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Retrospective look at three options for treating prostate cancer.

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Posted 2/20/2012 9:29 PM (GMT 0)
This is a comparative study between three treatment modalities ~ RP, EBRT, and Brachytherapy. We are starting to see more comparative data such as this release from Kibe; et al at Cleveland Clinics. I have several problems with this study and I have asked to see if we have differences in age medians in the three options outlined. Also this is a breakdown that does not quantify the risk categories. Still the survival benefit in choosing RP is significant but that still does not make it a premier choice for just any class of patient. What it does show us is that if the data holds true in other institutional studies based on risk classification, RP is still the gold standard in curative therapy and survival (I can already hear your voices of dissent). But it comes with a lot of SE's that can affect QoL. But for patients at the median age of diagnosis ~ 67yo ~ the outcomes of the other choices were definitely good enough to justify those choices.In other words, less SE's may outweigh the small survival benefits in many cases. The level of evidence in this study is 2B.

prostatecancerinfolink.net/2012/02/20/relative-10-year-survival-after-surgery-ebrt-or-brachytherapy-in-the-psa-era/

My disclaimer is that I have always had a bias in favor RP especially in intermediate and high risk cases and for younger men. This study, and a few other recent releases, only bolsters my feelings there. But each individual has to make the choice that's right for them.

Tony
Posted 2/20/2012 9:31 PM (GMT 0)
PS: Like Mike says in the article, I am certain that there will lots of push back on this post. But that's quite alright. I understand. It's important to note that the points that can be made to support the radiation options are quite valid and important points to consider. So please post away.

Tony

Post Edited (TC-LasVegas) : 2/20/2012 2:35:52 PM (GMT-7)

Posted 2/20/2012 10:07 PM (GMT 0)
The below article is interesting Tony.  It is long term data for surgery.  The authors claim up to 43 years out.  You and I are always looking for long term results. 

http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Local-distant-prostate-cancer-control-strong-after/ArticleStandard/Article/detail/711793

While our results indicate biochemical risk may be suboptimal, with 35% of men at risk for biochemical recurrence at 20 years, about 76% of men remained free of metastasis and prostate cancer-specific mortality 30 years after their surgery,"

I think I feel a little better.....Maybe, but I bet it won't last....

Posted 2/20/2012 10:21 PM (GMT 0)
Tony, if that is what the facts and data indicates, then so be it. I think the edge has always been towards surgery, but as you indicated, doesn't mean the other treatment options are bad or lesser choices. Goes back to my own mantra, no one size fits all. QOL is very subejctive, and living with SE is as personal as it gets. Each treatment should be moulded for the exact needs of each patient.

david in sc
Posted 2/20/2012 10:47 PM (GMT 0)
I echo David's response.
- the best thing to do is find the best treatment to suit the individual - as shown in different poster's signatures - similar stats do not mean similar treatments and/or similar outcomes - let alone quality of life issues -
- wishing you all the best,
Bronson
Posted 2/21/2012 12:16 AM (GMT 0)
Tony,

This coming Sunday (February 26th) marks the eighth anniversary of my

open Radical Prostatectomy (ORP) at age 65.

My Pre-op PSA was 2.2 with positive DRE and my Gleason was 3+3= 6.

My wife an I decided on surgery for several reasons:

1- I had seriously worked out most of my life and was in very good shape for my age.

2- I wanted to have a Plan B (EBRT, IMRT, IGRT) available in case of

post-surgical recurrence.

I can honestly say that I would make the same decision today without

hesitation.

My Post-ORP PSA remains undetectable as of 12/13/2011. 

My URO wanted us to speak with a RO before surgery but we declined and scheduled ORP.

I regained continence by doing kegel Exercises and taking a 2 month

Biofeedback regimen.

In December 2007 I received an IPP (Inflatable Penile Prosthesis)

which completely corrected my ED and restored my sex life. 

I am currently Co-Chairman of the UsToo Prostate Cancer Support Group

at Hackensack University Medical Center in NJ.

I have spoken with many men of all ages recently diagnosed with PCa.

I always recommend that they see at least 2 UROs, as well as, a RO and

MO before making a final choice of Treatment which they feel is best for them. I stress that the final decision is theirs and theirs alone!!! 

Tony, I would like to sincerely thank you and the other HW Moderators for making the Group such a wonderful place for men with PCa to come together for candid discussions.

Bob

 

Posted 2/21/2012 12:40 AM (GMT 0)
Tony -- i wonder how combination treatment stacks up against any single treatment?  i really think that's why you have great results.

ed

 

Posted 2/21/2012 12:52 AM (GMT 0)
Bob,
The special credit that is worthy of giving to is the responsible party who makes this site happen and that is to Mr. Peter Waite, the sites owner and founder. Peter has had a terrible time with Crohn's Disease and he was a web designer that really wanted a place to talk to his Crohn's peers. So he made a heck of a site that helps so many people with so many chronic ailments. The moderators here are all survivors ourselves and we all found this place for the same reasons. It's an always open 7x24x365 discussion forum that was there for me and has also supplemented well our UsTOO Las Vegas chapter which I chair. Thank you much for the kind words but I like to think it takes every member to make this place work right.

Tony

Post Edited (TC-LasVegas) : 2/20/2012 6:07:21 PM (GMT-7)

Posted 2/21/2012 12:55 AM (GMT 0)
Ed I believe you're right about adding adjuvant therapies. But I think it's improper to compare multi modal treatment plans against a mono therapy. I think it stands to reason that a whole new set of studies would need to be conducted and without bias to get any clear answers.

I also think you are right in that my results may have been helped with adjuvant therapies. So far so good. But only time will tell...

Tony
Posted 2/21/2012 1:06 AM (GMT 0)
Tony -- i am in the time will tell camp too.  surgery is probably the most refined technique when it comes to long term comparisons so i'm not sure how that will affect the ten years beginning say a year ago or today.

you can pick the statistically best treatment and it might be the worst choice for you.

ed

Posted 2/21/2012 1:17 AM (GMT 0)
Well said, Ed. I concur entirely. I think it's fair to say that we are lucky to have some very good options in each of these being compared. I don't think anyone should use this data to discount any of the available options. I do think that a younger man should put more emphasis on this information but that's my opinion. Simply put, as Chris said above, we younger guys want more long term data and we still can get the longer studies with RP than any other treatment choice.

Tony
Posted 2/21/2012 1:33 AM (GMT 0)
Tony -- my uro, a surgeon, advised against surgery because he figured i would also need radiation and he wanted to avoid side effects.  so we went with a combination treatment that began with BT. 

i figure the cancer that might really make the difference for me (and you) was treated by radiation and lupron....at least in the short and intermediate term.  and we both know that without surviving those periods there ain't no long term cool .

from what i've read on this board over the last couple of years i think you were very fortunate to have a skilled medical team that looked at the big picture.  of course you are biased toward surgery cool .

ed

 

Posted 2/21/2012 1:56 AM (GMT 0)
I will never deny my biases. It's the wrong thing to do.

I did extensive research on my own because I tend to be an "all in" kinda personality. My involvement in advocacy also helps today. I knew the quality of my team when we got started was good. And lucky is an excellent way to put it. As I later learned, each of my team are world class researchers and academic chair leaders in their field and today I have access to many others that specialize in so many aspects of prostate cancer.

Very lucky indeed.

Tony
Posted 2/21/2012 2:20 AM (GMT 0)
OK, and now for the dumb question from the not fully educated:  What is the difference between "Adjusted 10-year overall survival of the patients" and "Adjusted 10-year prostate cancer specific mortality rates for the patients"?  Laymen's view makes me think these should simply be inverts of each other.  If the survival rate is 88.9%, why is the mortality rate not 11.1%?  What am I missing in this terminology.  Is the survival rate saying how many are still alive vs passed away, whether those no longer living died from PCa or any other cause of death?  And the mortality rate counting just those that died of the PCa? 

If that is the case, the overall survival rate is a semi-useless figure.  That fact that someone died from something unrelated to the cancer should exclude them from the statistical analysis.

So what am I missing or not understanding?

Posted 2/21/2012 3:24 AM (GMT 0)
mts,
You have it right. The prostate cancer specific survival rates at ten years were as follows:

RP: 98.2%
EBRT: 97.1%
Brachytherapy: 97.7%

This after eliminating those that died of other causes.

I would say that the data is significant but it depends on how someone might use it, I would say it needs to be properly valued for each individual. I'd be just as interested to see more of these retrospective looks over a 15 year period. I think we will very soon...

Tony
Posted 2/21/2012 4:45 AM (GMT 0)
The results are statistically insignificant at 10 years. Any study that excludes clinical risk classifications is pretty much worthless as we all know that there is a huge difference in outcomes with any treatment option between a low risk G6 and a high risk G9. The study may include clinical risk classifications, and would be much more useful if the results were stratified by risk class and not lumped together. 10 years ago it was common to recommend external radiation for both older and higher risk patients
Posted 2/21/2012 1:08 PM (GMT 0)
An intresting retrospective analysis with 2550 patients by Zelefsky et.al., follow-up was 8 yr, extending >20 yr.

http://www.europeanurology.com/article/S0302-2838(11)00897-9/fulltext

Fig.1,2,3:
Appropriate dosing of >=81Gy will bring up to 80% of patients in complete remissing. After 10 years the study shows stable disease, so that one could view that as a therapy for younger patients, <60 years of age.

Fig.4
Adding ADT to RT will boost the results by about 50%, which is the std. procedure today.

Fig.7
But be aware of other risk factors, that present a far greater death rate... Sadly, we all get older - every day.

LR

Posted 2/21/2012 2:11 PM (GMT 0)
I've been doing an RP study myself, but with a smaller sample size. I haven't been conducting the study very long yet but I'm hoping to make it a long term study. To date the Adjusted 14 1/2 Month Overall Survival Rate of the patient is 100%.

 

Posted 2/21/2012 2:16 PM (GMT 0)
Tony,

This has been a great post and I like you am biased towards surgery. I am approaching my one year anniversary of my diagnosis and as I read the study many of its conclusions are the reasons my wife and I chose RP surgery. The side effects for me have only been the ED problems but it is still too early to know if that will be permanent. Continence has never been an issue and I really like the fact I can pee like I did as a teenager.  The best part of the RP was knowing that from the pathology my PC was confined in my prostate and I do not, at least for now, have to worry about whether or not it has spread.  I know that PC can still rear its ugly head in my body down the road, but it is not too likely. I made my decision and I am living with, and I do not second guess whether it was the right treatment for me.

Terry TWG

Posted 2/21/2012 3:28 PM (GMT 0)
Tony,

Thanks for posting this, but as John T says, it confirms that there is no real difference in the treatment sucess between the three.   Like you I am also biased......biased toward the treatment with the least risk and less severe side effects.   I am not biased toward a treatment method, per se.

My uro, another uro, my rad-onc, another rad-onc, and my med-onc; all said no surgery due to my high risk level.   They all explained the many different treatment options and cited results for each and all arrived at the same place.    There were some slight differences in opinion on things like HDR versus seeds, IMRT vs IGRT, and the length of HT; but all essentially said the same.   That surgery would not be curative or even controlling of the disease, but would present more significant and severe risk and side effects.  

It is valuable to have these studies available for newly diagnosed men and I believe they would encourage multiple opinions, as you suggest, before making treatment decisions.  

Posted 2/21/2012 4:50 PM (GMT 0)

John T said...
The results are statistically insignificant at 10 years. Any study that excludes clinical risk classifications is pretty much worthless as we all know that there is a huge difference in outcomes with any treatment option between a low risk G6 and a high risk G9. The study may include clinical risk classifications, and would be much more useful if the results were stratified by risk class and not lumped together. 10 years ago it was common to recommend external radiation for both older and higher risk patients

John T,

I read the original article and they actually included all the clinical risk classifications including PSA, biopsy Gleason grades and biopsy clinical stagings so I do not think it is worthless. They did a multivariate retrospective analysis and confirmed the results were statistically significant.

First of all, reversing the statistics, the prostate specific mortality are: prostatectomy-1.8%; brachy-2.3%; EBRT-2.9%, brachy was 28% worse, and EBRT was 60% worse. Yes these were all very small and good but statistically significant.

Second, the overall relative survival: prostatectomy-88.9%; EBRT-82.6%; Brachy-81.7%. What this said is that more patients who did EBRT and Brachy died of something else instead of prostate cancer. Secondary primary cancer? Other radiation damages? I don't know.

However, as I said many times, the comparisons for long term survival is not relevant and unfair to radiation treatment because I found radiation treatments progressed and improved so rapidly in the last decade. I am more than impressed with what the radiation physicists and radiation oncologists have done and I am quite sure the comparison in 10 years will show no difference statistically.

Regards,
Posted 2/21/2012 5:33 PM (GMT 0)
Newporter,
I think that what the study really shows is that death from PC is rare at 10 years and these rates echo the Active Survellience death rates for the same time period. This brings up another question; What should the true measurement of a treatment's effectiveness be: is it overall survival, disease free survival, rate of biochemical reoccurrance, or matastis free survival. I think a good point could be made for any one of these. I think it is very confusing for a newly diagnosed patient as the defination of success or failure of any treatment varies with the study.
The released study on 2nd hand smoke showed a 100% increase in deaths for those exposed, but the rate went from 1.5 per million to 3 per million; statistically significant, but hardly relevant. Katten is a excellent researcher and I trust his numbers. When we look at overall survival, age at DX would be the variable that matters most not the treatment.
Posted 2/21/2012 8:37 PM (GMT 0)

John T said...
Newporter,
I think that what the study really shows is that death from PC is rare at 10 years and these rates echo the Active Survellience death rates for the same time period. This brings up another question; When we look at overall survival, age at DX would be the variable that matters most not the treatment.

John T,

I appreciate your thoughtful responses. All excellent points especially the last. I had forgotten that there was a historical bias that pushed older patients towards radiation and am not sure if the research took that into account.

Again thanks for bringing that up.
Posted 2/21/2012 10:19 PM (GMT 0)
As much as I have tried to find a free full text of the original article I can't so I will have to rely on the Prostate Cancer Info-Link summary and the journal abstract since I'm not willing to spring for the 30 bucks.  Hence my conclusion is that of these summaries, i.e. that any differences in survival were modest and could be explained by "...an imbalance of confounders..." despite the authors attempts to adjust for them.

So, rather than the article annointing RP as the "gold standard" it appears that this is one of many, many studies that concludes that the curative rates for the main three treatment options are very similar, i.e. they all work and work well.  Given that, it still makes me wonder why a patient would choose surgery with all of the real and potential SE's when other good options are clearly available.

Tudpock (Jim)

 

Posted 2/21/2012 10:34 PM (GMT 0)
Jim,
When I say gold standard I include that you do not want the Midas Touch. For many men these results do indicate a survival benefit but it's too small to use it to say that this would always be the best option. Because for many men it isn't.

But as far as younger men we still don't know the long term SE's of newer radiation techniques. So I think there is plenty of reason to consider dealing with the SE's of surgery. #1 it works well. #2 younger men seem to heal better. I think that using a top line surgeon is a must. Folks should not be using doctors whose experience is sparse. In fact I think that many doctor that perform surgery for prostate cancer are doing a disservice when they fail to acknowledge their own limitations. But I can say that about all modalities, too.

Still I think this study is accurate but it doesn't go far enough. It needs another five years to see what we get at that time. Again, the level of evidence is 2b. That's about where every radiation study is and that's not good enough to make any claims...

Tony
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