Failed surgery? I don't understand!

I've seen it mentioned on here a few times of late about having to have further treatment because of failed surgery.

How can this be? If as a result of a biopsy it is found that the prostate has cancer, surely having it removed surgically is better than letting the cancer spread more and ultimately travel outside the prostate.

Take my case for example, I feel that the skill of the surgeon has left me fully continent by carefully nerve sparing.
So for that reason I feel that some cells have been left behind and now require salvage radiation to hopefully mop these up.

I had other options given to me prior to surgery. It was always my gut feeling to have Radical Prostatectomy and get the cancer out of my body. Other choices were, Radiation, Hormone Therapy and laproscopic surgery. All were said to have an equal chance of a positive outcome.

So I don't see my surgery as being failed, just my rising PSA that requires radiotherapy, and another part of my ongoing journey.

Am I being naive in my thinking, have I got this wrong?

Your thoughts and comments would be appreciated.

Thanks,

Chris.

hawkfan75 said...
You are not naive or mistaken. A needle biopsy is like shooting darts at a target. If you throw 10 darts you may never hit a bullseye, or you can hit it with one.
I was diagnosed with minimal cancer via the biopsy. I chose the surgery whereas others may have done something much less invasive. When I got my post surgical pathology report back, both my surgeon and I were surprised what was found. Fortunately, we then knew the actual extent, and my prostate was where it belonged, in some jar of formaldihide somewhere. I was in the position to get the additional radiation therapy to mop up any of those pesky cancer cells that were still hanging around. Fortunately, six years after my initial diagnosis and surgery, I am still pushing those zeros!

Will I be able to continue "cancer free" forever? Who knows. At least I gave it my best fight then, had the fallback option available, and with God's will and good doctors will live a long life and not die of this particular maliday.

Good luck with your fight!

Hawkfan,

Thanks for your reply,

Interesting what you say about your pathology report. The comment my surgeon made after surgery was, "The prostate was chokker block." It certainly made me fell that I'd made the right decision!

All the best in keeping those zeros.

Chris.

I find the phrases "failed surgery" or "failed RT" to carry a certain gross error. The problem is not that the surgery or the RT did not work (OK, in David's case I'll grant abysmal failure), but that they did not have the best case result of curing the PCa.

I think we all do a disservice to the best efforts of our doctors with a phrase that sounds more like "I went to get my prostate removed, and they took my left lung and pancreas instead" than "we tried the best we could, but the PCa had already metastasized".

I'm just in a mood this evening, so ignore me if you want, but the devil is in the details, and this is one detail I have a gripe with.

It is ashamed that most patients are not told the total truth on PCa up front and that around 30% of primary treatments fail to achieve cures (maybe higher including high risk patients whom more often end up in radiations or with ADT added tooo). The culprit is things like: PNI, micro mets (undetectable by scans), lymphnodes harboring PCa cells, perhaps escaping cells from surgery or biopsy (totally argumentative on that front). I suppose if some docs were totally blaytant in telling the patient of the gambles, they would lose a sale in effect. I believe in total disclosure on everything: odds, side effects, lingering possible issues, quality of life, risk of death during the proceedure and even what is the actual cost even though insurance company will be paying most or all of it. But that would be the righteous way to do things, so that is cast aside.

You have to look at all the reasons for a failed surgery.
1. There are cancer cells beyond the prostate in the blood stream or in the lymphatic system, systemic disease.
2. There is a positive margin where the tumor extends into the prostate bed and was not removed by surgery. 50% of all positive margins are in the apex.
3. There is residual tissue left behind from surgery; this always occurrs especially if the nerves are left intact. The residual tissue may contain PC cells.
Salvage radiation will work on # 2 and 3, but so would have primary radiation.
There is a significant difference in the skill of doctors in reducing the incidence causes by #2 and 3. At MSK the rate is 11% for the best and 48% for the worst with an average of about 22%.
Judging from the 70% that fail salvage radiation it would be reasonable to assume that most failures are due to the disease already being systemic at the time of surgery. The higher the Gleason grade and the larger the tumor the greater the probability of it being systemic.

John,
What if a patient over 15 years starts with brachytherapy, then has a rise in PSA in five years, has external beam radiation then has a rise in PSA in three years, starts iADT and dies with a climbing PSA of coronary failure at the age of 70?

Did all of his treatments fail? Or did they all provide years of successful disease control?

What truly failed this man?

Tony

Tony,
I think that any biochemical reoccurrance from a primary or salvage treatment given with the intent to cure is a failure regardless if a patient dies of PC or lives another 20 years. Of course most treatments will extend life to some extent and this is a good thing, but should not be considered a success.
AS is not intended as a cure, but if a patient dies of another cause while on AS it could be considered a success as the goal is to prevent side effects due to treatment and not to cure the cancer. If he dies of PC then it is a failure.
I think the important thing to consider is the original goal of the treatment and if that goal has been accomplished it is a success. HT is normally not given as a curative intent in most cases and if life is extended it is a success. If it is given as a curative option, such as the Liebowitsz protocol, and there is a biochemical reoccurrance then it is a failure.
JT

Hi Tony,
I for one went into surgery because I was hoping that it would take the cancer away. It didn't and forced me to make decisions that would affect my survival and my QOL.
Did I think at that time that the surgery was a failure? Yes I did.
Do I now think that surgery prolonged my life? Yes I do. But I had, at that time, to make a difficult decision. I was told by the surgeon that he left some cancer behind. I was having rectal problems and had to decide between RT or HT or a combination of both. In 1992 I was given 4 years to live. That information had significant consequences.

I along with my wife made the decision to avoid RT because of fear for additional side effects. Instead chose an orchiectomy;I decided to retire early; I arranged our financial matters for after my death; used my time to learn as much as I could to survive the disease that was killing me; I realized that by learning and helping others survive, I was helping myself survive. All these were/are positive things. I am still a positive person in spite of all the side effects of treatments. My goal is to beat the odds and die of something else than PCa. I am still trying hard...

RalphV

Hi Jeff,

Thanks for the calculations, but sorry, I don't understand the significance of the numbers.

Perhaps you could elaborate.

Have you guessed that I still have a lot to learn?

Thanks,

Chris.

One oF the unique things about PC is that "cures" are expressed in years. Usually 5, 10, or 15 year intervals. If I have a cold, and take some zinc, or some other sure fire remedy, I am considered cured, even if I get another cold next month.

If our body was pre-disposed to get PC because of heredity, chemical exposure, diet, etc, etc., could we also pre-disposed to reoccurrence ? Treatments that leave the prostate such as Hifu, or Bt, could have a pure reoccurrence in 10 years. Benign prostate tissue could begin to mutate again.

I have never used the word cure in my journey. I figure the odds of eradicating every PC cell is slim, and I may always carry a few cells around. Therefore if I never say cure, I never say failure. If and when my PSA begins to rise again I will look at it like another occurrence, much like if I got another cold.

Just the little head game I play with myself.

Goodlife

One needs to avoid the idea that "failed surgery" equates to "the surgeon failed".

"Failed treatment" is a very common occurence in many areas.

In my case the cancer had spread into the bladder neck and the seminal vesicles, so we were ready for the PSA not to come down as there was clearly a strong chance that despite the surgeon following the standard procedure some pca might be right next to the stuff that was removed.

Had they tried to knock out my PCa with RT they could clearly have missed all of it too as they had no idea after the biopsy that it had spread beyond the gland. I am thus very glad to have had surgery so that the RT was still available to clear things up.

Alf