What is surgical failure?

I don't know if there is a formal definition. But my understanding aligns with yours. To me surgical failure is identified by recurring and rising PSA. In my own case I didn't have positive margins but did have seminal vesicle involvement. To me that's a bigger potential indicator of recurrence than a positive margin. A positive margin might be only some Gleason 6 cells that are unlikely to survive. And even if the positive margin did lead to recurrence we know that SRT has better results on patients who had positive margins than with those who did not, because the positive margin increases the likelihood that a recurrence is still local.
Jim

Failure of the surgery to control the cancer when the surgeon intends it to do so. If the PSA rises after the surgery then the surgery failed in its mission to control the cancer. Just as if after radiotherapy the PSA rose to a level that would indicate the radiotherapy failed. In each case it would have been the objective of the practitioner to control or cure the cancer with their treatment.

If, however, it is known at the diagnosis that a mono-therapy would not be successful but surgery or radiotherapy is advised to de-bulk the cancer, then we wouldn’t consider the treatment as failed when PSA continued to progress. In these cases the objective of treatment is to achieve a remission, hopefully long and durable. In advanced stage diagnosis, most know that no treatment will result in total control or cure. But the treatments are meant to prolong life and reduce the side effects of the cancer advances.

Hal, in the case you are referencing, the OP recently stated that the urologist stated they are now treating locally advanced disease. While I think it is early to so state as they don’t even have a 3 month PSA test, it may be that the urologist and surgeon know, but have not yet explained, that the surgery was unsuccessful in its intent to control and cure the PCa.

Failure is strictly a rising PSA by definition for surgery or radiation, just different PSA measuring criteria that are not directly comparable. The details are only important when playing with nomographs and probabilities. A PSM is only significant if it is the cause of recurrence which is pretty hard to determine.

My post surgery PSA at three months was 0.2. Following a rushed adjuvant RT my PSA nadir was 0.1. Biochemical recurrence occurred not long after. The intent of my treatments was curative, but in hindsight I was already systemic.

JNF and Bohemond both touched on debulking the primary tumor. Although I'm not sure there is clinical evidence to make the claim, I do believe debulking has the potential to increase survival. Therefore, I have never viewed my RP as a wasted effort.

Maybe calling a treatment a success or failure depends on how you view it.

The numbers for recurrence after surgery are well known, and they vary widely from 5 to 73 percent at five years, depending on the Gleason score at the post-op pathology. The 35 percent “average” is for Grade Group 3 (G4+3) men.

The overall ten year BCR rate is about 35 percent.

https://medivizor.com/blog/SampleLibrary/prostate-cancer/examining-the-risk-of-disease-recurrence-more-than-10-years-after-prostate-surgery/

But, with SRT and ADT now being a part of surgical treatment plans, who knows what the outcomes will be? Certainly better than a monotherapy.

surgical failure? Isn't that like where the patient dies?

AJMan said...
While I guess it is correct when measured against ultimate objective I find branding a Surgery Failure” even in my case where PSA never went undetectable and has been rising since as being a bit overly dramatic. I think the full context of “The failure of surgery to fully eliminate the cancer” to be better.

I think the same way, AJMAN. 'Surgical failure' is overdramatic. I figure I'm only buying time with my surgery. I never expected a 'cure'. I expect I'm need other treatment down the road to buy more time and the cycle goes on until something else claims me. That's how I feel anyway.

Just like any mission it depends on expectations. If the goal of the surgery is to cure the cancer then then any recurrence of the cancer means the surgery failed in its mission. If the goal is to de-bulk and recurrence is already expected then the surgery was not necessarily a failure.

Now I'll muddy the waters a bit in line with discussing expectations. From my LDR Brachy I expected my cancer to be cured, I expected to remain continent and I expected to retain my sexual abilities. Those were my goals for the procedure. If one or more of those goals had not be achieved then the procedure would have been a partial failure in my eyes. So while I'm sure than Hal was only talking about cure, I think the overall question of failure of a procedure depends on what you expect from it.

Jim

Yeah, the flesh eating bacteria was not high on my list either. On that subject, I have a solid memory of when I had to have my appendix out. I was in the ER, they were giving me IV fluids, and they had even given me a dose of morphine. They had taken my glasses away. And then they gave me the form to sign. Wrong sequence!

I signed anyway--and then off to the OR.

I'm thinking surgical failure as it relates to prostate cancer, is any recurrence/rise in PSA ever. Regardless of time frame.

This is a relatively new article and study.

https://onlinelibrary.wiley.com/doi/full/10.1111/bju.14790

Their definition is

“Radical prostatectomy (RP) is a surgical treatment used for localized prostate cancer (PCa), with overall high disease‐specific survival rates. It has been demonstrated that the 8‐year disease‐specific survival for patients with pathological Gleason score of ≥4 + 4 is > 80% 1, 2. RP is considered successful if the PSA level after surgery drops to < 0.1 ng/mL. ”

Surgery as primary treatment is meant to be curative. That’s the goal in almost every RALP or open Prostatectomy, except for the (somewhat less common) debulking surgeries, where cancer is already advanced, and aggressive.
So for me, in the truest sense, surgical failure is a rising PSA that necessitates secondary treatment.
Of course I guess if one ex-eriences BCR 8-10 years post op, I suppose one could call it success. To me that would be failure, but with a benefit (8 - 10 years treatment free time) as a result.