Why so many recurrences after surgery?

ASAdvocate said...
I am seeing studies with five year results showing BCR-free percentages of over 97 percent for low-risk men, and 94 percent for intermediate-risk men, who had either SBRT or Proton Therapy (PBT).

Those are amazing results, above (far, far above?) what has been reported for RP.

And, I hear of few, if any side effects from men who had SBRT or HDR-BT, and NONE from men who had PBT.

Yeah, sounds incredible to me also, but both studies and real people on forums are stating it.

The debate and the progress goes forward. All new patients can benefit.

The BCR-free percentages for SBRT are neither "amazing", "far far above" or "incredible". The D'Amico classification of low and intermediate risk are based on clinical stage i.e. biopsy, MRI, guess work etc. In surgery, roughly 30% of these clinical stage low and intermediate risk patients have adverse pathology i.e., ECE, Gleason > 7, surgical margins etc when the pathologist examines the dissected prostate. Patients with adverse pathology have a much higher risk of BCR and may need radiation anyway. The simple conclusion is that based on current technology we are misclassifying patients at the clinical stage. With future genomic testing, better MRI etc, the classification technology will get better and fewer misdiagnosed high risk patients will undergo surgery. But this doesn't answer the difference in 5-yr BCR rates because the studies of SBRT patients were also based on D'Amico classification.

Misdiagnosed surgery patients with adverse pathology have a high probability of BCR and the option of radiation, which theoretically gives them the same chance of not dying from Prostate Cancer as the SBRT patients, albeit with significantly more side effects. The definition of BCR for a surgery patient (e.g., PSA of > 0.2) is different from a SBRT patient, and most undergo radiation only on BCR, Pratoman not withstanding . Due to these differences, the 5-yr BCR stats for surgery patients are inflated relative to SBRT while their survival rates are not different since most surgery patients with adverse pathology will eventually have radiation after BCR. I hope I've made it clear that comparing 5-year BCR rates for SBRT vs surgery makes zero sense.

Why not do SBRT since survival rates are the same and side effects lower? Don't forget the lucky 80% of surgery patients who didn't have BCR for 5 years. They escaped radiation and almost all conquer bothersome incontinence, while there are no additional urinary or rectal side effects, that sometimes happen during radiation. Erectile Dysfunction rates for surgery are pretty high but the older patients all have rapidly declining potency anyway. Some studies show 25% of AS patients will have ED a few years after PC diagnosis because of naturally worsening potency.

When I say "escaped radiation", its not to say that SBRT is definitively bad for you, but many people don't want any form of radiation and SBRT hasn't been around long enough for us to be sure. The distaste by some from radiation come perhaps from the fact that Brachytherapy and IMRT do have their share of unpleasant side effects or perhaps worry (justified or not) about other cancers from radiation.

Perhaps SBRT will yet turn out to be a miracle in terms of effectiveness without side effects, but the jury is still out on that one and from what I have read, the definitive studies won't be out until 2022. But it should be made clear that the key advantage for SBRT is the minimal side effects vs current standards of radiation and surgery. It's definitely NOT that SBRT is better at preventing the low and intermediate risk PC patients from dying from Prostate Cancer. The reason for the lower 5-year BCR rates in surgery patients vs SBRT is simply the fact that the pool of D'Amico classified low and intermediate risk surgery patients includes those who will eventually be cured by radiation.

tarhoosier said...
I have always wondered about the "second chance" theory of initial treatment choice. If X does not succeed I can still move to Y. I would want the treatment that gave the VERY BEST chance for success the FIRST time.

Perhaps its about fear of radiation, where there are still some unknowns, hence there is general preference for X over Y. With a clinical stage diagnosis, chance of eventual cure is the same for X, X+Y and Y so if your definition of "success" is "cure", then there is no difference. So, if you have a distaste for Y, try X first since there is a 80% chance you won't need Y. Eventual success is the same.

I'll keep saying it: not everyone has the luxury of time and/or money to travel distances to get the highest level treatments, and it's totally non-productive to criticize decisions made for those reasons. Add to it that we can get very US-Centric in our assumptions about what is available worldwide.

halbert-----I've been saying the same thing since I've been on this board. I chose RP because of the ease of "secondary" treatments. That "ease" includes taking into consideration such things as location of treatment and cost of treatment, including available insurance coverage. I am not old enough for medicare. I hope I do not need secondary treatment. My SE's are extremely minimal. Drip here and there and NO ED. Of course, ED was very prominent for about 15 months post-op.

A couple members posted on this tread have implied that I am either not "knowledgeable" enough or did not do my "scientific" research prior to my treatment decision. These are the same people that preach, prior to selecting a treatment option of the many options available if BCR should occur post primary RT (salvage RP, Salvage brachy, salvage Cyro, etc.). But, when responding to RT BCR posts, their response is, oh, sorry buddy, you're on HT for life now, Good luck (just check the current 1st page post about post primary RT BCR for proof.).

Back on topic. There are over 90,000 RP's a year. How many HW prostate members? The members that hang around HW are ones that need advice, either prior to primary treatment, or post primary treatment failure. Most success stories, and there are way more successes than failures, move on with life and from this board.

Thanks for bring the study /www.ncbi.nlm.nih.gov/pubmed/24510158 to my attention. It is quite amazing that surgery this good for G8-10 patients. I wonder why it was even used in these cases. Gleason scores aren't the only criteria; other measures of confinement must have given the doctors encouragement.

The Walsh book says that RP results are significantly different for high volume major cancer centers and other providers of RP. I wonder how much better the prospects for RP is at the better hospitals.

this is a tough discussion with no clear winner - decision depends on many factors. Outcomes depend as much on expertise as on luck.

The only winner when BCR happens are those nasty PCa cells.

Tudpock18,

I chose because my Uro thought there was a chance of cure.

It wasn't cured but looking back I'm still glad I had surgery.
Why?
It debulked my cancer.

Good points, ddyss. When my 1st oncological urologist suggested I needed a biopsy, last Dec, I was skeptical because my PSA is about normal for the size. I actually thought he was being somewhat fanatical. But I welcomed the more aggressive stance. When the MRI subsequently came back PIRAD-5, I was alarmed but the biopsy in Jan (2018) found no cancer. The second biopsy, in Sept 2018, did, 3 core with G8.

After talking to a RO and two surgeons (at two institutions) they all came to the same conclusion—that I’m a good candidate for surgery. The G8 is in the left base in the posterior in or near the MRI lesion. The tissue is greater there (as opposed to the apex) and both surgeons agree that by taking a large swarth, they can remove all the cancer leaving no margins. Bond scans, CAT scans, and the MRI itself indicate no signs of spreading.

I know the MRI and scans have finite resolution and biopsies sample a small part of the prostate. They are still convinced that even though it is G8, there’s an excellent chance that surgery will get it all. Even the RO came to this conclusion. I’m going for it! PS, I see your signature and appreciate your experience. Glad you weighed in!

Alephnul said:

“I chose because my Uro thought there was a chance of cure.

It wasn't cured but looking back I'm still glad I had surgery.
Why?
It debulked my cancer.”

My sentiments exactly. I’m sure hoping the debulking idea has merit. Even though my RP didn’t provide a cure, if getting rid of the primary tumor bought me some significant time it still will have been worthwhile.

It may be that in the future surgery will become a niche treatment for unusual (not necessarily rare) cases--but we're not even close to that day.

I would like to comment on a couple of the early comments to this thread--and the OP itself--which comes close to suggesting that the logical, thinking, 'scientific' person would choose radiation over surgery every time. I, simply, don't think that is a fair statement--in that the corollary is the idea that those who choose surgery are functioning solely from an illogical, emotional, non-research based position. If I said that about someone who chose radiation, there would be plenty of frothing at the mouth.

Take care, guys, about generalizing your opinions and situations into globally true assumptions. THAT, IMO, is the biggest problem in our society today--unwillingness to consider that the person you disagree with might actually have something important to say. I'll stop there--I know I'm wandering into dangerous territory.

halbert, I said the same thing earlier today. My statement was something to the effect that I chose surgery because I was not knowledgeable, according to InTheShop, and didn't do my "scientific research" according to tudpock18...or vice-versa (not sure who stated what). Then that post was promptly deleted. I assume by Tudpock (BTW, thanks for the email....NOT!)

ASAdvocate said...

Overall, I don't disagree with them, but I have great reservation about how they state their opinions. People who had surgery have had surgery....period. They should not be mocked as morons who deserve the side effects that they suffer. Well, I now am more sensitive to how hurtful those opinions can be.

Our support group attitudes are almost as nasty as our politics, and we really must try to rise above that.

Thats great! However, do note that the negative reaction to the RT advocates is not due to regret and therefore hurt. It is outrage because most surgery patients had great success in definitive cure and find the mocking to be outrageous misstatements.

The few surgery patients who had bad side effects from surgery or had adverse pathology are those who are likely to feel regret and be hurt. It's a terrible thing to rub it in for this minority, under the guise of saving the majority.