JU INSIGHT: Metastasis-directed Therapy Without Androgen Deprivation Therapy in Solitary Oligorecurrent Prostate Cancer
By: Jack R. Andrews, MD; Mohamed E. Ahmed, MBBCh; Vidit Sharma, MD; Cameron Britton, MD; Bradley Stish, MD; Ryan Phillips, MD; A. Tuba Kendi, MD; Vidhu B. Joshi, CCRP; Akshay Sood, MD; Mathew K. Tollefson, MD; Stephen A. Boorjian, MD; R. Jeffery Karnes, MD; Eugene D. Kwon, MD | Posted on: 01 Dec 2022
Andrews JR, Ahmed ME, Sharma V, et al. Metastasis-directed therapy without androgen deprivation therapy in solitary oligorecurrent prostate cancer. J Urol. 2022;208(6):1240-1249.
Study Need and Importance
Historically, metastatic prostate cancer regardless of disease burden has been considered incurable and treated with systemic therapy. The description of oligometastatic disease as an intermediate stage between localized and widespread metastatic disease has produced a seismic shift in clinical thinking that suggests some patients may be cured with a combination of local and metastasis-directed therapies (MDTs). In limited early studies, it has been suggested that MDT may provide benefit in selected patients. Yet, to date, controversy remains whether MDT without androgen deprivation therapy (ADT) has a substantive role in advanced prostate cancer treatment.
What We Found
In this study, we evaluated both surgical and radiotherapy MDT without ADT in patients most likely to demonstrate benefit, including patients with a solitary metastasis identified on positron emission tomography (PET) in oligorecurrent prostate cancer. We identified 124 patients (67 surgical MDT and 57 radiotherapy MDT). Of patients treated with surgery, 80.5% had >50% decline in prostate specific antigen (PSA; part A of Figure), and the 3-year radiographic progression-free survival was 29%. Median time to initiation of systemic therapy was 18.5 months. For patients treated with stereotactic body radiation therapy, 40.3% had >50% decline in PSA (part B of Figure), and the 3-year radiographic progression-free survival was 17%. Median time to initiation of systemic therapy was 17.8 months.
Although follow-up in this study is among the longest reported to date, this study is limited by its retrospective design, use of choline PET scan rather than more widespread prostate-specific membrane antigen PET/computerized tomography, and a very select patient population. Furthermore, there is significant heterogeneity between cohorts, which does not allow for direct comparison of surgical and radiotherapy MDT.
Interpretation for Patient Care
This study represents the first reported series of MDT without ADT in patients with solitary metastatic prostate cancer. These results suggest that MDT without ADT can delay systemic therapy and likely has a role in the treatment algorithm for oligometastatic prostate cancer. This study highlights the need for further prospective study.