Outcomes of very high‐risk prostate cancer after radical prostatectomy - validation study

This is interesting for those of us in this category, as "Very High Risk" prostate cancer cases. There's some history of that designation being useful, or maybe not so much. It's another retrospective database-mining type of study, so has the biases inherent to such. It's based also on those have surgery, an approach which has been gaining some favor for high risk cases (vs. the more usual preference for radiation).

HR vs VHR defined as:
Dr Chapin and his colleagues defined high-risk PCa as clinical stage T3 to T4, a PSA level greater than 20 ng/mL, or a biopsy Gleason sum of 8 to 10. They defined VHR PCa as the presence of multiple high-risk features, more than 4 biopsy cores with a Gleason sum of 8 to 10, or primary Gleason grade pattern 5.

These are surprising numbers to me. The NCCN guidelines don't make a real big distinction between high and very high risk, so the amount of effect in this study is more than I would have expected to see.

This link is to an abstract, not the whole article.
Outcomes of very high‐risk prostate cancer after radical prostatectomy: Validation study from 3 centers

Men with VHR cancer had a significant 2.8-fold, 6.8-fold, and 2.4-fold increased risk of metastasis, cancer-specific mortality, and overall mortality, respectively, compared with men who had high-risk but not VHR cancer.

Conclusions
In a validation study of patients who underwent treatment for high‐risk PCa, VHR criteria were strongly associated with adverse pathologic and oncologic outcomes.

mattamx said...
Unfortunately, that’s all a good fit for me.😐 Just have to hope for the best.

Ditto. Miraculously hanging in there so far, sometimes I feel amazed that I have made it almost 5 years after surgery only. Especially after reading numbers like those in the OP. After that, I am amazed that not only have I not had mets, I have not yet actually had a BCR. Not as of October anyway. Of course January hangs over me like the Sword of Damocles. ;) I might be very high risk, hard to say. I had multiple risk factors(positive margin, SV+. multiple cores totaling 8 and 9, etc. But, I did get downgraded post surgery to a primary 4 from 5, though still a 9 total. So I don't know, HR or VHR? I guess both suck. I guess I ought to figure it out since VHR has 6.8 times higher risk of PC specific mortality than mere HR. HR sounds like a party by comparison.

Then again, I'm going to die of something sooner or later, so why should I trouble my little brain about all of that? I have a friend, younger than me, who had surgery for PC, maybe about age 45-50? Had an attractive young wife, so after a couple of years he had a penile prosthesis so he could still take care of business. Not long after that, he died of a stroke. Then there is my (15 years)older sister, about 25 years ago now- no known health issues- standing in line to pay for an antique, falls dead, either heart attack or stroke. Then there is my 40 year old DIA, mother of 2 boys 10 and 13, dead within 6 months of diagnoses of mesothelioma, despite all the chemoterapy.

Let's face it: Life is risky business!

Redwing57 said...
Snark and sarcasm, not terribly surprising.

I just keep posting interesting things I find. Y'all can respond, or not, whatever makes you feel better.

For anyone interested in actual discussion, do keep in mind that these are "hazard ratios", nothing more. A hazard ratio of 6, that sounds huge, would result from comparing two things with say a 1 out of a million chance, with a 6 out of a million chance. The news media are big on this; "Six times higher risk!", but that absolute risk is still really small.

Whatever. Read and move along.

What snark and sarcasm? From who? Me? If so, I certainly did not intend such.

I'm not sure what the study is saying. Are men in the vhr group more likely to have a worse outcome after treatment? Are they recommending the vhr group forgo treatment?

P34 said...
I'm not sure what the study is saying. Are men in the vhr group more likely to have a worse outcome after treatment? Are they recommending the vhr group forgo treatment?

I did not get they were recommending no treatment. But they are saying we have a much higher risk of dying from PC than the lower risk guys even with treatment. That is not news, but I was a bit alarmed at how much higher it was for very HR guys(is that me?) compared even to the plain old HR guys, who I thought had it bad enough already.

BillyBob@388 said...


Ditto. Miraculously hanging in there so far, sometimes I feel amazed that I have made it almost 5 years after surgery only. Especially after reading numbers like those in the OP. After that, I am amazed that not only have I not had mets, I have not yet actually had a BCR. Not as of October anyway. Of course January hangs over me like the Sword of Damocles. ;) I might be very high risk, hard to say. I had multiple risk factors(positive margin, SV+. multiple cores totaling 8 and 9, etc. But, I did get downgraded post surgery to a primary 4 from 5, though still a 9 total. So I don't know, HR or VHR? I guess both suck. I guess I ought to figure it out since VHR has 6.8 times higher risk of PC specific mortality than mere HR. HR sounds like a party by comparison.

Then again, I'm going to die of something sooner or later, so why should I trouble my little brain about all of that? I have a friend, younger than me, who had surgery for PC, maybe about age 45-50? Had an attractive young wife, so after a couple of years he had a penile prosthesis so he could still take care of business. Not long after that, he died of a stroke. Then there is my (15 years)older sister, about 25 years ago now- no known health issues- standing in line to pay for an antique, falls dead, either heart attack or stroke. Then there is my 40 year old DIA, mother of 2 boys 10 and 13, dead within 6 months of diagnoses of mesothelioma, despite all the chemoterapy.

Let's face it: Life is risky business!

I probably misinterpreted your post. It seemed as if you were mocking the concern, the report, as being exaggerated or unwarranted given your better outcome. If you didn't mean it that way, then I'm sorry I took it like that. It's always a problem with internet and email, with no verbal or body language cues to know someone's intent.

Peace.

I always enjoy reading the posts that apply to us VHR guys in particular... those of us who were right on the edge of our cancer having progressed to mets or LNI, but fortunately came just short. My fear now is what happens after the Lupron finally wears off? The cancer specific mortality risk is alarming though. But OTOH, none of us will be getting out of here alive.

P34 said...
I'm not sure what the study is saying. Are men in the vhr group more likely to have a worse outcome after treatment? Are they recommending the vhr group forgo treatment?

No, actually I think the opposite is true. I've seen a couple studies saying things like this, and usually the conclusion is that the G9/10 cases warrant the most treatment, that maximum effort is needed. Things like adding a round of docetaxel chemo after a primary radiation plan, for instance (which I think Artist Mark did). The idea being that there's such a high risk of occult metastases that major systemic treatments are likely to be effective.

You know how we talk about ADT, seeing how much we can shorten it without too much risk? An article related to this study suggested quite the opposite, that perhaps permanent ADT right from the outset would be prudent with a G9/10 case (yikes!). My MO told me that in breast cancer they're debating hormone therapy duration, but from the opposite direction - they're debating how much LONGER women should be on it!

The main reason this study caught my eye is the way the distinction between HR and VHR has varied over the last few years. Sometimes it has seemed important, and other times not so much. The NCCN guidelines draw very little difference in treatment recommendations between the two, so that group doesn't see it as very significant. In any case, my hope is that studies like this help us remain motivated despite difficult treatments.

(I have another study that has some fairly dramatic views on the impact of the Type 5 cells. After reviewing the abstract, I had my cancer center's patient information office get a copy of the full report for me. It very clearly showed the distinction between cases with and without the Type 5 cells. That distinction has been blurred for a long time, by lumping all G8-10 together. I'm not sure if these are helpful or not, or just alarming.)

Redwing,
I have always taken interest in the things you post, including those items that were sometimes savaged by a certain member who no longer posts here. I think we all have some residual post-traumatic stress from those experiences. 🙂

Speaking towards what Prato said, I do have the belief/hope that my RP (and it’s side effects) weren’t in vain. I’m hoping the reduction in tumor load will contribute to my survival.

I firmly believe that EVERYTHING we've done to fight this disease is important. I've always felt it was significant that a surgeon was actually inside me and could see (and feel to some extent) everything that was going on in there. Also having removed the mothership of the cancer and not depend on just zapping what shows up on scans.

I specifically asked my RO about bringing an MO onboard as post-RT taxotere has become more standard rather than saving it for recurrence. There was also another bro here who went thru that, a school teacher (I forget his name.... Lupron brain) and I'm sure several others. I also opted for a full 18 months of Lupron in light of recent studies whereas my RO was willing to stop at 12 months.

Seeing how many guys here, in particular those whose pathology wasn't all that bad, ended up with BCR I feel it is important to throw everything possible at the disease as early and as long as possible... in my case and Matt's as it having been given a head start by urolgists who were reluctant to act when symptoms first warranted.

Post Edited (RobLee) : 12/6/2018 7:10:01 AM (GMT-7)