What is a "cure" rate?

Hello all,

My husband was recently diagnosed with PC (see signature) and we are now now looking at treatment options. The urologist has asked for CT and bone scans for staging purposes prior to our visit with him on the 1st of July.

Assuming all is good with these scans (please, god!) we are leaning towards surgery, purely because without the prostate cancer diagnosis my husband would have expected another 30 years of life at least - his mum is 87 and very active and most of his aunts and uncles are alive and relatively well. Surgery seems to be the "gold standard" for the younger PC patient and I think suits my husbands rather conservative instincts. Active surveillance would not suit his temprament - and I think he would never forgive himself if that cancer had spread anywhere or gone up a grade whilst he was waiting and watching.

Anyway, when looking at surgery as an option and comparing surgeons I have no idea of what to make of their statements on "cure" rate, which seems to mean negative margin rate. As I can see from this site, a negative margin does not mean that the psa will stay undetectable. Many peoples signatures show otherwise. Should I ask about the 5 year survival rate? How can we best judge the ability of a surgeon on their ability to get all the cancer out? How do we compare their "cure rate" results on Da Vinci vs open? I have similar problems judging their stats on urinary incontinance and potency. What do these terms actually mean?

An

Hi An... not sure I can give you the best answer as there are others here more qualified to get into that, and i'm sure they will respond. I did want to share with you my conversation with two seperate urologists, in seperate meetings just yesterday about my situation. I had Davinci on May 17.. pathology showed matters to be worse than suspected.. Gleason 7 - 4+3, and signs that some cancer still present after removal. They BOTH said they felt confident that radiation could "clean up" the remaining cells and I would be fine. Overly optomistic? Maybe... but they said they were being honest. I ask each, "if I simply didn't trat any further, how long would I survive?".. They both answer "My guess is 10 years". So based on your situation, AT A MINIMUM, I wouldn't be worrying about a 5 year window. ALSO, and most interestingly, they told me had they know my prostate was 75% cancer, with a 4+3 Gleason prior to surgery, they wouldn't have advised on surgery, they would have gone right to radiation (telling me they feel it is that effective).. So I left feeling a little better than when I went in, yet I also left feeling "you mean I had my prostate removed when i didn't need to?".... No simple answers, and no easy ones... But I think have have several and perhaps it's not as bad as you think. I hope it's not.

While the instinctive reaction is 'get the cancer out of me', I suggest that the best course for your husband, with a Gleason 6 and very small % involvement, is to get a second opinion about the Gleason score and other factors suggesting how aggressive his cancer is, and then very likely doing 'nothing'.
By nothing I mean no surgery and no radiation, but even WW is probably a poor title, he should be doing Active Surveillance.

If your husband's numbers hold on review, then I suggest that you will find the 10 year mortality for AS, surgery and seeds to be about the same.
You will NOT find the 10 year side effects numbers to be similar, with even good case scenarios being 20-30% side effects for seeds and surgery, and the 20% may be overly optimistic.

The reason you need the second opinion is that about 1/3 of the time the second look by dedicated experts upgrades the Gleason score, and also the second look may find an aggressive form of cancer. If that's what happens, then AS is off the table

Not an easy time, good luck.

An,

One thing that you can be thankful for is that your husband's diagnosis indicates a very early stage, low grade cancer.  I was diagnosed in March with very similar pathology and learned through an extensive research process that it was highly unlikely that PCa was going to kill me (at least not anytime soon) and that any of a number of treatments available today offered close to 100% long term cancer free survival rates.

I would disagree that in your case that surgery is the "gold standard" given the rate at which follow-on radiation is required and the potential side effects of urinary and bowel incontinence, sexual disfunction, and penile atrophy (the shrinkage of the penis after the prostate is removed and the urethera is reconnected).  While a good surgeon would likely minimize the potential of urinary difficulties, return of sexual function is more of a hit or miss proposition but surgeons with lots of experience post statistics of "the ability to achieve an erection sufficient for penetration at least once a month" at around the 80% level.  If that fits your idea of sexual function at your husband's young age then I would say go for surgery and best of luck to you.

While no option is free of side effects and no option guarantees a "cure" there are other treatments that pose less potential side effects for a man with the stage of cancer you describe in your husband.  Among the courses of treatment I researched included proton therapy, XBRT radiation, IMRT radiation, brachytherapy, HDR brachytherapy, cryosurgery, Cyberknife, HIFU, and AS.   While all of these might not be available in the UK (I'm assuming you're from the UK because of your use of the words 'whilst' and 'mum' they are certainly available throughout the EU and in the US and I know of many patients who travel here from the UK to seek treatment.

One thing about AS--I almost chose that because it offered the absolute least amount of near term side effects while keeping open the potential for treatment in the future if things progressed.  I learned through consultations with several doctors and my own research that the best chance of "curing" the cancer was treating it at the earliest possible stage. 

For early stage cancer patients such as your husband, statistics show virtually no difference in 10-year survival for surgery, radiation, or surveillance.  All of these options show survival rates into the high 90 percent range.  Given that just about any treatment course offers a high liklihood of defeating the cancer, why not investigate those options that pose less risk of side effects.

In my own case, I chose to receive radiation through the Cyberknife procedure and am in treatment now.  There is plenty of available information on the internet about this procedure and I understand a CK center was recently installed in the UK and that the Queen cut the ribbon for on opening day. 

I'd recommend that besides just investigating surgeons, that you also look at radiologists and others that have excellent survival statistics.

Best of luck to you and your husband as you sort this one out.

Instead of a costly bone and Ct scan your doctor should have gotten a 2nd opinion from an expert, Epstien, Bostwich, Oppenheimer, on his biopsy slides. This would be much more informative.
In the case of a true G6 the 10 year survival is about 99% with ANY treatment and 97.5% with out any treatment. So it is imperitive to confirm that this is a G6 and this is done with a 2nd opinion on biopsy slides.
Cure rates are expressed as no indication of growing PC. For surgery this defination is a stable psa of <.2 and for radiation a low and stable psa which could be much higher. Cure rates are much less than survival rates and for a G6 are in the mid 90%.
Cure rates are very important in choosing a treatment, but side affects and quality of life issues are also important. Since all treatments have similar results for low grade cancer you should be concentrating on the side affects and quality of life issues you will be facing.
You have pleanty of time (years) to make a decision, so don't hurry and evaluate all options.
JohnT

An. I cant say I disagree with anyone here who advises you to take your time, gather information, get other opinions, consider all the options and the ramifications of those options such as potential side effects, etc. It sounds like you may have caught this when it's early, and it does not appear to be overly agressive.. So You Do have time.

That said, I wouldn't classify that available timeframe in "years". My March biopsy showed 3 0f the 12 cores tested proved positive.. 25%. Gleason 7 3+4, all concerned told me they felt it was contained, found early, and removal of the prostate would likely take care of my problem. I had the prostate removed May 17, pathology showed a much more aggressive disease Gleason 4+3 with tituary 5.. and it was in 75% of my prostate, and was found in my bladder neck... ALL to the surprise of my urologist (and me). Ironically, they tell me yesterday that had they know my cancer was as and where it is, they would have advised against surgey, and gone direct to radiation. (I may look back, having paid that price, and look at that as simply a sad irony).

My point is, DONT wait years. Face it, identify what you've dealing with and confront it as you see best. ONE MONTH LOOKING THINGS UP, ASKING QUESTIONS TO YOUR DOCTORS AND ON BOARDS LIKE THESE... YOU WILL HAVE KNOWLEDGE, POWER. 1 MONTH AND YOU'LL HAVE A MUCH BETTER UNDERSTANDING. TRUST ME.

I really, really doubt that surgeons know their rates of cancer control in the long run. Aside from surgeons at places like Johns Hopkins who run single institution studies.

For example, I haven't been back to see my surgeon since I was referred for salvage radiation. Is he tracking me statistically, years later? I doubt it. He probably only glances at the reports the radiation oncology sends to him and my primary care doc.

What surgeons are more likely to know is their rate of positive margins. Not a fantastic tool for the patient, since it isn't all that great as a prognosticator all by itself.

I think it's very hard to compare surgeons objectively, because do the surgeons really know their own progression-free survival rates for 5, 10, 15, and 20 years? I would assume not. I'm not singling out urologists here--I bet the same holds true for cardiologists, pulmonologists, etc.

The literature does not usually refer to "cure rates" and for good reason. It's not easily quantifiable. What can be measured are things like progression-free survival, cause-specific survival, overall mortality, etc at specified time periods.

I am very interested in the potential cure offered by salvage radiation. What I study is not a cure rate, but the percentage free of PSA progression as time progresses from the end of radiation. Even if I read that 25% are progression-free at 10 years, I would not assume that those 25% are "cured" the way I define it, because if the percentage is still dropping from 8 to 10 years, why should it stop falling there?

The others who have written about 5 year survival rates not being that useful are right. The vast majority of men diagnosed today would not die from cancer within 5 years no matter what they chose, even nothing at all. With Gleason 6 (assuming it is--the risk is that biopsy path results often differ from surgical path results and perhaps he has another "real" Gleason) he can choose just about anything and should still not be bothered by prostate cancer a decade from now.

I suggest getting the book "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer" (2007 ed.), and not rushing into any particular treatment.

Best wishes.

Chris R, Galileo, yes, this is exactly what I want from my doctors, stats on their long term survival rates. 5 years doesn't tell me much because as I said earlier my husband is in his early 50s and really what he wants to know is the 20 year survival rate of a particular doctor. If we were in the US we would go and see Dr Partin I think because he does do this (assuming he also has a good rate of success on urinary incontinance and ED). We are in Australia though and our preference is for a surgeon here.

John T, we have had a second opinion with the most experienced pathologist we could find in Australia and the cancer diagnosis was from this experienced pathologist. The hospital pathologist diagnosed my husband with ASAP.

Although we are fully covered for the CT and bone scans from an expense point of view I agree with your opinions on bone scans - on reading since yesterday it seems that they are not necessary and could be dangerous. But we are seeing one of the most experienced surgeons in Australia and he wants us to have them prior to our visit with him. The bone scan is scheduled for Monday and I think I might call up the doctor today to ask him whether it is necessary given the circumstances.

I think we are starting to get more comfortable with the idea of surgery - although our primary focus is on the long term "cure" rate, urinary continance is the other key thing. The ED issue secondary for us and if it takes injections, viagra etc to happen then this is a good outcome. But for now we are trying to find the best possible surgeon. I will encourage my husband to wait on making a decision till he is as comfortable and knowledgeable about options and side effects as he can be.

The surgeon we are looking at now comes recommended and has done over 1500 open surguries and 400 robotic ones. These are his stats (from his website) for the robotic surgery how does this look like to you? His open surgery stats are worse but then I suspect that those are his more complex cases with higher Gleeson scores. I don't think he keeps any long term stats on long term survival rates.

PT2 positive margin rate: 3.5% (all focal).

Operating time: 1.5 - 2.5 hours.
Blood loss: Average 150mls. (no transfusions to date).
Conversion to open operation: Nil.
Hospital stay: 94% of patients leave by day 3 (most on day 2).
Removal of catheter: 95% of patients have catheter removed on day 6 or 7.
Major complications: <1%.
Re-admission rate: 1%.
Urinary stricture rate: Nil.
Urinary continence rate (no requirement for a pad): 75% by 3 months and 90% by six months and 98% by twelve months.
Sexual function rate: With nerve sparing techniques over 85% of patients have achieved sexual recovery within 12 months. Over 90% regain sexual function if under 55 years of age.

An