Radiation studies

With due deference to Casey’s considerable research abilities, his post is illustrative of what happens when you self-select articles (some of them very old), cherry pick quotes from those articles and blend in your own editorial comments.   This results in conclusions that reflect a bias.   For example, I personally have an acknowledged bias toward radiation therapies.   By using the very same sources that Casey has used, I have cherry picked information/quotes from those very same sources that support my bias:   1.      Prostate brachytherapy is a highly effective treatment modality for localized prostate cancer with long-term local and biochemical control similar to outcome observed after radical prostatectomy.   2.        Multiple outcome studies show results for prostate brachytherapy that are comparable to surgery.   3.      The reported benefits of brachytherapy include lower rates of incontinence and erectile dysfunction.   4.      Brachytherapy may provide some advantages to the patient in terms of health-related quality of life.   5.      Brachytherapy results in less ED than radical prostatectomy and Viagra is more effective in improving ED in radiation patients than in surgery patients.   6.      36 month ED following non-nerve sparing surgery is 75%; 36 month ED following bi-lateral nerve sparing surgery is 60%.     7.      Patient age may influence the likelihood of brachytherapy-induced erectile dysfunction. Potters and colleagues reported that patients < 60, 60 to 69, and ≥ 70 years old, respectively, had a 78%, 58%, and 50% potency preservation rate at 5 years following brachytherapy.   At 6 years, 70% of all brachytherapy patients with normal pre-procedure erectile function maintained potency and it was 92% when Viagra was used.   8.      Long term rectal issues were fairly common many years ago with brachytherapy treatment.   However, with modern brachytherapy procedures, those long term issues are now very rare.   Most brachytherapy rectal-related issues are manifested as diarrhea or rectal bleeding that occurs with the first year and usually resolve spontaneously without physician involvement.   Honestly, this back and forth debate on radiation vs. surgery is getting a bit tiresome.   I think I can find any number of studies that “prove” that radiation is “better” or vice-versa.   The definition of “better” is in the eye of the beholder (patient).   This debate continues to rage among urologists, radiation oncologists and medical oncologists and it is unlikely that the “amateur medical scientists” (Postop’s term) here at HW are likely to resolve it…especially given our own biases and investment in our chosen procedures.   So, my conclusion and advice to my biological brothers if they get prostate cancer will remain the same:   For patients who are candidates for both surgery and radiation the curative outcomes are similar.   Both procedures come with side effects but I believe the side effects with radiation are less onerous and the resultant quality of life with radiation is better.   So, if you have to choose between the two, I recommend radiation.   However, if the cancer diagnosis indicates, you should consider the least invasive treatment, i.e. Active Surveillance or perhaps another treatment with low invasiveness like TFT.   In any case, explore multiple options and seek treatment from an experienced physician to optimize your chances of a successful outcome.   Respectfully submitted,   Tudpock (Jim)                

I agree with Tud that studies can be found to support anyone's particular bias.
I don't mind anyone using studes to support their positions, but what I do mind is the misconceptions about radiation that keep popping up that many patients are lead to believe are true, or may have been true 15 years ago but are no longer valid.
1. Brachytherapy is only for low grade disease. The truth is that brachytherapy is used for all grades of pc and results for the higher grades are similar or better than surgery.
2. Radiation causes secondary cancers 10 years down the road. Was true for older ERBT, but does not occurr with brachytherapy and is about 1% for the older ERBT.
3. Long term side affects always arise from radiation treatments. For the vast majority of radiation patients the side affects you have in 2 years are the ones you are stuck with.
4. You will get ED in 3 years instead of immediately and after 3 years ED from surgery will be better. Long term ED rates from radiation are lower than surgery in the long term and much lower in the short term,and are more easily treated with meds than ED from surgery.
5. Radiation is only for older patients. Many younger patients have very good results with radiation.
6. The chance for long term reoccurrance are greater with radiation. In fact the long term reoccurrance with radiation occurrs 5 years later than surgery. The reoccurrance rates for both flat line in 5 years and long term reoccurrances for either do happen but are very rare.
7. Proton therapy is more effective in reducing side affects. True in the 1990s when compared to ERBT, but no longer valid with the newer IMRT.
8. There is a 2nd chance with failed surgery, but none with radiation. Any cancer that can be cured by salvage radiation would have most likely cured it the first time. Reseeding and HDRT are used for salvage radiation and so is cryosurgery.
7. Incontinance is rare in radiation and still is a major issue with surgery, both short and long term.

Casey, I don't believe we are that far apart.  I may have oversimplified a bit and there are some cases where I would recommend surgery as well....I agree with the list JT has provided on this subject.  In general though, all things being equal, I personally would likely recommend radiation more times than not...

Tudpock (Jim)

Tud:

Well, some folks seem to be a bit more even-handed than others.

We all tend to want to support the choices we made.

I think that David (Purgatory), for example, was always very careful not to push one particular modality over another. There are others here where, frankly, when I look at the name of the poster I can predict the tone of the post. However, that isn't the worst thing.

Yes, Tud, your bias is clearly towards radiation, as you readily admit. But I still learn a LOT from your posts. I don't think everyone has to go out of their way to attempt to be evenhanded. I chose surgery and I am sure that when I state my carefully considered reasons for surgery it will be helpful to someone who has to make a treatment choice.

Incidentally, don't forget that radiation and surgery are the major choices but some fortunate folks can also consider AS. Then, of course, there are some other treatment possibilities.

When I first got on HW, actually it was before my formal dx., reading all the opinions helped me make my choice.

Mel

I read with interest the post by Casey59. I read the three references given. The first was the most troubling. I noticed, however, the 2004 article date, and the fact that the study covered a period of two years beginning in 1998. I immediately remembered both my husband's urologist and his oncologist making the point that radiation treatment had made huge strides in the last three years alone, and was much, much better today.

Although the quote given from the third article is disturbing, when I read that article I found that the last sentence in the concluding paragraph was "Longer term data suggest that brachytherapy is a well-tolerated treatment for localized prostate cancer, with a toxicity/side effect profile comparable to other treatments used in this setting." Talk about confusing.

I've noticed from the time I started researching this issue that there is an amazing number of completely contradictory reports, studies, abstracts and opinions online. No wonder we are all discombobulated. Unfortunately, or maybe not, Carter read the first article mentioned in Casey59's post, and decided against brachytherapy. His choice is not between surgery and radiation, as he ruled out surgery fairly quickly. His choice came to be between IMRT alone, or the combination of IMRT and brachy. His oncologist did mention to him urinary stricture and rectal fistulas, so he was already concerned. Whether his choice now is the right one only time will tell.

I want radiation to work! I want it to be uncomplicated! An astounding number of men who post here end up having both anyway. It needs to work for everyone.

I feel so much compassion for all of the men and their families who must make these decisions. Some men cannot have surgery for a variety of reasons. Some men cannot have radiation; they may have already had radiation for different reasons in the past and have passed the limit allowed. We all have reasons for our balkiness as well. Those of us who have lived with the consequences of mistakes made by surgeons will never feel the same about surgery. Those who have a gut reaction to the idea of burning pain on urination, or diarrhea, are not going to turn easily to radiation. Our lifestyles may limit the side effects we can comfortably handle. A man with a new grandbaby may not want seed implantation that prevents him from holding the baby for a period of time. For all of these reasons, I wish so much that the whole issue of choice meant an easy and successful solution for each guy. But wishing doesn't make is so.

Cross your fingers for us.... nine weeks of IMRT ahead. Simulation begins Monday morning. And I wish the best to all of you. I KNOW how you have struggled.


Juliet (and Carter!)

I see the treatment selection process this way: Each patient’s goals and priorities in the treatment of their prostate cancer should individually be evaluated and considered to individualize treatment plans.   Due to the individual variation in the perception of quality of life—everyone sees this differently—objective evaluation of outcomes and side effects is difficult to generalize. One size does not fit all, and while there are some "good" treatment modes, none are perfect.  But, I am repeating myself here...   Jazzman’s original question/comment about secondary cancers from brachytherapy were not addressed in the prior postings of this thread.   Hopefully, my original posting here helped clarify in a balanced way that there are other consequential late effects from brachytherapy (besides secondary cancers) that might be more concerning, but hadn't yet been mentioned.  [By the way, I went back to my original posting in this thread and edited out all the article references published greater than 15 years ago; in fact, I deleted anything not published in the 2000's.  It should be fine now.]   Post Edited (Casey59) : 10/18/2010 12:42:41 PM (GMT-6)

Postop,
I fully support your efforts to futher this discussion. Just two points of caution in your research quest; Insure that the studies you compare uses clinical data and not pathological data and that the radiation studies are the newer IMRT and not the older ERBT.
Also some other research articles:
Brian Quaranta, "comparing radical prostatectomy and brachytherapy for localized prostate cancer" Oncology Sept 2004
Edan Shapiro "Long term outcome in younger men following permanent prostate brachytherapy" Journal of Urology April 2009
Catherine Buron, "Brachytherapy versus prostatectomy in localized prostate cancer: results of a French multicenter perspective study" International Journal of Radiation oncology Biology Physics, March 2007