Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
In this video, we're going to cover Basic-Royal prostate cancer. Basic-Royal would be synonymous
with oligometastatic prostate cancer. "Oligo-" is a Greek word that means "few." Specifically,
five or fewer metastases. The whole issue with prostate cancer is whether or not it
has spread. Whether or not it can spread. How extensively it spread. That's the number
one defining factor in determining how serious the situation is and also for designing a
treatment protocol.
Historically, medical oncologists have concluded if any metastases have occurred there must
be many additional microscopic metastases spread throughout the body even though they
may be invisible on scans. This has led to a very negative viewpoint in terms of treating
the metastatic sites with something like surgery or radiation. The old game of whack-a-mole
comes to mind. You treat one spot, another one shows up. You treat that spot, another
one shows up. And what are you accomplishing? So this conclusion that there's always additional
metastatic disease that's going to show up down the line (if a single met has already
been found that is) has been in place now for over 100 years.
So what's changed?
Well, first of all, we realize that the biology of this disease is quite variable. Some cancers
spread easily and other cancers don't. So, not every single cancer that has this early
spread will have additional spots, and this has been shown in a number of studies now.
Therefore, this opens up the possibility of treating those spots with something like surgery
or radiation. And in speaking of radiation, the radiation technology has improved so vastly
in the last 10-15 years, these days different spots throughout the body can be treated usually
with no side effects whatsoever. So there isn't much downside to pursuing radiation
therapy to a metastatic site. When the number of sites becomes excessive, of course, there
can be a cumulative effect especially on the bone marrow where prostate cancer tends to
spread. So the arbitrary cut-off threshold is usually about five spots max. That is arbitrary;
more or less certainly would be debatable in certain situations. Another thing that
has changed with the progression of technology over the last 10-15 years is the improvement
of scans. So the types of scans we have can detect much earlier disease at a juncture
where it's much more likely that that's the only metastatic site. So better scans, better
radiation, we also have better systemic therapy—things like better hormone treatments, better chemotherapies.
So while the radiation can take care of any visible metastases, these systemic therapies
can attack the microscopic disease that may be lurking in the wings. So a combination
of radiation, plus good systemic therapy is enhancing the possibility of achieving a cure.
Throughout most of this video, I've been primarily talking about using radiation to treat the
metastatic sites. Some doctors are using surgery. This is a potential approach in people that
have primarily lymph node metastases, not bone metastases. Personally, I'm not a big
fan of surgery because the radiation therapist can not only treat the affected node when
they're detected on a scan, but they can also radiate the region and cover other potentially
microscopic areas of disease and lymph nodes that are close/adjacent. Surgeons go in and
can remove the lymph node and a couple of others perhaps, but they don't have an ability
to cover a whole field the way a radiation therapist is able to do. Now, I'm sure surgeons
will dispute this, and there are studies showing benefit with the surgical removal of cancerous
lymph nodes, so what I'm saying doesn't completely preclude the possibility of surgery, but since
radiation has so few side effects and is at least as effective and perhaps more effective,
in general, I'm not a really big fan of surgery for oligometastatic cancer.
So in summary, men that have early metastases should not give up hope. They should consult
a medical oncologist who can talk to them about multi-modality therapy with a combination
of the right scans, radiation therapy, adequate systemic therapy possibly with chemotherapy
or a second-generation hormone like Xtandi or Zytiga, and with this very aggressive approach
most men are going to go into a complete remission and some can be cured.