Defining Cure and Remission

In a reply to Compiler in his thread " Can PC be cured after failing surgery and SRT" I stated that depends on your definition of the term. To that Mel replied:

"Do I really need to define CURE?

Gone...finito...."

No definition is clear what it is to be cured. That's why I asked the question. It reminded me of a seminar I attended at last years American Society of Clinical Oncology specifically on the topic. I had been meaning to do a piece on it. So today I did. I hope you all can get there, where ever there is.

advancedpcatalk.freeforums.net/thread/193/defining-cured

"Cured" is an interesting descriptor and we have had these discussions before. It's always fascinating to me how different people view it. As an incurable optimist and "glass half full" kind of guy, I consider myself cured and my doc has also used that term. I guess it will be "oops" if I get a recurrance but, in the meantime. I'm one happy dude having been cured of cancer.

Jim

good post, and thanks for lumping me with London instead of Paris.

not to drag this in another needless direction, but your quote brings up another valid point in my opinion...

"When cure is possible, is it necessary?"

I know that almost 4 years ago I felt very differently about this than I do now, that the experiences I have been tested with since, as well as adapting to the new reality of PCa me, are probably the reason for this. It just seemed a lot more necessary then than it does now. Perhaps that will change again and again.

davidg said...
 "When cure is possible, is it necessary?"

I know that almost 4 years ago I felt very differently about this than I do now...

davidg, your comment is illuminating.  I felt the same, and this enlightenment is probably quite typical of “Londoners” like us — I was 3+4; three positive cores, but not very much % in each positive core (I’ve forgotten exactly how much); and low PSA, under 10 ng/mL.

 

Like you, I also felt “very differently” when first diagnosed, and up until the time that I realized that I was probably overtreated.  I thought I was something special—an anomaly—being diagnosed with prostate cancer in my 40’s.  Prostate cancer is supposed to be an old man’s disease.  Then I found out I was merely part of the latest fad, following the trend of younger and younger men being diagnosed with smaller and smaller amounts of “weird cells” that somehow gets lumped together with those Parisians, only to be “rushed” into treatment before I could catch my breath.  I became a statistic in the fastest growing sub-specialty in medicine today.  Welcome to the club. 

 

Yes, my perspective of “cure” is very different that it was when I was first diagnosed.  I was such a noob.  I have a great deal of respect for those who are fighting real disease, rather than the demons of doubt.

I agree with the differences you point out, Peter.  Again, it's the Londoners and the Parisians.  It's two very different diseases.

So I guess this discussion puts me in Paris rather than London. Both places would be nice to visit but I'd much rather live at home.

I think we are making this way too complicated.
CURE clearly means that the cancer is GONE. No more cancer cells whatsoever; hence, no cancer.

Of course, the problem is totally academic because of the limits of our ability to measure our cancer. We all know that today's undetectable joy can be tomorrow's 10.44 PSA horror, if you get my drift.

So, my question was really this: is it possible to get rid of the cancer after failing the two "curative tx." of surgery and SRT. I gave the setting of failing those tests, finding a few specific lesions on say a C11 scan, and radiating those areas (or surgically attacking them). I think Dr. Kwon indicated in a presentation that this was possible. Naturally, we would not know for sure. But a string of undetectables for 5 years might make it look promising.

I do realize there are probably micro-mets, meaning NO CURE.

Incidentally, I emailed him, but never got a response.

But aside from the definition, many of you point out that it is how we view our situation that matters.

Mel

Thank you all for very thoughtful replies. Yesterday I sent the thread at PCAF to several medical oncologists. I have received 4 replies so far and I will post their thoughts soon. It's interesting to see the variances arriving. The patient community has a wider disparity. But that's to be expected. I need some more consents to post the replies so please stay tuned. In the mean time keep it coming. I am releasing the discussion to more websites tomorrow. (I like to see how much HW kicks butt in the replies and support)

Love you all!

From the National Cancer Institute website:

"remission

A decrease in or disappearance of signs and symptoms of cancer. In partial remission, some, but not all, signs and symptoms of cancer have disappeared. In complete remission, all signs and symptoms of cancer have disappeared, although cancer still may be in the body.

cure

To heal or restore health; a treatment to restore health."



Remission is straightforward. Many of us are clearly in remission with an undetectable PSA, clear scans and asymptomatic. Some are partial, some complete.

Cure is tougher in my opinion. Cancer organizations state cure rates as having survived for some defined period without signs or symptoms. One of the large brachytherapy centers uses ten years symptom free with PSA of <.20. I don't see anyone disagreeing with that definition. However there is well established evidence of recurrance after that point. A client of mine went sixteen years with undetectable PSA following surgery only to see his PSA rise and had to start ADT. By definition he was cured, but in reality he wasn't.

We are tilting at windmills; drowning in semantics!

Mel

Davidg

If my client had no prostate and was cured of his cancer, then it could not come back. Though he met an arbitrary definition of cure, he obviously wasn't cured. Rather he was in a very long term remission. Some cancer had been left in his body and it remained undetectable for many years. It then started growing, became detectable and warranted treatment.

It is natural to seek a cure since it closes the book on the disease.......or should close the book. It sounds unnatural to say I am in my 15th year of remission hoping I get many more. Naturally, by then we would think we were cured and for many at that stage, they very well may be. Personally, I have seen too many people that were assured by their doctors they were cured only to see a recurrence. They were more upset about the docs "lying" to them than they were about the recurrence and the treatment it would require.

And the NCI definition adds to the confusion for me as it does not require the elimination of the disease, but rather the restoration of health. Now the question is can one be healthy and have cancer? Certainly many men with low grade PCa are healthy......and many remain that way without treatment......but are they cured?

Jerry L. said... I think the use of these words is directly related to the Gleason score. Jerry L, I think your comment is right in line with what davidg and I said earlier about  "The Tale of Two Cities" ( with one exception ).     The exception is that Gleason score alone does not say enough to define the case risk profile.   For example, I was Gleason 3+4, but I had a “ favorable risk ” profile (just like many tens of thousands of other men diagnosed every year).   I had a low PSA (under 10ng/mL) and only a few cores positive out of 12 with not much cancer in them.     I never should have had my prostate removed.   I wish someone with the sage perspective of hindsight would have slapped me on the head and said, “Stop freaking out!   Wait and see if you do ever need treatment.   You don’t need it now!”   Nobody did that for me.   I was getting inputs online (at another site) but all I heard was things like, “Surgery is the best choice for a young, healthy guy like you.   You’ll be fine.  Just get a good, experienced surgeon.”   I am “fine.”   (Talk about semantics…let’s define “fine.”)   But I didn’t have to go through what I went through.   The fear, the tears, the worry.   I didn’t need to go through that.   All I needed was a little better “patient education.”   I definitely felt like I did my “due diligence,” but ALL that effort focused only on aggressive treatments, and finding the very best, most skilled surgeon in my major, major metropolitan area.   All I could think was, “Holy ****, I’m in my 40’s and I’ve got cancer!”   In reality, I didn’t need to pull that treatment trigger.   Hindsight is 20-20, but I’m pissed that nobody slapped me.  

JNF,

I think your once-and-for-always notion of a "cure" for PCa, while it works well for PCa, would seem odd in other contexts. Someone who gets occasional headaches, for instance, will be likely to think of a medicine that reliably knocks out a headache as a "cure." It's no guarantee that the patient will never have another headache but, as long as the same treatment will deal with the problem should it recur then that treatment will still strike the patient as a cure. Similarly, a pill that makes rhinoviruses go pifft would strike most people as a "cure" for the common cold, despite offering no guarantee that the patient won't need need to be cured again with next year's cold.

One admitted difference is that if you kill all the cold viruses, or you correct what-the-hell-ever is wrong with ones head to cause a headache, then the disease is no longer present in the body whereas prostate cancer that recurs must have been there all along. But if you look at that in light of the fact that men over 50 have a better than 50/50 shot at having detectable prostate cancer cells present, then if those patients doomed to recur aren't cured, does that mean that over 50 percent of the middle aged men you meet are sick?

I think the reason we don't think of more high-risk prostate cancer patients as "cured" has something to do with the fact that the treatments aren't repeatable. What worked last time is off the table if the stuff comes back. I think it's all about confidence.

Because its about confidence it will be hard to find a satisfactory bright line for a definition. Ten years without symptoms and with an undetectable PSA? Well, that's pretty good. You can have some confidence that the beast is beaten. Some. But maybe not quite enough. Are those guys "cured" after ten years. Sounds like you're not confident enough...