U.S. senator announces he has PCa and will be getting RP for it

Sammas and others who responded to my question....Yes, It's been the norm (and this is a steady statistic) that most low to mid risk PCa patients get surgical treatment over the radiation therapies. I continue to believe that the way it works in the real world is a consultation post biopsy where the conversation goes something like this:

Urologist: Well, Joe, your biopsy report is back, and you've got cancer. Here's what the Gleason score means, and since you're a G6 or G7, that is considered low risk, you probably don't have metastatic issues--but to be sure we're going to send you for a CT scan and a bone scan. I can do surgery to take care of it, and cure is likely. If you want, I can refer you to the Radiation docs if you want to go that route.

Joe: Well, doc, let's get the scans done and then get it taken care of. I don't want to mess around.

Urologist: OK. See my nurse to get the scans scheduled. Here are some pamphlets to read. I'll be in touch after the scans are back.

End 15 minute consultation (which is all the insurance will pay for).

@Halbert...That’s pretty much how my consult with my urologist went. With the help of forums like this I was better prepared to ask questions. He was very honest in saying the only area of radiation he had much experience in was ‘seeds’. When I started asking questions about SBRT, HDBT, guided options, etc. it became apparent on how thin his understanding of those treatments was. He did encourage me to explore radiation options and was willing to suggest some names to call.

Urologists in private practice spend their lives in the surgical world and I believe most practice what they’ve been trained to do. I think urologists in an academic setting like Mayo, Cleveland Clinic, John’s Hopkins, MDA, etc. possibly take on a broader view of treatment options simply because they’re exposed to them. If radiation oncologists were the ones initially diagnosing prostate cancer we would have far fewer guys choosing surgery as an option. Knowledge is power and making an informed treatment decision can be life changing.

While discussing treatment options with my urologist and oncologist, they both stated that either of their approaches had about the same efficacy rate. If my urologist was disappointed that I chose radiation, he didn't show it. He performed the fiducials implantation procedure in preparation for radiation, and was a complete professional. He continues to be as we begin to monitor the PSA testing post-radiation.
I believe that at the end of the day, the goal of these medical professionals is to help people.

ASA,

So what you are saying is that among men who choose definitive treatment (i.e. setting aside those choosing AS), RP and RT are about equal choices. Here is my source (for high-risk men):

Trends in prostatectomy utilization: Increasing upfront prostatectomy and postprostatectomy radiotherapy for high‐risk prostate cancer (2020, Full Text)

"Abstract
We aimed to determine patterns in frequency of radiotherapy for prostate cancer and definitive surgical management. There is prospective evidence indicating benefits of radiotherapy for some patients after radical prostatectomy (prostatectomy), with recent evidence suggesting benefit of early salvage radiotherapy. Trends in postoperative radiotherapy have not been elucidated. We analyzed the National Cancer Database for prostate cancer patients treated with curative‐intent therapy between 2004 and 2016. Patients were risk stratified according to NCCN treatment guidelines. Linear regression was utilized to examine trends in treatment with initial prostatectomy and trends in postoperative radiotherapy among treatment risk groups. Multivariable logistic regression was utilized to examine clinical‐demographic variables associated with prostatectomy and postoperative radiotherapy. From 2004 to 2016, 508,450 patients received prostatectomy and 370,314 received radiotherapy. Median age was 63.6 years. There was increased utilization of prostatectomy from 47.9% in 2004 to 61.3% in 2016 (ptrend <0.001). 24,466 cases received postoperative radiotherapy. Similarly, postoperative radiotherapy utilization increased from 2.2% in 2004 to 4.0% in 2016 (ptrend <0.001). The subgroup with the largest increase in postoperative radiotherapy was clinically high‐risk disease (5.3% in 2004 to 7.8% in 2016 (ptrend <0.001). Clinical high‐risk disease (OR 1.751), Gleason 9‐10 (OR 2.973), and PSA >20 ng/ml (OR 1.489) were factors predictive for postoperative radiotherapy. The proportion of prostate cancer patients who undergo definitive prostatectomy and postoperative radiotherapy is increasing. This increase is greatest in high‐risk cases. Overall, the proportion of patients who receive any radiotherapy is decreasing. Association with preclinical factors suggests optimization of patient selection should be considered."

[Emphasis mine]

MDA, as you paper states, has a larger chunk of men choosing non-definitive treatment (probably lower risk), and they (rightly) probably duly present RT (as well as RP) as a valid treatment choice to newly diagnosed men. Their database is, of course, very small compared to SEER. Keep in mind I made my comment about us not knowing the senator's Gleason score, which may not have been G6. What I am interested in is the percentages for RP vs RT for high-risk men (G8-10) choosing a definitive primary treatment.

Djin

Post Edited (DjinTonic) : 4/7/2021 11:24:34 AM (GMT-6)

ASAdvocate said...
Djin,

If you look at Table 1 in 2019 study I cited, they analyzed 392,000 men with prostate cancer. The SEER data shows a slight majority of the men who chose either surgery or radiation, chose radiation. You have to combine the external beam and brachytherapy numbers.
....

Yes, across all risk groups, the choices are about equal; however, G6-7 men must be choosing RT in even higher percentages (although the data isn't broken down by risk group in your study), since study of the same SEER database shows the majority in the G8-10 group choose surgery, with the trend increasing up to the last analyzed year: "There was increased utilization of prostatectomy from 47.9% in 2004 to 61.3% in 2016"

For high-risk men we should compare RP + MaxRP with MaxRT.

Djin

ASAdvocate said...
What I have read is that the rise of RP in high risk men over the past 15 years is not due to any studies showing that RP is superior, but rather that men want to avoid the ADT that is usually part of the RT treatment.
...

Yes. in fact, we are dealing with behavior/treatment decisions. That a treatment is a more popular isn't evidence of superiority. In my case I gave weight to indicators that my high-risk PCa was diagnosed early and I wanted the chance of a definitive treatment that avoided both ADT and radiation.

We may also see a greater number of men avoid overtreatment if, as it would seem, SOC for post-RP adverse findings shifts from adjuvant to salvage RT for (at least) low- and intermediate-risk men in light of three recent studies designed to answer this question.

Djin

Post Edited (DjinTonic) : 4/7/2021 2:12:59 PM (GMT-6)