CR's take on PC treatment--AS does result in higher death rate; Consumer Incontinence is high, etc.

Consumer's report on Health (10/10) take on prostate cancer
treatment --AS (Active Surveillance) vs. SUR (surgery) vs
RAD (external radiation) vs. SEEDS (Radiative seeds implant)

(Hope this has not duplicate a previous post)

Synopsis :
(1) for low-risk and intermediate risk --10 year death rate
is higher for AS by about 2% (vs. SUR) to 1% (vs. RAD)
(2) 1/2-2/3 of AS does not need further treatment within 5 years.
(3) 2-year urinary leakage (> 1 leak per day) is 14%/7%/10% for
SUR/RAD/SEEDS
(4) 2-year BM problems (frequent, urgent, bloody, or painful)
is 1%/11%/8% for SUR/RAD/SEEDS
(5) see the newsletter for recommendations

The October 2010 issue of "Consumer's report on Health"
newsletter contains an interesting (and to me surprisingly
detrimental) take on the effect of Prostate cancer treatment
and on AS. While I often view some of Consumer's report's
result as perhaps somewhat unreliable, it is at least honest.

The 10-year death rate is based on an observations study
published in 2010 of 6849 Swedish men diagnosed with localized
prostate cancer (treatment in the 1990's, so, the results might
not reflect what one might get today).
For low-risk (Gleason 6, low %, PSA <10) and intermediate
risk (localized) cases, the 10 year death rate is
AS 3%/5%, SUR <1%/3%, RAD 2%/4%, SEEDS probably similar to RAD.
Thus, while AS saves you from side effects (see below),
it does raise the anxiety level, and DOES COST higher death rate--
2% extra compared to SUR, and 1% compared to RAD.
Note that for people who choose AS, 1/2-2/3 does not need further
treatment within 5 years (this means perhaps 40% does need further
treatment within 5 years, and for those people, their 10-year death
rate is higher than if they have chosen SUR/RAD at the beginning
--perhaps up to 5% vs. SUR). I don't know the statistical uncertainty
in this, and whether other studies back these results up.

The 2-year long term adverse effect is based on a 2008 study on
survey on 1201 men. The rates for SUR/RAD/SEEDS for 3 major effects are
poor sexual function --53%/58%/46%
urinary leakage (>1 per day) 14%/7%/10%
BM problems 1%/11%/8% (frequent, urgent, bloody, or painful)
They also note that Robotic have similar results as open, but the
Robotic clients are 3-4 times less satisfied (they expected better
results based on marketing hype--note that Robotic does have
faster recovery, and less likelihood of need for blood transfusion.
However, for those case with cancer that has spread, open is probably
more effective in removing nearby cancer (like my case--I regretted
not having chosen open, since my PSA DID NOT drop after robotic surgery)
I wish for a larger sample for this study, though.

My wife subscribes to CR Health reports, but I haven't seen this issue yet. JohnK wrote a nice summary. These state are along the line of what I got out of my readings. A number of the very best PCa studies are from Europe, especially from Sweden, including the only randomized double blind study of surgery vs wathchful waiting, and the best randomized controlled study of PSA screening. Maybe because its easier to organize large studies and collect data within national healthcare systems. These patients were diagnosed and treated in the 1990s. Don't think HIFU was an issue then.

For me, the two things that these studies (and all the studies I read) don't tell, but that I wonder about are,

1) What happens after 10 years? Early and intermediate PCa is slow growing, so it's reasonable to expect more problems showing up in the 10-20 year time frame and beyond. A big issue for us younger guys.

2) What about outcomes other than prostate cancer death? How about urinary obstruction, bone mets, need for hormonal therapy, etc etc? How much does early treatment reduce the risk of those things that might show up in some men that may not end up dying from PCa?

Re : 3% death rate (AS) is statistically different from
<1% death rate (SUR) ?? (6 sigma ??)

While I would not know for sure, one can estimate the number
if one assume that the 6849 cases are roughly divided into
4 equal parts --i.e., 1700 per part (it is not likely to be
more than a factor of 2 off, I would guess).
In that case, 3% would be 51, and <1% would be around 10.
That is at least a 6 sigma effect, so it is significant.
Again, I wish there were other studies that confirm these
findings.

I also agree that European studies are likely to be easier to
do (in addition to national health services and record-keeping,
people they are more agreeable to being monitored,
and less "privacy" concerned).

The Sweedish study is one of the oldest study on AS and is ofter used to justify that the benefit of PSA screening in saving lives is not cost justified because there is only a 2% benefit of having surgery vs doing nothing. The study also contained a high % of men with a Gleason 7 and other stats that would not be considered candidates for AS in today's world.
A recent study relased by Dr Carrol (UCSF surgeon) showed that at UC Davis, patients on AS that were treated after 2 years on AS had the exact same results of those treated immediately. This supported the studies from Hopkins and Sunnybrook that showed the same thing. Also the Sunnybrook study, which is one of the largest showes that 2/3 of the patients that started AS are still on the program at a medium of 67 months. Which means that over 1/2 have been on for over 6-7 years.
The generally quoted QOL issues are at odds with the above:
Impotance Incontininence stricture Proctitis

Surgery 50% 8 5 -
Seeds 35 - 1 1
IMRT 35 - - 2-4


Martin Sandra, New England Journal of Medicine Mar 2008
John Davis, Journal of Urology April 2005
John Wei, Journal of Clinical Oncology Nov, 2003
David Miller, Journal of clinical Oncology April 2005

The above numbers are taken from the results of the BEST doctors and are on the high scale of what to expect if treated. Incontinence is very rare with seeds or IMRT, and I have never seen anything until now that indicates that it is a problem. I would take the QOL issues quoted by consumer health with a large grain of salt.
JT