What is the Role of Locoregional Therapy in Metastatic HSPC?


Following their discussion on systemic therapy, expert panelists consider the value of locoregional therapy for a subset of patients with metastatic hormone-sensitive prostate cancer.


na McKay, MD:Now we’re going to kind of shift gears to talk about what’s the role of local therapy in the mHSPC [metastatic hormone-sensitive prostate cancer] setting. We’ve seen some data from the … and the STAMPEDE [NCT00268476] trial looking at the backbone of ADT [androgen deprivation therapy] and the addition of radiation therapy in that context. Now we’re seeing data evolve about the addition of radiation therapy from the PEACE-1 [NCT01957436] study. How do you all approach the role of local therapy for de novo metastatic disease?

Scott Tagawa, MD, MS, FACP:It’s complex. So, I've always discussed it. Forever, I’ve always discussed that and had a bias of at least preventing morbidity down the line because we all have these nightmare patients with metastatic HSPC and they’re progressing in their local and they have hematuria, obstruction, etc. So we remember that. And then came some of the retrospective data, then some prospective data with survival benefits. The lack of OS [overall survival] data in PEACE-1, particularly in the low-volume risk group is not incredibly surprising to me because we have much better systemic therapy. Still, the data in terms of progression and urinary symptoms makes it a reasonable standard of care to give to patients but doesn’t mandate that and validates ongoing trials. I still enroll in SWOG 1802 [NCT03678025], for instance.

Rana McKay, MD:What do you all think about local therapy?

Arash Rezazadeh Kalebasty, MD:Local therapy, I think to Scott’s point, it’s very important to keep these patients out of the [ED (Emergency Department)] down the line. The quality of life can be significantly impacted by local disease. So overall survival may not be the best end point to look at it. Maybe the quality of life when they’re alive and they’re living at home versus in the [ED] every other day with a big catheter and whatnot. So, I consider it, especially when the radiation oncologist feels comfortable radiating this without causing a lot of problems. So that’s what I consider for my patients, especially low volume. For somebody that has symptoms, we really try to keep him out of [ED]. For whatever it takes.

Sumit K. Subudhi, MD, PhD:I’m thinking about it, especially in those patients that present with significant lower urinary tract symptoms, or they have quality of life issues, meaning they’re having so much urinary frequency at night that they’re getting up every couple hours. I’ll work with our radiation doctors so that when we do get a maximal response from the doublet systemic therapy, then we can consider adding radiation to help prevent what Scott was saying.

Rana McKay, MD:Now, I think it’s an important discussion. I don’t think we have totally clear answers, especially with the low-volume patients who live a long time, they do well…and can sometimes be challenging. I think we’re going to eagerly await more data from PEACE-1 as it evolves with more modern-day therapy that’s escalated.

Transcript edited for clarity.

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