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Why so many recurrences after surgery?

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Posted 10/10/2018 10:46 AM (GMT 0)

JayMot said...
Tudpock18,

To answer your question, "why a knowledgeable patient would choose surgery over one of the many radiation options." ......I guess I am not as knowledgeable as you.

J

Maybe so, maybe not. Each of us here has our own opinions. I'm unabashedly a fan of radiation over surgery for most men who are diagnosed with prostate cancer. That doesn't mean I'm right nor does it mean I am more knowledgeable than anyone. Heck, maybe I'm totally wrong. However, that's my opinion based on my individual knowledge -- as well as my emotions of course.

BTW, I did not delete one of your posts. And I heard nothing from any of the other mods about deleting one of your posts as I told you when I responded to your email. And, would you please consider setting up a signature to go with your posts so that other members can understand where you're coming from re your treatment.

Jim
Posted 10/10/2018 11:46 AM (GMT 0)
It is typical in this forum that each time somebody asks about surgery outcomes there is a flow of posts about what we have already discussed many times before.
With respect to this general discussion, I can say that I followed the advice given here and I talk to two RO offering the most praised treatments, SBRT and HDBR. Both were very helpful, gave me their own statistics and explained me in detail the procedures and secondary effects. They added that both radiation and surgery are reasonable for most clinically localized cases (in contradiction with the non-professional opinion of some people here). Also, I went to a surgeon urologist whose first question was if I have already done the pre-op tests and told me that surgery is the only good option available. I made my own research. I should add that I am a professional science researcher and therefore I consider myself to be qualified to understand what I read in medical publications. And, finally, I chose surgery. Why? Because a mix of facts, some personal, some local, some psychological and some learned here. I explained them in a long post right after my surgery and I do not feel the need to justify my decision every time this topic is discussed. Key points were that I had a large prostate requiring additional treatment together with radiation and that my surgeon has a excellent technical reputation despise the biased advice he gives to his patients.
But I will explain with more detail how, ironically, I was also lead to choose surgery by what I learned in this forum because it is related with the real question that was posed in this thread, why there are so many recurrence cases after surgery. I followed the evolution of some of these cases, probably the same ones that inspired the question we are trying to answer now. And I discovered that the onset of BCR can be monitored after surgery with great precision and, more importantly, that acting early may give some advantage. I know the number of declared BCR after surgery is higher than after radiation. Then, I compare the definitions of BCR after both treatments and the conclusion is that they are not meaning the same and only surgery offer the possibility of a fast reaction while you have to wait several years to know if there is a recurrence after radiation. Whether this translates or not in a higher overall survival is something very difficult to show. But, at leat , it helped me to put in context the claim of my HDBR RO that he has had just one recurrence in more than 700 treatments after 7 years. However, it is clear that some types of radiation may offer a one shot cure in cases where there is a clear clinical evidence of extraprostatic extension. Therefore, each case is different. But I am sure most people reading this forum have not be blinded lead to a given treatment. At least, not to surgery.
Posted 10/10/2018 1:36 PM (GMT 0)

Fauntleroy said...
From reading these posts, seems like the majority of treatment failures are from surgery as a primary treatment?


I think that there are really two much bigger questions:

(1) Why do so many men proceed into a treatment decision (of any sort) based largely on a single, non-expert reading of their biopsy slides. I suppose I know that answer to that—they simply have rushed their decision and not done a diligent background analysis to learn about their disease before pulling the "cancer hysteria" trigger—and so they don't realize that local, non-expert prostate biopsy readings are WRONG nearly 50% of the time (about 25% are too high, and about 25% are too low). Since most biopsy findings are in the low- or intermediate-risk categories, a correct biopsy reading makes a CRITICAL difference in treatment decisions. For example, if a too-high initial reading gets corrected downward, then typically Active Surveillance and no immediate treatment is the very best choice. On the other hand, if the initial reading is too-low and the expert reading is higher then a good choice (depending) might be to switch from surgery to radiation. Or worst case, if the too-low DOESN'T get corrected by an expert reading, the patient might NOT switch from surgery to radiation when they should have.

(2) Why do so many men choose surgery when the estimated risk is clearly high that their cancer has NOT been contained...thus leading to likely failure based on risk calculations. Nomograms are outstanding estimators of outcomes...they cannot tell you exactly what your case will result in, but they do tell you what many, many other cases very much like yours have resulted in so that you can understand the probabilities and risks, and from that information most people can make a smart decision. I think that it is less-so these days—even though as recently as only a few years ago this was VERY prevalent—that the urologist/surgeon is putting inappropriate pressure on naive patients to "rush" into surgery, but we definitely DO still see a trickle of these examples. I think today surgeons are playing the "go for a cure" card too aggressively, and patients are putting too much faith that they wouldn't get steered wrongly by their doctor/businessman.

Moreover, in the big picture, the "failure rates" are about the same, and any mis-perception of significant differences is simply that...mis-perception.
Posted 10/10/2018 9:31 PM (GMT 0)
Another reassuring study on high risk guys for those of us- whether we wish we had done different or not- had surgery. (if high risk did this well, surely low to mod would have done even better:
1: G8-10
2: median age 66
3: median PSA 29.6 (!)
4: 275 (47.4%) had LN invasion ( !!!!! )
5:At 5 and 10 years after RP, BCR-free survival was 76.7% and 49.6%, respectively. Similarly, the 5- and 10-year CSS rates were 87.3% and 69.5%, respectively
6: Patients with specimen-confined disease (P < 0.001) and patients with negative LNs (P = 0.012) had significantly better CSS rates than their counterparts with less favourable pathological characteristics.( BB adds: I'd like to know what it was, since even this very high risk group as a whole was pretty good.
7:CONCLUSION:

Presence of high Gleason score at RP represents a poor prognostic factor in the outcome of patients with prostate cancer. However, RP provides excellent long-term cancer control outcomes in the subset of patients with specimen-confined disease.
/www.ncbi.nlm.nih.gov/pubmed/22487441

I guess my question is: how much larger would the the BCR free groups be with RT, with this very high risk group? I would not been surprised if 75% of this group(just as I would not be surprised in my case) had BCRed at 5 years and 80+%(rather than just 50) by 10 years. Next question is, how many would BCR in the low risk or medium risk groups? It has to be < 10%. How much less BCR would it be with RT?

But this gives us a better idea of the lower risk guys: /www.ncbi.nlm.nih.gov/pubmed/22757970
"RESULTS:

The estimated biochemical recurrence-free survival (BCRFS) rates 10 years after LRP were 80.2% in patients staged pT2.....The 10-year clinical progression-free survival rates were 97.2% (pT2), 84.4% (pT3a) and 78.1% (pT3b/4), and prostate cancer-specific survival estimates were 100% (pT2), 97.3% (pT3a) and 90.6% (pT3b/4)."

So only 80% BCR free at 10 years for the pT2 group. I assume RT would be a good bit better than this? But as far as actual clinical(symptoms) progression, 97% free of that at 10 years, with 100% survival. Even 90-97% survival for the high risk guys, who would have usually had some RT as well. Not too shabby.
Posted 10/11/2018 1:34 AM (GMT 0)
So, let me pose a question that is related--we know that about 25% of RP patients show an upgrade in pathology when the whole gland is examined. So, wouldn't it be safe to assume the same is true for RT patients?

With that in mind, one of the serious challenges was pointed out above--that the definition of BCR itself is not the same for RP vs RT patients: For RP, it is assumed that PSA should become non-detectable within 3 months of surgery. For RT, it is assumed that PSA will never go to non-detect (or only infrequently), instead it goes to a nadir that may or may not be all that stable (all the talk about bounces, for example), and that BCR is defined as several rises above nadir over time. At the same time, the researchers are insisting that post RP BCR be declared at ever decreasing PSA values.

It certainly looks like, then, that BCR is going to be more frequently declared in RP cases because there is a hard number associated with it. In other words, BCR following surgery is a data-driven, absolute value proposition: Above PSA X, you have it, below it, you don't. With RT, well, it's more fluid.

My cynic says that works to the RT practitioner's advantage: Since they are the arbiters of the definition of BCR in their cases, then they will only declare it when they are SURE. Since they are also the arbiters of the definition of BCR (and the treater therof) for RP patients, it is also to their advantage to forever lower the boundary of BCR so they can cook the books to make RT look more favorable from the standpoint of BCR.
Posted 10/11/2018 2:13 AM (GMT 0)
That’s a very short term perspective. The wheat gets separated from the chaff, without a doubt.
Posted 10/11/2018 10:41 AM (GMT 0)
Hal, I suppose anything is possible in the theoretical world. But if such a widespread and vast conspiracy to cook the books really existed don’t you think the uro- surgeons of the universe would rise up and point it out?

My conspiracy theory is that the surgeons all need to make boat payments so they never give the patients the option of radiation so they can reap all of the profits for themselves. I think it’s a pledge that they must sign when they get out of surgery school....

Jim
Posted 10/11/2018 11:01 AM (GMT 0)
Jim, I said it was my inner cynic....but I do think there is a valid point of difference to understand that the definition of BCR, and the determination of whether BCR is taking place or not, is not the same for surgery vs RT--so to a certain extent comparing BCR rates is about apples and oranges.

Just like comparing clinical stage for RT patients and post surgery pathology for RP patients is not a fair comparison. I would argue, that for good statistical comparison, BCR rates, long term survival rates, etc, we should always compare clinical stage data.
Posted 10/11/2018 11:29 AM (GMT 0)
Is there any worry that the slow death of cancer cells by radiation masks the existence of cancer that radiation failed to destroy? If it takes years for the PSA to drop, it takes that long for the much smaller signal from surviving cancer cells to exceed the PSA decline and establish nadir. Is that delay a worry?
Posted 10/11/2018 12:13 PM (GMT 0)
... and that’s why the decision is a choice of personality.


Living with uncertainty vs living with more certainty
Posted 10/11/2018 1:02 PM (GMT 0)
The difference in BCR definition is really very simple and many are conflating it.

We know that after the complete removal of the prostate that only one thing can express PSA....and that is PCa. Thus, the post removal PSA should be undetectable or nearly so to indicate complete cancer removal. If not, then it is a well established guideline to indicate the possibility of BCR that may require treatment consideration. Of course it is also possible that a surgeon leaves enough healthy tissue behind to produce significant PSA that remains stable and does not represent BCR. So even the surgical definition is not absolute.

We know that after radiation, there are normally surviving benign prostatic cells and often a semi-functioning prostate. Thus, we know that there will continue to be some expression of PSA that is not indicative of PCa. Thus, based on years of research and history, in the same way with surgery, groups of very smart people have established guidelines that basically says two things: first, that a small expression of PSA that remains stable is more likely from benign tissue, not PCa and does not signal a BCR; and second, that a PSA progression above nadir + 2.0 certainly signals a BCR and requires treatment consideration.

This, in no way "stacks the deck" in favor of radiation, it merely recognizes the facts of difference between surgical removal and radiotherapy ablation. We call this science.

As to the mental aspects of the slower PSA regression from radiation, that is individual and largely driven by the doctor or the patient's own research and self-education. It was never a problem for me because I sought facts, not feelings, about what to expect. My docs were clear and what they told me I confirmed through research that is widely available to all. I would certainly trust that no surgeon would ever raise the issue as a negative to using radiation and a positive to surgery to help a patient decide on surgery. I am certain that has never and will never occur........yeah...sure.
Posted 10/11/2018 1:08 PM (GMT 0)
Jack, good to hear from you...hope you made it through Michael OK.
Posted 10/11/2018 1:43 PM (GMT 0)
I have two older brothers who both had PC with about the same stats as me DXed within 2 years of each other. For treatment one selected surgery, one selected LDR and I did IMRT.

six years later, all of use have low PSAs .4 for the RT brothers, undetectable for the surgery dude, no BCR and few SEs.

My case sample showed no differences between these modes of treatment.

My conclusion: Don't stress over the selection, just do what you're comfortable doing.

Andrew
Posted 10/11/2018 1:48 PM (GMT 0)

InTheShop said...
I have two older brothers who both had PC with about the same stats as me DXed within 2 years of each other. For treatment one selected surgery, one selected LDR and I did IMRT.

six years later, all of use have low PSAs .4 for the RT brothers, undetectable for the surgery dude, no BCR and few SEs.

My case sample showed no differences between these modes of treatment.

My conclusion: Don't stress over the selection, just do what you're comfortable doing.

Andrew


This anecdotal example clearly illuminates that a treatment mode decision—particularly for favorable risk cases like this—is primarily an emotional one, not a scientific one...the science tells us there are pluses and minuses about each mode, but in general cancer control outcomes are about the same. Do what you're comfortable doing.
Posted 10/11/2018 2:54 PM (GMT 0)
Andrew, it looks like you could have gone either way based on your biopsy. Given your youth I might have expected your doctors to recommend surgery or even AS. Yet you chose RT. We have one friend who fought the surgery recommendation, got RT, and 14 years later he's doing well. We have another who deliberately sought out surgery and 10 years later is doing well.

I'm of the opinion that the skill of the doctor is far more important in either case, perhaps more so in surgery?
Posted 10/11/2018 3:04 PM (GMT 0)
Here's how some men make their treatment decision:

Brother number #1, Doc says, "It's cancer, I can operate next week and since you'd already maxed your out of pocket expenses on your health plan, it will be a $50 co-pay." Brother, "Okay, what day do I need be there?"

Me: Doc says, "It's cancer, you can have surgery or radiation. Since you have the health plan, we cover both for the same co-pays." Me, "Radiation sounds better."

Brother number #3, Doc says, "It's cancer, but with your cerebral palsy we can't operate or do beam radiation, but we could do LDR brachy seeds." Brother, "When?"

Honestly, the folks on HW are the few who do lots of research and look for the best alternatives for their situation.
Andrew
Posted 10/11/2018 3:51 PM (GMT 0)
Fauntleroy: "From reading these posts, seems like the majority of treatment failures are from surgery as a primary treatment?"

InTheShop: "makes you wonder why so many men select it."

I was hoping that you would walk back this statement somewhere along the line. Looks like that was just false hope. Can I ask why you made such a statement?
Posted 10/11/2018 4:04 PM (GMT 0)
Andrew, I agree that few men do research, especially prior to a primary care doctor referring the guy to a urologist. Some time back I attended a lecture by a noted oncological urologist, Mitchel Benson. His hospital, New York Presbyterian had purchased Lawrence Hospital in a suburb of NYC and they wanted to convince suburbanites that they could get just as good treatment at Lawrence as they could in NYC. Benson was going to do surgery at Lawrence. As I was talking to the men in the audience afterwards, I discovered they had all been diagnosed with PCa and most had been treated. We men generally are more reactive than proactive.
Posted 10/11/2018 4:09 PM (GMT 0)
Jay - you've been offended by my post. I doubt there is anything I can say that would satisfy you. You've gone out of your way to misinterpret everything I've said and make it personal to you. None of what I've posted is directed at you. At no time was I questioning your treatment decision, and I believe that at other times and on other posts I've generally been encouraging to you, and your treatment decisions.

I fail to understand why you've decided to start attacking me.

In this case I was sarsactly affirming to the OP that, "yes, it's a question." And then I went on to explain that using the experiences here are a poor way to answer that question.

drop it and move on. Your continued harassment of my posts is not welcome and likely a violation of forum rules.

I suggest that you add me to your ignore list if you don't like what I post.

Respectfully,
Andrew
Posted 10/11/2018 5:07 PM (GMT 0)
My Bible study class has roughly 40 members (husbands and wives). When I was diagnosed in 2014 and had made my decision to have radiation I announced to the class that I had PC and my wife and I would be leaving for Florida for 8 weeks of Proton radiation treatment. The class wished us well and afterwards several men came up to me to discuss their experience with PC. I was not aware that so many in the class had been treated. The average age of the class is around 70 so I suppose it's not too surprising.

Of the 8 men who discussed their treatment, all but one had surgery. As far as I know all are doing well. All of the surgery guys go to the same Urology group as I do. The group has 4 urologist, all surgeons. One is MD Andersen-trained in Robotics, the others in retropubic and perineal. My urologist there is Duke-trained in the perineal approach and been practicing 30 years and has probably done several thousand surgeries with good success. The Robotic surgeon has done very many also and has an excellent reputation. My urologist there is the best doctor I have ever had in terms of bedside manner, spending time with his patients, listening, and making himself available by phone any time. It's no wonder he has so many patients who when they find out they have cancer, dont even consider another treatment. I suspect this is true for most men regardless of where they live.

I am probably one of very few patients who considered other treatments. I still go to him for my annual check ups and he is still just as considerate as he was when I was diagnosed. He spends a lot of time with me at my appointments, most of which is focused on my radiation treatment and my worrying about BCF. The number one factor which caused me to not have surgery was he told me that my chances of permanent ED were 50%. That was simply too high compared to radiation. If I am to believe the statistics on radiation, I have about an equal chance for cure, so it came down to side effects for me. I will say now after 4 years of bounces, I have serious doubts that I made the right decision. I'm afraid with my long history of prostatitis, I will have bounces the rest of my life, assuming I dont have BCF first. With surgery I wouldnt have to worry about bounces. Is it prostatitis, is it the bike ride I took 3 days ago, or the sex I had 4 days ago? I'm sick of it. If it's not close to zero, then I know it's probably back and lets move on to the 2nd round.
Posted 10/11/2018 6:53 PM (GMT 0)

Fauntleroy said...
From reading these posts, seems like the majority of treatment failures are from surgery as a primary treatment?


I think this is an incorrect perception. One reason is that "the nadir+2 definition of failed RT" will delay the determination of biochemical failure for many years for those who chose radiation, as described in
Is it possible to compare PSA recurrence-free survival after surgery and radiotherapy using revised ASTRO criterion--"nadir + 2"?
BCR can be detected quickly after surgery (and hopefully cure is still possible with SRT). BCR after radiation will not be detected until after many years after treatment. Is cure possible then?
Posted 10/11/2018 7:19 PM (GMT 0)

Gemlin said...
BCR after radiation will not be detected until after many years after treatment. Is cure possible then?

I'm sure you know how highly speculative that question is. In theory, (just like surgery) yes it's possible. How likely? Depends. If the PC is still contained in the prostate then focal salvage options like HiFU, cyro are possible. If you had a primary mono-therapy of RT,. i.e. if you had beam, you can follow up with brachy. if you had brachy, you can follow up with beam. There are surgeons who will do RP post RT, but that's very rare.

If there is a met - cure is off the table. However, if there are mets, I would expect RT to fail faster than years.

There are so many variables involved that it's really an impossible question to answer with any certainty.

and also remember that while surgery can fail faster you still have the concern of "are there already mets."
Posted 10/11/2018 7:26 PM (GMT 0)
Gemlin,

Not really. A client recently experienced BCR more than 15 years after surgery when his PSA went from undetectable and started going up. He is now on ADT. He thought for 15 years he was cured, but then wasn't.

Everyone wants absolutes, but they just aren't available with PCa. I am an advocate for radiation versus surgery because of my own personal experience and that of many others on this board and other men I have dealt with. It is my personal experience and on this board that most men that used surgery had never been assessed by a radiation oncologist to consider radiation treatment. I am sure that most men that used surgery never even met with any other surgeon or had a second reading of their slides.

I am working with a friend in Miami to find a great urologist. He isn't even diagnosed yet and a well known high volume surgeon has already explained how he will save his life and is pushing him to get a biopsy. My friend has had some gradual increase in PSA so his GP put him on antibiotics and referred him to the urologist. So his PSA dropped from 5.5 to 3.5. The rock star surgeon said the DRE was completely normal, but demanded to do the biopsy. My friend hesitated and said not yet so the surgeon made him sign a disclaimer form before they would let my friend out of the office. What treatment. Do any of you think for one second that this surgeon would properly explain other treatments and encourage my friend to get an assessment for radiation therapy or even AS? Plus, my friend is a triathelete and rides his bike many miles every day and no doc had ever asked him anything about his exercise habits. The information came from me about how such activity can increase PSA. Every time he has had a PSA he rode his bike the day before and morning of the test.

I am sure there is a clear surgical bias by many, if not most, urologists. I am confident that many, if not most, urologists do not fairly represent alternative treatment methods and certainly do not make referrals to other specialists as part of the due diligence I think all men should pursue. Thus, many men do not choose surgery, because to choose, you must first have multiple options under consideration. They are told what to do, and they do so.

When a man does properly consider all options and then makes a choice, I applaud and support him regardless of the choice he makes. But, as many others have stated, I always wonder why more men don't choose radiation over surgery. My case was easy, I was simply to high risk to consider surgery and three different surgeons told me so. Somehow I found some great unbiased docs. Unfortunately, few men are that fortunate.
Posted 10/11/2018 7:53 PM (GMT 0)
IntheShop, Ok, I'll move on. Yes you did offend me. And, I feel like I speak for all other RP members on this forum when you stated (paraphrase): "it makes you wonder why so many men selected RP when there are so many more BCR's for RP over RT". I don't know any other way to interpret that than what it is. Last time I post about this. We fought, we tied, time to step up to the bar and have a beer and move on. Next topic anyone? lol
Posted 10/11/2018 7:57 PM (GMT 0)

JayMot said...
IntheShop, Ok, I'll move on. Yes you did offend me. And, I feel like I speak for all other RP members on this forum when you stated (paraphrase): "it makes you wonder why so many men selected RP when there are so many more BCR's for RP over RT". I don't know any other way to interpret that than what it is. Last time I post about this. We fought, we tied, time to step up to the bar and have a beer and move on. Next topic anyone? lol


If it makes you feel any better, I can't figure out why any man under 60 would have radiation therapy instead of surgery for (most) PC cases. I wouldn't want to have so many years in front of me to deal with the late-term effects 5-, 10-, 15-years down the road, like a leaky butt...I just think that after those initial years go by I'd want to have put the PC treatment & side effects into the rear-view mirror rather than be increasingly be haunted by them. Do you know where the phrase "never trust a fart" comes from?

But to each their own choice!

Post Edited (Normal59) : 10/11/2018 2:56:21 PM (GMT-6)

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