For decades, the conventional wisdom has been that men with metastatic prostate cancer are best treated by depriving them of their naturally produced testosterone, or the primary male sex hormone. Recently chemotherapy has been added to this approach. For the last twenty years, in a different vein, Drs. Sam Hellman and Ralph Weichselbaum have been championing the idea that patients with only a few metastatic cancer lesions have a fundamentally different disease, and that in addition to systemic therapy those metastases should be removed or destroyed . That approach has now been tried with metastatic prostate cancer, an unlikely candidate given its indolent nature. In a recent paper in JAMA Oncology, doctors from the Netherlands have treated a group of men with metastatic prostate cancer and fewer than five metastatic lesions with radiation to those lesions in addition to drugs that lower testosterone. The choice of hormone deprivation — intermittent androgen deprivation — was found to be inferior to continuous deprivation in 2013, but the authors fail to explain why they chose it. Nonetheless, the results were strikingly positive, with the men who received radiation doing much better. Men in the hormone-only group survived an average of only 15 months before their disease worsened, whereas men who received radiation in addition to hormone deprivation continued in remission much longer — continuously at the time the paper was written.
Dr. Stark’s comment: this approach is surprisingly positive, especially when you consider the indolent nature of metastatic prostate cancer, but it defines a new standard of care for these patients. I suspect we haven’t heard the last work about all of this.