Worse prostatectomy outcomes? …or are they really better? Or the same? Look at the big picture.

Very interesting!

Newt:

Yeah, you have redefined WORST.

(Well, I guess they could accidentally remove Willy)

Mel

Jack, I have to echo BillyBob. My thought after reading your post was exactly 'Very interesting'. Thanks for the info...Jim

On the other hand more surgeons are willing to do surgery for cancer that has advanced to the pelvic area (but not further). The norm is/was that the surgeon would first check oneor more pelvic lymth nodes. If the cancer has spread they would close you up and focus on a non surgical option. The thought was at that point the negative side effects of surgery (tell me about them!) out way the positives. (If they know that it has spread past the pelvic area them surgery is really not an option.) Some recent data has shown a positive longevity effect with surgery for cancer that has spread to the pelvic area once you get past the first 10 years. I like the fact that with surgery the PSA tests will have more meaning when the values are low, getting a better evaluation of the tumors with the pathology report (vs a biopsy), and having a lot of options still on the table for follow up treatment (which may start next week). As I am "just" 58 I am hoping for a lot more than 10 years. Now my goal is to being the stock in Depends and viagra down.

That is not to say that some of the other newer treatments should not be considered as the first approach, nor would I say my choice of treatments is better than someone else's. But for me, I like having the prostate and positive lymph node (1 out of 14 removed) out. For others the trade off may not be there.

Dr WHO, I agree with your point...which is, I believe, that there has probably been an increased number of high-risk patients undergoing surgery as first line treatment, and that this, too, could be a contributing factor to the changes I reported in the original posting of this thread.

I say "probably" because I haven't seen data to support this, but it has been an observation of mine, as well as your own personal experience (or so it appears).

The application of radiation therapy, radiation therapy + ADT, or ADT alone as first line treatments for high-risk PC was certainly more appropriate and more exclusively utilized a decade or so ago. However, the ability to diagnose men with high-risk disease relatively early in the course of their disease (prior to distant mets) may have shifted the playing field in favor of surgery for a subset of men…most particularly for "younger" men in whom nerve-sparing may be an appropriate possibility.

The ability to select the correct patients for such procedures is obviously crucial to the overall success rates.

Whether leading members of the radiation oncology community would agree with this argument is questionable…but for the subset of patients with a “just get the darn cancer out” mindset, it does seem as though radical surgery for high-risk cases is a better bet today than it might have been a decade or more ago, and more surgeons would recommend it today as an option.

You do what you do, so it is what it is. Make the best and don't look back.

JackH said...
Dr WHO, I agree with your point...which is, I believe, that there has probably been an increased number of high-risk patients undergoing surgery as first line treatment, and that this, too, could be a contributing factor to the changes I reported in the original posting of this thread.

I say "probably" because I haven't seen data to support this, but it has been an observation of mine, as well as your own personal experience (or so it appears).

The application of radiation therapy, radiation therapy + ADT, or ADT alone as first line treatments for high-risk PC was certainly more appropriate and more exclusively utilized a decade or so ago. However, the ability to diagnose men with high-risk disease relatively early in the course of their disease (prior to distant mets) may have shifted the playing field in favor of surgery for a subset of men…most particularly for "younger" men in whom nerve-sparing may be an appropriate possibility.

The ability to select the correct patients for such procedures is obviously crucial to the overall success rates.

Whether leading members of the radiation oncology community would agree with this argument is questionable…but for the subset of patients with a “just get the darn cancer out” mindset, it does seem as though radical surgery for high-risk cases is a better bet today than it might have been a decade or more ago, and more surgeons would recommend it today as an option.

Well, mine(Chairman of the Vanderbilt high volume prostate surgery/urology unit) sure as heck did, he called it a slam dunk, due to his hunch based on my DRE(and his 30+ years of doing DREs) that there was a good chance that I was contained despite my G9. And we would not know for quite a while without lymph nodes and surgical pathology if my G9 was contained. Oh well, didn't quite work out, but I agreed with him- at the time- that it was worth a shot.

Jack H:

>>>>>>>>>>>>>>
This is true, and I've said this myself many times.

"You can lead a horse to water, but you can't make him drink."

>>>>>>>>>>>>>>>>>>>
This presumes there is some clear choice/path out there.
I guess there is, if you know what others' choices should be.

Mel

There is a difference between making a knee jerk emotion-based decision and making a decision based on knowledge of your own emotions.

This all presupposes that all the facts are divulged to the patient (as opposed to a urologist who only does surgery and recommends surgery to every PC patient.

Assuming one can think clearly and has all the information, then the only one who can/should make decisions is that person.

Mel

I suggest there is a fundamental difference between the two statements:

"you can lead a horse to water but you can't make him drink" is dripping with veiled contempt for the fictitious horse and presupposes that the "leader" knows what is best for the "horse".

The second statement grants independent agency to the person involved and presumes that they can be trusted to make the best decision for themselves in their individual situation.

This is the fundamental problem with specific advice-giving, and is why I personally try very hard to be careful about it. My thinking can be summed up this way: If I advice a specific course of action to someone else (As in, in regards to PC, telling someone what treatment they should or must pursue..key words being should or must), then I must accept responsibility for their outcome. In this forum, and personally, I try very hard (and sometimes I think I succeed) to limit my advice to two things: "Look HERE or THERE for more information" and "Here's what I did and here's how it turned out".

Jack:

>>>>>>>>

compiler said...
Assuming one can think clearly and has all the information, then the only one who can/should make decisions is that person.

And now it appears we have come full circle. Your comment here closely echos my earlier one: "You can lead a horse to water, but you can't make him drink."
>>>>>>>>>>>>>>>>>
Those are two diametrically opposed statements. I don't know how else to say it.
Your statement continues to reek contempt on the patient: if you don't see it my way, then there's nothing I can do. That is what YOU are saying.

Mel

compiler said...
Those are two diametrically opposed statements.

There are differences, but only in perspective. The are actually much more similar than different. I'm surprised this is stumping you; or perhaps you are just playing along to string this out...sometimes hard to tell with your posts. That's a different topic.

Is it two sides to the same coin? As I said, it's merely the perspective from which each is presented. One the "what," the other the "how." I come at things from the big picture, big thinker, inquisitive or thinking through the "what." You are the type--much like pratoman--who shoots a thousand questions at a notion. You are focused on the "how." You want to know how something works, I want to know what Laws of Physics are being applied.

You can lead a horse to water. In the world of newly diagnosed PC world, "how" do we do that effectively? One effective way we tend to do this (thanks to sage Casey59) is to point them to the "Newly diagnosed..." sticky to start or boost their PC patient education. We want them to be knowledgeable and informed--to understand the things that perhaps we didn't, and get the "information," as you put it, that they need in their early, possibly gullible, stages. Not all men realize initially that PC is a spectrum of diseases, with lots of favorable-risk cases, and a smaller number of unfavorable-cases. Favorable-risk guys don't often realize that they have the element of TIME on their side to educate themselves--to get the "information" (your word, again, focused (appropriately) on "how") they need--to understand the full range of possibilities for themselves, including an understanding of all the harms and benefits of various treatment paths. Let's lead them to a good patient education.

You cannot, however, make them drink the water. All you can do is lead them there. They have to make their own decision. And then they have to live with it. The "only one who can make that decision is that person." Extending that point further, we sometimes see guys who think it's their doctor's decision on what treatment they get. First of all, it's not; it's their decision. Second, they often don't realize the doctor's "business" perspective...typically recommending what they do as "best." A lot of guys don't realize these things at first, and sometimes they just drink the Kool-Aid and rush into things. I've seen it. You've seen it. They have to live with it.

You can lead a horse to water (how? by helping exposing them to a good patient education), but you can't make them drink (they gotta make their own decision).

"What" and "how."

Full circle.