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Posted 1/26/2011 12:20 AM (GMT 0)
Posted today on the New Prostate Cancer Info Link/

All 190 study participants were asked to complete a series of three validated surveys at about 5 years after their initial treatment. The results from these surveys are detailed below:

  • 168/190 patients (88.4 percent) completed the surveys.
  • Of the survey responders
    • 102/168 (60.7 percent) had BT (and 16/168 or 9.5 percent had been randomly assigned).
    • 66/168 (39.3 percent) had an RP (and 16/168 or 9.5 percent had been randomly assigned).
  • Median ages of the responders were
    • 61.4 years for BT patients
    • 59.4 years for RP patients.
  • Median follow-up was 5.2 years (range, 3.2 to 6.5 years).
  • There was no difference in HRQOL between the two treatment groups with regard to bowel or hormonal domains.
  • Men treated with BT had better HRQOL scores with regard to urinary domains (91.8 v 88.1; P = 0.02).
  • Men treated with BT had better HRQOL scores with regard to sexual domains (52.5 v 39.2; P = 0.001).
  • Men treated with BT had higher levels of overall patient satisfaction (93.6 v 76.9; P < 0.001).

The authors conclude that, “Although treatment allocation was random in only 19 percent, all patients received identical information in a multidisciplinary setting before selecting RP, BT, or random assignment. HRQOL evaluated 3.2 to 6.5 years after treatment showed an advantage for BT in urinary and sexual domains and in patient satisfaction.”

Posted 1/26/2011 12:44 AM (GMT 0)
I saw this the other day.
There is certainly a higher degree of satisfaction among the Brachy guys here to go along with the report. We still don't have that age old question about prostate cancer specific survival, but we may never. Still the brachy guys should be happy with this report. I also believe that if everyone used a better quality surgeon they may be able to improve upon these numbers. It's a bias that I still have but I am one those who chose wisely regarding my surgeon. The followup range here is fairly short and it would still be interesting to see this study follow for a longer term.

Tony
Posted 1/27/2011 1:53 PM (GMT 0)
John, thanks for sharing.  This is consistent with the QOL study done a couple of years back by the New England Journal of Medicine.  Except the study you posted is even more compelling with a 5 year median by which most SE's should have mainfested themselves.  The NEJM study was 2 years as I recall.

With 15+ year studies showing that brachy is just as curative as surgery and with the QOL advantage it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery.  But to each his own of course.

Tudpock (Jim)

 

Posted 1/27/2011 3:58 PM (GMT 0)

Tudpock18 said...
John, thanks for sharing. This is consistent with the QOL study done a couple of years back by the New England Journal of Medicine. Except the study you posted is even more compelling with a 5 year median by which most SE's should have mainfested themselves. The NEJM study was 2 years as I recall.


With 15+ year studies showing that brachy is just as curative as surgery and with the QOL advantage it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery. But to each his own of course.



Tudpock (Jim)

Jim, it no longer baffles me. But for most with low risk numbers those who opt for radical surgery seem to commonly be those who panic at the word cancer and thus the "get it out of me NOW!!!" reaction. Many you'll see under the knife six weeks after their biopsy. In fact many would elect the day after if they could. Also there's the overblown justification that brachy makes SRT difficult while generally ignoring SRT's only 30% success rate. At times I find it hard to believe that over 3 years since my own dx is that little has changed. There's still way too many men who panic and now have a lower quality of life be it for months or permanently. The most valuable advice has always been to after dx take a deep breath, educate yourself on your option and most importantly don't panic and do question and evaluate all options presented to you.

That said looking back over time I remember posters here who thought I was insane not opting for radical surgery and weighing QOL issues along with the old cancer panic. When I even rejected brachytherapy and opted for TFT a clinical trial you'd think I had committed myself to terminal PCa for sure by a few reactions here. Or else I was praised as being brave going where few chose to go or risk. I saw neither but an obvious choice and now near 3 years post TFT I can only sing its praises. The only side effect I have is maybe a 60% loss of ejaculate. I never had a day of incontinence and my worst PCa experience was a total of 5 days with a catheter. See what can happen if you DON"T PANIC and look at all options. I admit I'm a best case scenario but PCa research has advanced and that old gold standard of radical surgery is showing its tarnish. It will remain an option for aggressive PCa as it should but as I've been saying for years now these will be looked back as the days of massive over treatment of PCa with thousands of lower risk Pca men suffering a lower QOL they never needed to have experienced.

Ziggy9(Rick)
Posted 1/27/2011 4:30 PM (GMT 0)

Tudpock18 said...
...it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery...

Well, that's a bit of an overstatement.

There are case conditions where I could see myself choosing different treatment modes, but there really is no one-size-fits-all solution that could be recommend across the board...newcomers should be wary of such statements.

The American Urological Association (AUA) publishes a free online document titled "Guideline for the Management of Clinically Localized Prostate Cancer" (LINK).  Close to 90% of all new diagnosis are "Clinically Localized."

I closely followed the recommendation of the Guideline that each patient closely examine four facts/dimensions about themselves in order to make the most personally appropriate treatment decision:  my cancer's characteristics, my overall health, my life expectancy, and my personality/values.

It should not be so bewildering that a very-informed treatment decision might have been different than someone else's, because my (or anyone's) four dimensions (above) are different from everyone else.

I think that the important take-away from the last few posts here are that newcomers should be strongly encouraged to make a very-informed decision about treatment (including deferred treatment/Active Surveillance, which has been shown to have the highest QoL).  The Guideline mentioned above is an excellent tool created specifically to assist newcomers in the decision.

Posted 1/27/2011 5:32 PM (GMT 0)

Tudpock18 said...
it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery.

I can tell you why I chose surgery over seeds even though I qualified for both

1) My prostate and I had an adversarial relationship prior to my PCa diagnosis. It could be stubborn and make it difficult to start my stream and usually caused a weak stream. It also found humor in making my urine stream hard to stop and dribbling for a bit when I thought I was done. My prostate also didn't like to sleep more than 2-4 hours at a time, making me get up to urinate every night 1-2 times for the past 3 years. And sometimes when I was done urinating, I had the feeling I had to urinate 15 minutes later. Pretty much all these symptoms are gone. I even can sleep the whole night without getting up 1-2 times a week and the other nights I only need to get up once.

2) I saw a statistic that brachy seed patients had a relatively high incidence of having to have a TURP procedure sometime in their future. This is where a surgeon clears out the urethra of intruding prostate material, sort of like cleaning tree roots out our of a sewer pipe. It is not a major procedure at all but still not something I looked forward to

3) I have two friends who had their prostate removed by the uro who eventually did mine and had great results.

4) I have another friend who was very happy with his seed treatment and tried to convince me how bad surgery was, but he also told me (his words) that for a week or 10 days he felt like he was peeing out razor blades. Ouch.

5) I bought into the concept that if a brachy seeded prostate eventually had to be removed, it was a very difficult procedure with very high incidence of incontinence and ED.

6) Emotionally, I was one of the people who wanted the prostate out just because I had cancer in it, even though medically it wasn't an absolute necessity.

In retrospect, I made my treatment decision hastily (about 10 days after diagnosis and 2 days after my last consult) but even with all the info I have acquired from this site and other places, if I would have waited until today to make my decision I still would choose robotic surgery.

Dan
Posted 1/27/2011 5:37 PM (GMT 0)
I was a little surprised at the sex domain percent. I had assumed it would be in the 80 to 90 percent. Of course not sure I understand what all is in the domain stuff.
Posted 1/27/2011 5:39 PM (GMT 0)
>>I saw a statistic that brachy seed patients had a relatively high incidence of having to have a TURP procedure sometime in their future.<<

April -- do you have a reference for this and for the need (why?) and difficulty of seed removal?

thanx,

ed

Posted 1/27/2011 6:04 PM (GMT 0)
Ed,

Sorry it was so long ago I don't know where I saw it. I remember I read it shortly after my diagnosis last April and probably the visual of that procedure stuck with me more than the facts justified.

Now that I know what I know now, probably the incidence of having a TURP done after brachy may be higher than not having ANY PCa treatment, but that is the wrong statistic to focus on. It should be the rate of TURP after brachy versus the rate of treatment to relieve strictures or other obstructions caused by scarring from surgery.

My own gut feeling now is that the rate for brachy then TURP is a lot lower than prostate removal surgery then obstruction (scarring) removal.

Dan
Posted 1/27/2011 10:22 PM (GMT 0)
April, please note that my statement was about patients who are bracy candidates.  That is not everyone.  With your history of urinary problems you were probably not a candidate...at least not a good candidate.

And, Casey, it's may be your opinion that my statement is an overstatement but it's my opinion that that it's not.  It is my personal belief that for patients who are  good candidates for both brachy and surgery that brachy is a better choice.  I base that on curative statistics, QOL statistics, spending 2 years on this forum hearing patients' stories and my personal experience.  If I said outright that "brachy is better" then I could accept your characterization of "overstatement".  When I state it as my opinion then let's just agree to disagree.

Tudpock (Jim)

Posted 1/28/2011 2:11 AM (GMT 0)

Ziggy9 said...


I even rejected brachytherapy and opted for TFT
Ziggy9(Rick)



TFT ?? Rick, I don't see TFT listed in the abbreviations. Please help me to understand what the heck TFT is. Thanks from a guy who chose brachytherapy and who is very happy with the results of that procedure which was performed last May.
Posted 1/28/2011 4:36 AM (GMT 0)
I was interested in brachytherapy but not a candidate because of an oversized prostate. The uro didn't rule it out, but clearly it was not the best choice for me.

Also, my wife and I babysit our 3-year-old twin grandchildren three days a week. The granddaughter in particular loves to spend long periods of time cuddled up or on my lap. I didn't have a lead apron, and I sure didn't want to keep her off my lap for fear of radiation exposure.

The twins were wonderful about avoiding my incisions. They saw those and knew where they were. But how do you tell a toddler about radiation danger?
Posted 1/28/2011 11:49 AM (GMT 0)
Tudpock18 said...
...it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery...

I couldn't agree more.
Posted 1/28/2011 12:21 PM (GMT 0)
Brachy/seeds was not high on my list of options when I was diagnosed, though I would have liked to have had a treatment that gave me a better QOL than where I am.

My stats at diagnosis mean that I could have had brachy, however with the knowledge I got from the post-op pathology that showed I had seminal vesicle invasion, I cannot but assume that the seeds would not have dealt with the PCa.
SVI is something that is very rarely (if ever) detected at a biopsy as my understanding is that that is not a place a uro wants to stick a biopsy needle, so when they are offering brachy how do they work out if there is or is not any cancer outside the gland?

Alf
Posted 1/28/2011 2:50 PM (GMT 0)
Add to the brachytherapy argument the difference between low dose permanent and high dose temporary and you see how technology is progressing to help us.

I chose the high dose for the greater effectiveness and reduced side effects. Placement of the dose is more accurate, seeds don't migrate. no hot/cold spots because the body goes through normal changes in the 90 days the seeds are emitting their dose, no concern about holding my grandaughter as I was not radioactive. I researched several HDR centers and the best permanent centrer right here in Atlanta and then chose HDR.

My urologist is purposefully doing more to limit his surgeries and is using more HDR brachy specifically for the QOL issues. Add to the argument the advances with robo-surgery and the hype it is getting, but then temper that with the recent Duke study showing a much greater early failure rate than open surgery. No wonder this is all confusing and challenging for the newly diagnosed.

I have always done what I could to avoid surgery and I avoided it for my PCa treatment. I have had minimal side effects. The worst of which was one day of urniary burning following the first HDR session. The urologist used an ointment with the catheter the second time and I did not burn at all.

My anecdotal observation of the comments on this forum is that there are more problems reported by those who had surgery than those who had radiation. The information that JohnT provided shows the metrics backing up that observation.

The challenge is to get this information into the hands of the newly diagnosed for them to consider during their due dilligence.
Posted 1/28/2011 3:20 PM (GMT 0)

erbob said...

Ziggy9 said...


I even rejected brachytherapy and opted for TFT
Ziggy9(Rick)



TFT ?? Rick, I don't see TFT listed in the abbreviations. Please help me to understand what the heck TFT is. Thanks from a guy who chose brachytherapy and who is very happy with the results of that procedure which was performed last May.

TFT stands for Targeted Focal Therapy. It's a clinical study akin to a lumpectomy for breast cancer instead of a mastectomy. As in that only the cancer is targeted leaving the rest of the prostate intact. It's for low risk cancer and one must have a 3D saturation mapping biopsy to better locate the cancer and confirm there's not more than originally thought. I required a 45 needle sample, it depends on the size of the prostate. I knew of one guy who had 90 needles. about 58% I last heard pass and go on while those with too much cancer are urged to get more standard treatments. Mine was treated by cryotherapy(ice balls) but my doctor who is also the director of research here has also done it recently with a laser. The only side effect as I have said is maybe a 60% loss of ejaculant. Plus if the cancer does reoccur I still have all the traditional treatment options open to me.

No matter what treatment is chosen I recommend as always one takes his time and educates himself to all options. I was first leaning toward robotic surgery then brachytherapy as my cousin urged me to do for he had it done. I was likely going to do that except for a timely local broadcast here in Denver where a local anchorman did a special about his Pca and journey. Through that I learned of the local TFT study and about 5 months after the local TV reporter had it done so did I by the same staff at the University of Colorado Medical Center. In fact my doctor told me both mine and the reporters PCa were nearly identical in volume although mine was at a slightly better location. Since then both I and he have tested negative with two traditional biopsies and semi annual PSa tests. He's gone past three years while I hit that anniversary in April. After another good Psa I'll go back to just annual tests. Like I 've said the worse ordeal of my PCa was 5 days with a catheter. If you would have told me that the day after my dx back in November 2007 I would've never have believed it. Talk about an unexpected best case scenario. I know I was extremely lucky just by timing and geography to have this result.
Posted 1/28/2011 4:26 PM (GMT 0)
Alf,
The radoactive seeds have a range of 1mm. The planning is done to cover the entire gland including the nerves, uretha, and seminal vessicles. Some Brachytherapists, if they have good images and know where the tumor is can place a larger dose in the tumor area. If the tumor is at or near the margin then combination IMRT/Brachy should be used as you can extend the margin 5mm to 10mm. This is essentially what happens in SRT for failed surgery, but is done as a preplanned operation rather than a reaction to a BCR. The nerves, urethea, and seminal vessicles are quite resistant to radiation so the prostate tissue around them can be treated without affecting those areas. In surgery if cancer was found around them they would have to be removed. A tumor involving the nerves or in the APEX can be treated very well with seeds. A similar situation for a patient having surgery would most likely result in loss of the nerves or a positive margin.

JT
Posted 1/28/2011 6:39 PM (GMT 0)
"A tumor involving the nerves or in the APEX can be treated very well with seeds. A similar situation for a patient having surgery would most likely result in loss of the nerves or a positive margin."

John I have a well renowned robotic surgeon from the City of Hope coming to speak at our UsTOO meeting on the 17th of February. I don't know if you are in SoCal right now but I would like to invite you out to meet him and if you like you can challenge his knowledge on what causes positive margins or nerve loss. His specialty is nerve sparing procedures and he has over 1500 under his belt (Or should I say under our belt). I'll buy the dinner and drinks.


"With 15+ year studies showing that brachy is just as curative as surgery and with the QOL advantage it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery. But to each his own of course."

Tud are you assembling multiple studies here? Because I am under the impression that we don't have any studies that compare the efficacy or morbidity of brachytherapy at year 15 versus surgery. The one mistake I see commonly here is the use of non-randomized single clinic retrospective studies to compare data against other non-related studies. This is an improper way to arrive at any usable conclusions.

Not everyone is a candidate for radiation guys. Even radiation oncologists are not in agreement on whom to radiate versus send the patient to a surgeon. For example, we recently had a radiation oncologist at our UsTOO group telling us that he would not do radiation on most younger men in their 40's ~ and he used my case as an example. He stated that while brachytherapy is showing excellent promise on disease control it is still in the discovery phase on it's efficacy and morbidities over the long term. He also stated that younger men tend to heal very well after surgery and it is safer to go that rout than than to foray off into the unknown.

Also, I am looking at a lot of "doctor" talk here and I am fairly certain that there is a lot room for error. The superiority of surgery versus radiation is certainly not resolved today and it likely won't be for many years. Instead of questioning the thinking of why one of our brothers chooses surgery, this site is a better site when we support regardless of anyone's chosen therapy.

Good luck to all. I know we all can use some...

Tony

Post Edited (TC-LasVegas) : 1/28/2011 11:43:10 AM (GMT-7)

Posted 1/28/2011 6:39 PM (GMT 0)
PS: I have updates the abbreviations list on top of our forum. TFT is included.

Tony
Posted 1/28/2011 8:10 PM (GMT 0)
Tony, you asked, "Tud are you assembling multiple studies here? Because I am under the impression that we don't have any studies that compare the efficacy or morbidity of brachytherapy at year 15 versus surgery. The one mistake I see commonly here is the use of non-randomized single clinic retrospective studies to compare data against other non-related studies. This is an improper way to arrive at any usable conclusions."

Of course not.  You know better than I do that long term randomized comparison studies do not exist.  So what we are left with is to compare non-randomized studies and that's just the way it is.  What would you have us do, ignore any and all studies because they don't meet the criteria that unlikely will never be met?  I don't think that's a good idea.  So if you want to pretend we can't make comparisons between radiation and surgery feel free.  Personally, I think that's a fantasy world.

Furthermore you said, "Not everyone is a candidate for radiation guys." I agree and don't ever recall saying that nor do I ever recall anyone making that statement. 

Furthermore you said, "Instead of questioning the thinking of why one of our brothers chooses surgery, this site is a better site when we support regardless of anyone's chosen therapy." I don't see anything specific on this thread that questions why any specifc "brother" chose surgery.  I understand that as a pro-surgery guy you would prefer that many of us radiation guys never entertain the idea that radiation might be superior in many instances.  But, until and unless you edit me for breaking the rules I will continue to express my opinion.  You may think that makes the site worse; personally, I think diversity of opinion and approach makes the site better.

Tudpock (Jim)

 

Posted 1/28/2011 8:53 PM (GMT 0)
Tud you were very specific:

".. it still baffles me a bit as to why any patient who is a brachy candidate would not make that choice over surgery."

You are very clear here. What isn't clear here is what defines a "brachy candidate" in your book. In the professional industry, some RO's might say it's perfectly fine to radiate anyone with prostate cancer regardless of age, stage, or other factors. Some might say don't radiate the younger guys like in the RO I mentioned. I was just clarifying why someone might do surgery over brachy when they may appear to be brachy candidates.

We can easily run through a very serious danger zone if we try to assemble pieces of data in ways it was not intended to be used and express it like facts to others searching for answers. I know in the past I too have done that. And now I have seen many studies look good early but not stand the test of time.

I don't think I am anymore as pro-surgery as you are pro-radiation. The difference between you and me is that I have been in both treatment rooms and it was part of the original plan although I had hoped to skip radiation all together. But even more so I am "pro-survivor" as it pertains to anyone treated in any way. This includes you.

If I offended you by outlining a logical response to your statement above, then I apologize.

Tony

Post Edited (TC-LasVegas) : 1/28/2011 2:19:15 PM (GMT-7)

Posted 1/28/2011 9:18 PM (GMT 0)
Tony -- i've met a few guys who didn't qualify for BT and not because their numbers were too high or they were too young.  now, if they shopped around maybe they would have qualified but as you probably know most guys see only one doctor before the treatment decision is made. 

most of us do our research after the fact.

ed

Posted 1/28/2011 9:25 PM (GMT 0)
F8,
Well said. I know far more today than even after I completed surgery, started hormone therapy, and completed radiation all within 9 months of my diagnosis. But I would not have been able to even motivate myself to learn this much without advanced prostate cancer driving me to do so. Most newcomers should know more than they do before they take on treatment. But it is the nature of a cancer diagnosis to react. And unfortunately opinions will vary even among oncologists of a common therapy.

I think Zufus says it better than I do when he says "it's a jungle out there" or calls it the "Twilight Zone"...

Tony
Posted 1/28/2011 10:14 PM (GMT 0)

TC-LasVegas said...
But it is the nature of a cancer diagnosis to react.

 

Just a comment of agreement on this, if I may...

Another way I've seen this said is that "the anxiety that emerges from a cancer diagnosis is such that men cannot be dissuaded from treatment."

This problem runs deep.  Ours is a culture which rewards pills and procedures.  The structure of our physician reimbursement system incentivizes intervention and high tech...this needs overhaul. 

The growing body of evidence reassures physicians that it is safe to observe before treating many men with localized prostate cancer.  Despite this, large numbers of men leave the doctor's office after initial diagnosis with a "treat it now" perspective engendered by the initial presentation of the physician.

How do we incentivize doctors to present a more balanced view of the less rewarding approach of active surveillance for the significant population of men presenting with appropriate case characteristics?  Conscience-based medicine?  I don't think that's enough...

One of the small number of the world's problems that I don't have the answer for... smilewinkgrin

Posted 1/29/2011 2:39 AM (GMT 0)
Tony, I am certainly never offended when you have logical responses.   I do have a little issue however when you try to paint folks with contrary points of view as radicals, e.g. “not everyone is a candidate for radiation guys” infers that I or someone else on the thread said that everyone is a candidate for radiation which implies being some sort of kook or at least off the wall.   That works well in politics but not on a forum where everyone has a chance to provide a thoughtful response.   I also was not offended but took issue with your position suggesting our site is better when we fall in lock step and support regardless of chosen therapy.   I would certainly agree that it is rude to attack someone specifically by criticizing their choice.   However, part of what keeps the HW PCa forum vibrant (and the most popular on HW) is the willingness of posters to question approaches and provide alternative thoughts.   Frankly, I’m personally not interested in a forum where everyone sings Kumbaya and marches to the same drummer.   Thank you for your question about what defines a “brachy candidate”.   I am perfectly fine with the definitions used by most top urologists and radiation oncologists.   That is:   Low AUA score, i.e. not have a significant problem with prostatic obstruction/urinary problems such as hesitation, double voiding, excessive voiding at night, etc. Gleason 6 (or Gleason 7 with very small volume of cancer on biopsy). Prostate size of 50cc or less (or can shrink to that size). PSA 10 or less. No indication of spread beyond the prostate as indicated by the T-score.   In other words all indications of clinically localized disease. Now there may be other very patient specific items that may cause brachy-denial, e.g. some anatomical or previous medical issue that is patient specific.   However, absent that I still feel that most patients would be better off choosing brachy over surgery if they are candidates for both.   You may disagree but I hope you understand why with similar cure rates and fewer side effects it makes a lot of sense.   (I also feel that for most patients who are candidates for brachy + IMRT that is a better choice than surgery….but that’s a subject for another debate.)   Finally, I do agree with you that you are just as pro-surgery as I am pro-radiation.   We can both be pro-survivor and still disagree on approach.   Let’s just not pretend to be unbiased…   Tudpock (Jim)
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