expert roundtables

Oligometastatic Prostate Cancer: Can We Get to Cure?

by Glen Gejerman, MD, Daniel J. George, MD, William K. Oh, MD, and Oliver Sartor, MD MD, FACS

Overview

Oligometastatic prostate cancer reflects a shift in thinking about the detection and treatment of certain limited presentations of advanced disease. Experts in the field reflect on their experience of striving for cure in the oligometastatic setting, albeit with limited clinical data to draw on. They also offer their insights on the prospect of a shift toward more aggressive, earlier treatment of low-volume disease in select patients with recurrent prostate cancer.

Q:

What are your thoughts on the oligometastatic disease state and the prospect of achieving cure?

Expert Commentary

Oliver Sartor, MD

C. E. and Bernadine Laborde Professor of Cancer Research
Medical Director, Tulane Cancer Center
Associate Dean for Oncology
Tulane University School of Medicine
New Orleans, LA

There is a lot of discussion about oligometastatic disease lately. Particularly as these new methodologies come to the forefront, some people are even talking about the possibility of curing oligometastatic disease. I was just kind of curious: do you guys think that’s a possibility? Is this something we should even be talking about with our patients, or do we need to really stick to talking about cure when the disease is still confined?

Daniel J. George, MD

Professor of Medicine and Surgery
Divisions of Medical Oncology and Urology
Director, Genitourinary Oncology
Duke Cancer Institute
Duke University Medical Center
Durham, NC

Well, I can chime in on that one. Yes, Dr Sartor, that’s what patients want to hear, and frankly, that’s what we need to be striving for. I don’t think we can make any promises on any of these things, but if we’re not even trying in a newly diagnosed oligometastatic patient to try to get to a complete response, we’re never going to get to cure. I think that it is appropriate to say that’s what we’d like to achieve, but we don’t know yet if we can do that yet. Anecdotally we’ve seen some remarkable cases that would suggest that we can, but anecdotes are just the first step. What we will need are prospective studies that suggest, in a phase 2 setting, that yes we can achieve that. Then we’ll need to see it in a randomized study. But to me, this must be part of our goal. It’s the most important thing for these patients. Frankly, particularly for the younger patients who have a long-expected survival otherwise, I think we’re doing a disservice if we’re not at least entertaining that as a possibility.

“If we’re not even trying in a newly diagnosed oligometastatic patient to try to get to a complete response, we’re never going to get to cure.”

Daniel George, MD, Medical Oncology

William K. Oh, MD

Chief Medical Science Officer, Sema4
Clinical Professor of Medicine
Division of Hematology and Medical Oncology
Icahn School of Medicine at Mount Sinai
New York, NY

I think that we’re in a philosophical shift, where prostate cancer, especially metastatic prostate cancer, was viewed as an eventually lethal disease in older men who would likely “die with it rather than of it.” But we do know that there is a shift going on, not only because younger men are getting prostate cancer and that men are not dying of other problems like cardiovascular disease, but also because there’s a tremendous amount of morbidity and poor outcomes related to living with prostate cancer that we haven’t been addressing aggressively.

“We have to wait for data from prospective clinical trials to emerge, but the thinking has appropriately shifted to really treating more aggressively in these patients.”

William Oh, MD, Medical Oncology

Also, we now have multiple new therapies for mCRPC, for which I think there’s been a shift in thinking. The question becomes: can we move these new therapies – the AR-targeted therapies, these new bone-targeted therapies, and aggressive local therapy – earlier in the disease course, to really do what Dr George is suggesting, which is to not let the cancers grow at their own pace but to try to change the natural history of the disease? I agree, though, that it’s a lot of anecdotal evidence right now. This is still a difficult area to study. But I think that, for example, taking out the primary tumor in men with oligometastatic disease or treating the sites of metastatic disease in such patients – these are things that are being studied in prospective clinical trials. Although we have to wait for those data to emerge, the thinking has appropriately shifted to really being more aggressive in these patients.

Glen Gejerman, MD

Co-Director, Urologic Oncology
Medical Director, TomoTherapy
John Theurer Cancer Center
Hackensack, NJ

I would agree with that, but I think an important distinction is whether the patient has hormone-sensitive disease or is castrate resistant. We all know that patients can be treated for years and they’re hormone sensitive – and different modalities will work – and we can really get a very nice, long, disease-free interval. Once they shift to being castrate resistant, however, it becomes much more difficult to manage. I think we really need to advance the field of modalities for that phase of the disease if we want to speak about cure. But certainly for patients who are hormone sensitive and have oligometastatic disease, a very aggressive approach with the hope of cure is, I think, reasonable.

“An important distinction is whether the patient has hormone-sensitive disease or is castrate resistant.”

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