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Debunking Peter Grimm study and question about cancer return?

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Posted 2/12/2013 1:39 PM (GMT 0)
Fellow Prostate Cancer Folks:

I'm in the final stages of deciding between robotic surgery and radiation.

Was recently rediagnosed as Gleason 7 (3+4) by Johns Hopkins.

See my stats.

Their all day interdisciplinary consult (including radiation folks) recommended surgery.

But they would still do radiation if I asked (external, with hormones).

My question today is about the Peter Grimm study, showing measurably better rates on cancer not returning with brachytherapy.

I've asked both surgeons and radiation guys about this, and they sortof generically say they've seen the study but don't really back it's findings.

But I can't get a sense of why the study wouldn't be reliable.

Can anyone shed light on that?

And I guess second question.

I've been looking at the issue of positive margins with surgery.

When cancer returns how often is it in the prostate bed, versus how often is is somewhere else in the body?

And does radiation (either external or seeding) do a better job of killing the cancer in the prostate bed area?

If the vast majority of cancer returns are somewhere else in the body (as some have told me) then wouldn't that make the issue of surgery vs radiation less important in terms of cancer return, as neither treatment as your first course of action would catch those returns?
Posted 2/12/2013 4:48 PM (GMT 0)
My doctor advised surgery then radiation if needed as opposed to radiation then surgery. His thinking was that surgery before radiation is cleaner and more effective compared to surgery after radiation. My understanding was the radiation damage made a clean surgery more challenging.

I have a brother who went the radiation route and recovered completely (over 10 years ago). I, on the other hand, had surgery and am glad I did as it helped identify the cancer in my bladder.

I guess there is no one right answer, just the answer that is right for you.

Hope this was helpfully.

Pat
Posted 2/12/2013 5:30 PM (GMT 0)
My understanding is that any PCa treatment fails because the cancer has already escaped the prostate. Short of an inexperienced doctor I can't see any other reason for failure. That would hold true for surgery or radiation. I also understand that radiation ideally covers any margins.

I saw a total of seven doctors before I decided. Two were surgeons and one of them told me straight out surgery would be best given my stats and age (he himself had performed nearly 1000 robotic surgeries). Four of the doctors gave no definitive answer although one of them suggested that men who have surgery are often looking at salvage radiation as well and said that then they can be left with side effects of both treatments.

It's a hard choice to make.
Posted 2/12/2013 6:23 PM (GMT 0)
Re the Grimm study: The fact that they could not provide good reasons to disprove the study is all you need to know. The study's criteria was set by a group of 25 of the best prostate specialists in the world including surgeons, radiologists and pathologists as well as oncologists. All studies are referenced and one can go to the exact study to review it's findings; there were about 750 that met the criteria as to length of time, risk classifications and number of patients. The facts are the facts and this group of 25 reviewed them, so it is not one institution, one doctor or one treatment type that was represented.
I have an advanced degree in operations research and i saw nothing that would make this study suspect or invalid.

Any reoccurrence is dependent on your individual stats, the gleason grade, psa and signs of extracapsular extensions. Using the total universe of G7 patients there is about 30% chance of reoccurrence. Of all reoccurrances there is a 70% chance that it is systemic rather than local. Only local failures can be treated successfully with a salvage treatment.
Radiation absolutely has a better track record of killing cancer in the prostate bed. That's why they use it as a salvage treatment after a failed surgery. If used as a primary treatment it will take care of any cancer up to 15mm in the bed. There are also areas that radiation is more effective than surgery, in the apex, around the nerves and other areas that a surgeon will leave bits of prostate tissue that may contain cancer.
The reason that brachy is so effective is that it uses a much higher dose, 130 to 150 gy compared to the 81 gy used in external radiation and the radiation is concentrated to the prostate.
15% of all G6 cancers will fail surgery, these are Walsh's and Scardio's numbers, all all are local failures due to the above reasons by excellent surgeons. Dattoli in his published results for high risk patients had no local failures and all radiation failures were due to systemic spread. Neither surgery or radiation will cure a cancer that is already systemic, but radiation either external or brachy has a significant advantage in preventing local treatment failures.
JT
Posted 2/12/2013 6:48 PM (GMT 0)
Aachen, I'll just say that you may have opened the proverbial can of worms on this one. about a year and a half ago this very topic had a thread - that got ugly really fast. Reminds me of the Civil War in the U.S. - brothers (surgery) fighting against brothers (radiation), just not a pretty sight. . . .

So then I'll throw this out here now - let's not start slinging arrows at each other - everyone should just take the Grimm report for what it is, however they wish to - and not force their ideals down anyone else's throat.

For my part, it was a huge part of my decision on what treatment I chose.

Peace.........
Posted 2/12/2013 6:53 PM (GMT 0)
Yooper.

Your point is well taken. And I too hope to avoid a flame war.

But if I could at least get more detail on the return cancer part - what percentage is in the prostate area and what percent is outside the area.

I think John T mentioned some stats, which are helpful.

But any and all additional information is useful to me.
Posted 2/13/2013 6:37 PM (GMT 0)
Aachen,

Thats an excellent question and I hope someone is able to quote some specific stats to answer that. It has been my understanding that post radiation there are very few cases where there is reoccurrence within the treated boundry. Although there are many facts to be considered in this, total dose, skill of rad oncologist, technology.
I posed this same question to Dr Dattoli prior to my treatment and he stated that of the many, many men he has treated after their initial diagnosis, he could count on one hand the number of cases of reoccurrence he has seen in the treated area.
Posted 2/13/2013 7:22 PM (GMT 0)
John, I agree that of all recurrences only about 30% are local and treatable by radiation. I'm currently undergoing SRT and know it's only a 30% chance of a cure. However, besides being better than 0%, I look at it this way. Even with systemic disease, it probably begins in the prostate bed. Let's say the recurrence is caught early enough that 90% of it is in the prostate bed. SRT would kill that 90% and bring, say, a .5 PSA down to 0.05 before it begins to rise again. If you have, say, a 1 yr doubling rate that's over 3 years of slowing the disease. Or, if it's going to kill you, that's another 3 years of life. Yes it's all hypothetical but it gives me hope to keep fighting.
Posted 2/13/2013 7:40 PM (GMT 0)
Come on John, that's not all he needs to know if the medical professionals he consulted with advised as much. these things are not black and white issues. Perhaps he should simply ask the professionals more in depth questions that he can get help on from you given your experience. I wouldn't want to assume his doctors are not properly informed or that they have a bias.

None of the experts I spoke with, and they were not all surgeons, said that radiation had a better track record than surgery. They all said they would be equally effective in my particular case but that given my age surgery was more advisable.
Posted 2/13/2013 8:08 PM (GMT 0)
I think davidg has this right, and that -- despite his advanced degree in operations research -- JohnT oversimplifies the issue. I think John had radiation treatment, so it is understandable that he would favor this treatment. The "Grimm" group also appears to have been heavy on ROs and medical oncologists who have been critical of the perceived over-use of surgery. I suspect the outcome might differ depending on what group of doctors do the study, which of them takes the lead, etc. And even so, none of this is the product of a controlled, randomized trial. It is all retrospective. And then there are issues of patient age, risk of secondary cancers, the timing of side effects, the efficacy of secondary treatments, the psychological issues, etc. Sadly, its just not so simple.
Posted 2/13/2013 9:30 PM (GMT 0)
You guys bring up some good points. It is very true that radiation treatments have come a long way over the past few years and may not be as likely to trigger new cases of cancer 15 years down the road. But this is still not a proven fact.

On the other hand, if EBR should fail, it is TOO LATE to use surgery as a salvage treatment because surgery cannot be performed once the prostate area has been irradiated. Too much scar tissue for the surgeon to access the prostate.

One thing for certain, in spite of what others may post, surgery is STILL the GOLD STANDARD of cure that all of the OTHER treatments strive to emulate. This doesn't mean that surgery will not eventually be replaced by super sophisticated forms of RT in the future -- but we are not there yet. And, until we reach that level of technology, surgery will probably remain the gold standard.

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1.
Semi-firm erections now happening 14 months post-op & slowly getting a bit stronger.
Posted 2/13/2013 9:46 PM (GMT 0)
Without entering the debate,
Beware of bias and data collection methods while examining studies. Understand they are almost all flawed when they are not conducted in a controlled protocol. A person whom is not a surgeon nor does his group do surgery, will gather data by grabbing data from various sources and studies not designed to be used in this way. Dr. Grimm is a fine doctor and may have the most superior knack for implanting seeds because his numbers for BT do not match the industry reporting of SE's for BT.

Tony
Posted 2/13/2013 9:58 PM (GMT 0)
The Grimm study is out there, published and documented. We can come up with all sorts of conjecture, but I have never seen any evidence to support that it is not valid. There will NEVER be a controlled randomized trial as this has been attempted and there were too few patients that would agree to it; so that issue is dead. It's the best information we have and I would like to have some of the critics of this study tell us exactly how they would structure a study based on the information we have available. The criteria of this study is good and all included studies were peer reviewed. It was the first attempt to do an apples to apples comparison of treatment options using the same criteria and risk stratification, and has a very large data base, 750 studies of at least 100 patients each.
I admit that I do have a radiation bias; but that bias is due to its reduced probability of side effects and superior control of localized cancer. If another treatment like HIFU or laser or something else was proven to have less side effects while maintaining cancer control at similar levels to surgery I would be biased toward that treatment also. If a new method of surgery was developed to eliminate the current side effects I would be biased towards that. There is a lot of long term data out there and this study attempted to use what we have available.
My entire PC treatment philosophy is for low risk cancer the treatment that produces the least amount of side effects should be the preferred treatment and for aggressive cancer the most aggressive treatments regardless of side effects should be the preferred treatment. I believe that low risk patients are treated too aggressively and high risk patients not aggressive enough. When the risk of death is high you pull out all the stops and when it is low you minimize the treatment effects. Many may not share this philosophy, but it follows Strum's strategy for a successful outcome.
1. Understand the biology of your cancer.
2. Choose the treatment that fits the biology of the cancer you have.
3. Pick the best artist to do the treatment.
Posted 2/13/2013 10:07 PM (GMT 0)
there are plenty of folks who had surgery without side effects, minimal side effects, or fewer side effects than people who opted for other treatments. There are a ton of variables to consider which should lead a man to your closing points 1,2,3 so that personal bias is only determined when all those variables are considered.

Which is probably why Aachen's doctors advised him as they did.
Posted 2/13/2013 10:10 PM (GMT 0)
John you must not have seen this trial...

clinicaltrials.gov/show/NCT00023686

This is a Level 1 randomized trial. We are still a couple years away from the 2018 results...I do not know if we will see early results.

Tony
Posted 2/13/2013 10:30 PM (GMT 0)
I committed to not "pushing" my choice of treatment - but at the same time won't sit back and ignore opinions that I feel are flawed.  Sorry Chuck - with all due respect surgery USED TO BE the "Gold Standard", but that is very much outdated.  And yes your point about not being able to go the surgery route after radiation is (almost) correct (very difficult but not impossible) - but so what, that doesn't mean there are no other options for salvage therapy, because there of course are.  And that is only an issue if the primary course of radiation results in recurrence, and like it or not the statistics indicate the chances are not likely. 

At the end of the day I believe that both approaches are very good - and that it is up to the individual to make their decision on treatment.  I chose BT, you chose surgery, and at this point we're both successful as are others - and isn't that the whole point?  Again, we Brothers all should be fighting the beast, and not each other.  I won't slam surgery, but also won't stand by idly when there is slamming going on. . . . .

Bottom line - the Grimm report is out there, facts from prior medical studies are summarized and given.  Shoot darts at that if you will, but until the medical world comes up with valid reasons to discredit the Grimm report, I ain't buying laymen's opinions against the results of this study.

'Peace.....'

Posted 2/13/2013 10:35 PM (GMT 0)
Other than pre-conceived bias, I fail to understand why it is so hard to understand two very simple points:

1. If a patient is brachytherapy-qualified, then brachytherapy and surgery offer similar cure rates.

2. Generally brachytherapy offers almost no incontinence issues and lower incidences of ED than surgery.

IMHO, all this other stuff about SE's is mostly noise.

This does not mean that either option is best in a particular case. But...geez...why do we have to debate the same things over and over. These are the facts, period, and there have been multiple, many, a lot and tons of studies posted on HW that lead a logical mind to this conclusion.

Jim
Posted 2/13/2013 10:49 PM (GMT 0)
www.jurology.com/article/S0022-5347%2805%2966717-1/abstract

"Results

Pretreatment erectile function assessment revealed scores of 0 in 57 (14%), 1 in 46 (11%), 2 in 77 (18%) and 3 in 236 (57%) patients. In 313 patients who were potent with a score 2 or greater before therapy the actuarial freedom from any decrease in erectile function score was 64% and 30% at 3 and 6 years, respectively. The actuarial preservation of potency, with a score 2 or greater, was 79% and 59% at 3 and 6 years, respectively. The 2 factors found to have a significant negative effect on potency in univariate and multivariate analyses were high implant dose (D90 greater than 160 Gy. for I-125 and D90 greater than 100 Gy. for Pd-103) and a pretreatment erectile function score of 2 versus 3.
Conclusions

The rate of potency preservation after brachytherapy is high, although a decrease occurs from 3 to 6 years. Pretreatment erectile dysfunction as well as higher implant dose are associated with greater impotency."

I'm sure results have improved since then. As they have for surgery where surgeons like mine, and others, achieve success rates in the high 80s for ED and 90s for incontinence.
Posted 2/13/2013 11:07 PM (GMT 0)
Tud - with all respect, your post makes the issue seem much simpler than it is and blows by some very important issues, including -- to name just a few: (1) efficacy past 15 years (a real issue for younger guys); (2) the risk of secondary cancers past 15 years; (3) comparison of the efficacy of salvage treatments; (4) the ability to know with confidence who is "brachytherapy-qualified" given the frequency with which biopsy path reports turn out to have been inaccurate; (5) the clinical and psychological value of definitive pathology that comes only from surgery; and (6) the enhanced ability to determine relapse post-surgery compared to post radiation. I am not an advocate of surgery. I am an advocate of considering all reasonable options, getting advice from experts with different perspectives, and not giving undue weight to anything one reads on the internet. I am wary of people who seem too certain that they are right, or who make complex issues seem more simple than they are. I wish it were obvious which is the best primary treatment for a low or intermediate risk prostate cancer. If it were obvious, then everyone would do the same treatment and there would be no debate. Sadly, it isn't obvious and there is no one size that fits all.

Post Edited (medved) : 2/13/2013 5:06:02 PM (GMT-7)

Posted 2/13/2013 11:15 PM (GMT 0)
jco.ascopubs.org/content/28/9/1508.abstract?sid=b6d8c0cd-b1fc-4dfb-a3e0-1bd70cac6a3d
Posted 2/14/2013 1:01 AM (GMT 0)
Davidg, posting a 12 year old study that is not comparative and that makes obvious starements is both useless and irrevalent...I believe you can do better than that.

Medved, with equal due respect I also believe that choice of treatment is a complex issue and have said so many times on this forum. However there are certain simple facts that even the most ardent pro-surgery surgeons accept, e.g. Walsh. That was the only point I was tring to make; not that either brachytherapy or surgery was superior.

Med, we can argue the pros and cons until the cows come home and I could debate each of your points one by one but it's probably not a helpful exercise. I still think the best we can do at HW is state the facts honestly, provide our opinions as such and hope our new members take the time to educate themselves before making a potentially life changing decision.

Jim
Posted 2/14/2013 1:06 AM (GMT 0)
There are tons of old studies in any field that relevant. As I mentioned myself, requiring updates, but relevant nonetheless.
Posted 2/14/2013 1:18 AM (GMT 0)
I'm going to make my decision by this Sunday...brachytherapy or surgery.  Right now I'm leaning towards the surgery, but trust me, when I think about recovery and side affects, the brachytherapy sounds very appealing. For me, the concerns that Medved raised are what have me leaning towards the surgery.  I'm only 52 and I'm not sure what the long term affects of the radiation will be outside 15 years. 

But this is how I feel.  I can tell everyone is very passionate about how they feel.  I think this is great.  It makes me very happy to see so much vigor and life in these posts.  No one wants to think they've made the wrong choice and I don't think anyone has.  What it tells me is both options have been very successful. 

I congratulate those who've made their decisions and wish good luck to those who are about to make theirs.  May we all be involved in lively discussions for many years to come and perhaps one day soon, we won't need to discuss this topic again.

Posted 2/14/2013 1:26 AM (GMT 0)
Decisions, yes you have caught on to one of the real beauties of HW...lots of great info and passion to boot.

Re your concerns about secondary cancers from brachytherapy, I would urge you to follow the thread currently on page 1 on this subject. Our esteemed member, Tony C just posted a link to a study that showed secondary cancers from brachytherapy were actually less common than those found in patients who had RP. Re the Medved points, as I said I don't want to debate those (again) as it has been done many times on HW. However if you want a different take on these ponts you are welcome to email me or I'm fairly confident that JohnT would respond to your questions and he is the REALLY smart one on HW!

Jim
Posted 2/14/2013 1:39 AM (GMT 0)
Tup:

the this was 2 years old btw

jco.ascopubs.org/content/28/9/1508.abstract?sid=b6d8c0cd-b1fc-4dfb-a3e0-1bd70cac6a3d

As for Brachy, I think it's a great option for many. I stayed away from it because I saw my boss go through it with one of the best in NYC, witnessed his side effects (he was doing HT also) and decided it wasn't for me. I also didn't find the idea of a prolonged process appealing.

I tried to get my Italian friend to consider it strongly as I thought it would be good for him. He didn't want it. And if my daddy has a turn for the worse on his next PSA exam (it's rising), I'd definitely urge him to consider it and would get him an appointment with the guy my boss went with.
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