Why so many recurrences after surgery?

makes you wonder why so many men select it.

But, don't let appearances device you and be careful about drawing conclusions from the random info posted here. A lot of guys select surgery over RT/other treatments so the pool of possible failures is higher. We tend to only hear about the ones that have gone wrong. RT does fail, but we hear about it less. Also it's confusing as a lot of RT reported here is SRT, not primary. RT is sometimes used in combo treatments (RT+HT, SBRT+Brachy, etc). There are a number of things that can skew the results.

This forum isn't the best source for scientific data on treatment results. Everything is subject and suffers from self reporting flaws.

I think there are some studies on the question, but I don't have access to those at the moment.

Andrew

Here's a 2018 paper you might find interesting: Management of Biochemical Recurrence after Primary Curative Treatment for Prostate Cancer: A Review
It states, "Within 10 years, 20-40% of post-RP and 30-50% of post-RT patients will experience BCR."
I found those statistics surprising. The post-RT number is from a 2006 study -- pretty old considering the advances in PCa treatment in the past decade and the lag time to gather evidence of BCR, so there's reason to doubt the numbers are so high.

Here’s a 2015 study, albeit retrospective, so subject to selection bias, showing surgery has better results. Of course I’m sure if one had the time and inclination, one could find a study to contradict this one and a study to contradict every study. This study addresses PC specific and overall mortality though, not BCR (we each get to decide which is more important) also this study seems to not account for various types of radiation other than external beam.

/www.ncbi.nlm.nih.gov/pubmed/26700655

“CONCLUSIONS:
Radiotherapy for prostate cancer is associated with an increased risk of overall and prostate cancer-specific mortality compared with surgery based on observational data with low to moderate risk of bias. These data, combined with the forthcoming randomized data, may aid clinical decision making.

I think there is no clear definitive answer, and Andrews point is a good one. Every situation is different

It would be great info to have but hard to come by because PCA is so variable. A lot depends on grade and containment in the prostate. The Sloan Memorial https://www.mskcc.org/nomograms/prostate/post_op has good personalized info about recurrence after surgery. not sure if there is something similar for other treatments

These decisions involve a lot of tradeoffs, studies are imperfect and subject to a spectrum of biases, individual results are not predictable, and on, and on, and on. Surgery works for many, as does radiation. Surgery fails for many, as does radiation. Who, how much, when? Good questions, limited answers.

We're here to support each other. These discussions are perhaps best suited to helping us consider the tradeoffs our doctors are asking us to make.

If someone says something that ruffles your feathers it's less stressful just to move on. It's going to happen, count on it. We're imperfect people facing life-threatening and life-changing decisions, under too much stress, with too little information, and no certainties.

I'm less certain than ever about everything. Everywhere, shades of gray uncertainty....

The surgical outcome statistics--whether they are referring to BCR, longevity, or side effect profiles are notoriously difficult to find--and to determine if there is any meaning to them. Face it, surgery--all the way back to transperineal open surgery--came first, is still probably the most common primary treatment worldwide, and therefore has the highest individual likelyhood of trouble cropping up in the future.

More and more men are choosing primary radiation--but I suspect that primary surgery still outnumbers ALL of the radiation modes combined by a large ratio. I return to what I was told at my pre-treatment consults:

As a low risk (became a low-intermediate risk after surgical pathology) patient, my long term prospectus was essentially the same whether I did surgery or radiation: something above 90% probability of going at least 10 years without BCR. Those numbers change as the risk category rises, and I suspect that for G8, 9, 10, the odds of BCR regardless of treatment mode is going to be high.

Anyway, the others have responded well: you see more BCR CASES in surgical outcomes because there are more raw number surgical cases. As a percentage, maybe it's not inflated at all. Also, in a forum like this, you're more likely to hear trouble stories that good news stories, so selection bias rolls it's way in.

Some of this seems site specific. Some sites (one or two) that I visited during my pre-treatment research had a lot more RT failure guys (I’ve long since deleted them).

Because so many are not really BCR...that can never be proved...due to skewing...so its a win win situation for everyone...the skewers...are happy it 's skewed since it can be blamed on someone/thing else...the doubters( like me) of the BCR are happy be cause they can not be proved wrong ...because of the skewers...seriously...You see we really don't mind being wrong...we ' just don't want to be there when it happens '... thanks and apologies to Woody Allan for paraphrasing his feelings on dying...

so for low to moderate risk cases "we demonstrated consistently higher mortality for patients treated with radiotherapy rather than surgery"

they sure die fast over there or they have to be old studies.

There's another problem with gathering data from any forum - self selection and the theory of the worst. Most folks come here for support. Men who have one treatment and are done don't need support so tend not stay around this kind of forum. That skews the pictures to cases that haven't had the best outcomes.

You can't really look at this data set and come to any conclusions. Also the treatments are rapidly changing all the time. RT today is nothing like 10 or 20 years ago so looking at long term data is problematic. One of the newer RT modes, SBRT, is showing great results, but it's only been the last 5-10 that there is any data on it.

Surgical methods haven't change that much in the 10 years. On the other end of treatment, ADT, and chemos have changed a lot.

While we all are examples here and each case can teach and some cases give hope - you need to go outside the digital walls of this forum for data. To argue which is better, surgery vs RT is an impossible task.

Some guys will choose surgery, some RT, some AS and in many cases they're just taking their best guess.

Andrew

In addition to previous contributions, I want to remark something else. It also has to do with comparing apples to apples. Surgery allows for a very precise follow-up because without prostate PSA should be very small or null. However, BCR in radiation has a much more relaxed definition and it may take several years to emerge. It is estimated that radiation BCR curves are behind surgery curves with at least a three years lag. Therefore, when comparing radiation and surgery BCR we are comparing different things. Overall survival is also biased, this time in favor of surgery, because statistically significant studies correspond to times where radiation techniques were not so good as they are now and, maybe more importantly, because radiation pacients were older (maybe they are still older now). Usually, surgery guys who say they would have radiation if they had the chance are mainly thinking about secondary effects, not in desease control.

Great discussion. I love finding these in the morning to get me thinking. Of course, having PC gets you thinking about these kinds of things. Someone said in their comments that it is all about trade-offs. I think that is true with PC treatment and life. The longer you live the greater opportunity you have for reoccurrence or associated cancer from RT. If you still have a prostate the higher the grade the better the chance. If you have surgery you have a better opportunity for staging cancer ie., determining it if was a higher grade and if it has metastasized. This was recently published by JAMA only comparing two types of RT with findings limited to whether radiation dose escalation to 79.2 Gy compared with 70.2 Gy would improve OS and other outcomes in prostate cancer. The NRG Oncology RTOG 0126 Randomized Clinical Trial compared Standard vs Dose-Escalated Radiotherapy in Medium-Risk Prostate Cancer Question Does dose-escalated radiation therapy improve outcomes for men treated for localized prostate cancer? "Findings in this randomized clinical trial," dose escalation was associated with a significant improvement in the rates of clinical endpoints such as biochemical control and distant metastases, but there was no significant improvement in overall survival. Patients who received high-dose radiation therapy had less need for salvage local or systemic therapy. Meaning: Radiation dose escalation did not improve overall survival but reduced the need for secondary therapies. Importance of optimizing radiation therapy techniques for localized prostate cancer can affect patient outcomes. Dose escalation improves biochemical control, but no prior trials were powered to detect overall survival (OS) differences. This trial was 8 years. We need longer trials for RT, with surgery you will find out sooner than later.

68 yrs., marathon runner, 9 of 44 IMRT @79.2, 10.5.18. PSA .012, 8.12.18, 1.42 June 18, 2018 (Lupron 5.21.18 & 8.15.18), 12.7 May 2018, 13.7 Jan. 2018, 2.1 May 2012. SpaceOar 9.6.18, testosterone <.7, 8.15.18, Tot Mayo 19 ng .17 testosterone Free 6.18.18, Gleason 3+4=7 involving 15% of the right apex and 15% of the right mid, 3+3=6 prostate cancer involving 5% of the left base. Pathology interpretations by John Hopkins, UNM Cancer, and SF Path 3+4=7 or 4+3=7 MD Anderson Proton Center w/o %. T3 MRI w/ contrast 1.8 lesion left side 5P, Neg. Bone Scan. Prolaris test 3.5 consistent with intermediate and a PTEN test negative. Father PC age 78 RT & ADT now 93 yrs. Neurogenic bladder due to lumbar disk disease and recurrent bladder neck contracture with urinary retention man. 20 years doing catheterizations. TURP & scaring 2003, Finasteride 5 milligrams daily since 2002.