Video: How do You Treat Oligometastatic Prostate Cancer and What Does Cure Mean? | Ask a Prostate Expert
Ask a Prostate Expert | Transcription
Alex: So, our next question is in the advanced category as well, and this is something that I know patients hear and get very confused by. So, they don't really know what "oligo," so "few mets." Oligo means few, and so "few metastatic" so "oligometastatic cancer," and that can kind of sound scary. It sounds like some weird alien disease. "What do you mean I have oligometastatic cancer?" So, can you kind of explain what is oligometastatic cancer? I know it's kind of that transitional phase, so explain the transitional phase of why it's more important to pay attention to.
Dr. Scholz: Well, it has become important because of advances in technology. Historically, with relatively inaccurate scans and ineffective treatments, the advent of any metastatic disease was sort of like saying it's getting to be mortal. It's about time to write your will and it's very life-threatening, and that belief was pervasive because the scans would only pick up big chunks of cancer and the doctors had learned through experience that if you tried to treat those big chunks of cancer that other smaller spots would then surface that were flying below the radar that weren't seen on these older scans. So, if you tried to treat metastatic lesions, it was kind of like a game of whack-a-mole. You hit one and then one would come up, and it wasn't a very useful treatment to go chasing after therapies directed right at the metastatic lesions.
But, things have changed. Two things: one is that the scans now, when they're detecting metastatic disease, it is at a much much earlier stage, and therefore there's a possibility that what is being seen on the scan is the only cancer that has metastasized and that if you could administer an effective treatment at those metastatic lesions, like surgery or radiation, that maybe some of those people could even be cured even though they had early metastatic disease. And if they're not cured, possibly put into an extended remission. So, the other thing that has come along is that the—especially radiation treatments—are not much more focused and powerful. So, when they direct the radiation at these metastatic lesions, it can be done non-toxically and it can almost certainly sterilize the cancer that's in that field. It can cure those spots. So, thinking on how to treat oligometastatic disease has evolved radically in the last 3-5 years. In the old days, because radiation was sort of unfocused—kind of like, you know, with a spray can—and their radiation was getting all over everything, it would make people sick, it would suppress their immune systems, and everyone would want to avoid it like the plague unless someone had really bad pain that needed to be controlled. So, in a relatively short period of time, the thinking is completely reversed and the attitude now is, use the state-of-the-art PET scan to find cancer at the earliest possible stage and then go aggressively with both medicines that circulate in the bloodstream plus radiation treatments that can zap those metastatic spots and get people into extended remissions.
Alex: And the reason for the bloodstream is for micrometastatic activities? So to kill anything that could possibly be traveling somwhere else?
Dr. Scholz: Yes, so our modern scans are great, but they still can't detect things below two or three millimeters across, so there's always the possibility of small spots that are out there and those tiny spots are susceptible to eradication with medicines—more powerful hormonal agents, more powerful chemotherapy treatments—and so the combination of treating the visible spots plus getting systemic therapy to control any invisible spots is a powerful way to put these cancers into remission.
Alex: And earlier you mentioned the word "cure" and I know that a lot of people kind of have different definitions, but I would like to hear your definition of cured from a medical oncologist because a lot of people think it'll never come back, and is that really what it means? The word "cure" for this type of disease?
Dr. Scholz: Well, cured means to have a stable low PSA for five years with a recovered testosterone level. That's what a cure would mean, although there may be a small percentage of people who would relapse after five years. Most people that are in remission for five years with a recovered testosterone will remain in remission for the rest of their lives which is the same thing as being cured. So, it seems counterintuitive, but we've definitely seen patients that have gone into complete remissions for more than five years, have been able to get their testosterone back, and their cancers haven't recurred even though they had proven metastatic disease when they were initially treated.
Alex: So, when it comes to this transitional stage of oligometastatic, I know that kind of the thinking is if you've been on Lupron or you've been on another drug and it's been working for quite some time that you have time, but when it goes to a metastatic state, especially oligometastatic, and you have these new scans that can see it, is there a new sense of urgency that the patient should be paying attention to, that the type of prostate cancer that they have, there's a new aggression to it?
Dr. Scholz: Yeah, so there's oligometastatic disease in men that have been on Lupron and the Lupron stops working—that's a more serious situation—and then there's men that have oligometastatic disease that have never even been exposed to hormonal treatment, and those people have a better outlook.
Alex: I know that a lot people can kind of—I've talked to guys on the Helpline and they don't realize the Lupron stopped working and they're in a serious situation. "Well, it's metastatic, you know, the Lupron has worked forever, I mean how bad could this be? It's only a couple of mets." No, it's a different type of cancer. Let's pay attention. And it's not to freak them out, but it is to address the issue very quickly so that they obviously don't have further spread.
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