see this link), we hope to get more out of the radiopharmaceutical if used earlier.

Privé et al. reported the results of a pilot trial in 10 recurrent men treated with Lu-177-PSMA-617 at Radboud University in Nijmegen, The Netherlands. They were all:

  • Recurrent after prostatectomy ± salvage radiation (PSA > 0.2 ng/ml)
  • Rapid PSA doubling time (< 6 months)
  • Between 1-10 metastases detectable on a PSMA PET scan or USPIO MRI
  • At least 1 metastasis > 1 cm
  • Unable to receive SBRT to metastases
  • No visceral metastases
  • Have not begun salvage ADT
  • Treated with a low dose (3 GBq) on day 1; second treatment (~6 GBq) after 8 weeks (compared to dose in VISION trial of 7.4 GBq in each of 4 to 6 cycles)

After 24 weeks of follow-up after Cycle 2:

  • 5 patients had PSA reduced by > 50 percent (1 undetectable)
  • 2 patients had stable PSA
  • 3 patients had PSA progression
  • 6 patients had a radiographic response
  • 4 patients had radiographic progression
  • ADT-deferred survival was 9.5 months (median)
  • Those with lymph node only metastases had the best response
  • Those with any bone metastases had lesser response

After a second dose, comparing their 24-week PSA to their 12-week PSA:

  • PSA was continuing to decline in 3 patients
  • PSA was rising again in 6 patients
  • Side effects were mild (no grade 3) and transient:
    • Fatigue in 7;nausea in 3
    • Dry mouth (xerostomia) in 2

There are lots more questions than answers:

  • Would a higher dose and more treatments be more effective?
  • Would a higher dose and more treatments be more toxic?
  • Is it like Xofigo in that it’s more effective with micrometatases? If so, would a combination with SBRT targeted at the larger metastases be more effective?
  • Since it was more effective on lymph nodes, would it make a good combination with Xofigo for patients who have both lymph node and bone metastases? (See also Th-227-PSMA.)
  • Because there seems to be a continued abscopal effect for some patients, would combining it with Provenge be optimal?
  • Would pretreatment with ADT or a new anti-androgen (Xtandi, Erleada or Nubeqa) increase expression of PSMA, and increase radiosensitivity?
  • Can we predict who will benefit?

Use in other patient populations remains to be explored: high-risk, newly diagnosed metastatic, castration-resistant but chemo-naive. Optimal sequencing with other therapies remains to be explored.

Editorial note: This commentary was written by Alan Edel for The “New” Prostate Cancer InfoLink.

Lutetium-177 PSMA-617 in treatment of mCRPC: trial results

According to a media release, issued earlier today by Novartis, the company has provided preliminary data about the results of the international, multi-center, Phase III, randomized, VISION trial, which has been evaluating the efficacy and safety of lutetium-177 PSMA-617, a targeted radioligand therapy, in treatment of men with progressive, PSMA-positive, metastatic, castration-resistant prostate cancer (mCRPC) … READ MORE …

Xofigo 2.0

Xofigo (radium Ra 223 dichloride) is a systemic radiopharmaceutical. Radium is chemically similar to calcium and is taken up by bones in places where bone is actively growing, as in prostate cancer bone metastases. … READ MORE …

Lu-177-PSMA-617 vs Jevtana (cabazitaxel): which should I do next?

We saw recently (see this link) that of chemotherapeutic and hormonal medicines for treatment of metastatic castration-resistant prostate cancer (mCRPC), Jevtana (cabazitaxel) is the preferred third-line treatment after Taxotere (docetaxel) and Zytiga (abiraterone acetate) or Xtandi (enzalutamide). … READ MORE …

ADT and risk for COVID-19 infection?

Early in 2020, in the initial stages of the COVID-19 pandemic, there was a suggestion (based on data from a small Italian study) that men who were using androgen deprivation therapy (ADT) to manage their prostate cancer might be at lower than average risk for becoming infected with this virus. … READ MORE …

“Dose painting”: simultaneous integrated boost to the dominant intraprostatic lesion

Two technologies have come together to allow for a new kind of radiation treatment known as simultaneous integrated boost (SIB), or, more informally, “dose painting.” … READ MORE …

SBRT for high-risk prostate cancer patients

As we have seen, stereotactic body radiation therapy (SBRT) is a preferred therapy for low- and intermediate-risk patients (see this link). It is effective, safe, convenient, and relatively inexpensive. However, its use for high-risk patients remains controversial. … READ MORE …

Whole pelvic salvage radiation may be better than precisely targeted lymph node salvage radiation

Last week, I looked at a retrospective study of metastasis-directed therapy (MDT) at the Mayo Clinic among oligorecurrent patients (see this link). … READ MORE …