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Which Treatment Is Best ?

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Posted 6/23/2013 5:05 AM (GMT 0)
The "Grimm, et al" report is one of the definitive study synopsis' of PCa treatment results over a 12 year period, and was published in 2012 thus making it very relevent. Many have (and will I'm sure will again here in this thread) tried to discredit this report because it starts with "Grimm" - but IMHO you simply can't ignore the facts as presented. This was simply a presentation of fact gathered from many, many studies - not to discredit one treatment approach or another, but again to present results.

I get very frustrated when folks try to discredit what is simply a summary of a significant amount of treatment results - I truly wish it would simply be viewed as another bullet in the chamber towards fighting the beast, and not a p!$$!ng contest over the various treatment options. MichaelT and others have had great success with HDR BT, Davidg and others have had great success with surgery, I and others have had great success with LDR BT......

This report was the coup de grais when it came to making my final decision on treatment (that, and finding 'the best' practitioner) and I say that as being a relatively "young guy" - not 45, but 55 and not 65 either. . . . . and again it was pretty clear, for me, with my PCa stats (everyone please hear these caveats.....) that BT was the right way to go - for me. I purchased the full report to fully understand what this was about as I am very leery about "statistics" until I clearly understand the data set and how it is presented. Because their 'terms and conditions' allow me to share this with anyone 'directly affected' - I have and continue to offer to send this to anyone so inclined. (Michael T thanks for the shout out BTW!)

When I weigh in for the newbies I have tried very hard not to "push" MY choice of treatment on them - nor do I push to discredit other treatment options - all that's simply wrong as we all have to make our own choices. At the same time I always try to avail myself to those that are at that point in their journey where they need to be aware of all of the options available, to pass along to them what I have found, learned, and experienced; and to me, the "Grimm, et al" report is a "must read."
Posted 6/23/2013 6:48 PM (GMT 0)
For my part I don't have an agenda (other than to promote deeper understanding) and was not trying to "discredit" the Grimm review paper per-se. To the contrary, I think it is very interesting and compelling insofar as showing that BT can provide excellent outcomes. I was, however, questioning whether the surgical outcomes considered were representative of the best surgical care available.

For low risk patients there were only six surgical studies considered. Looking at the two of these papers that are freely available reveals the following:

Nguyen et al: overall positive surgical margin rate = 23% for cohort that was 72% pT2 / 28% pT3
Kane et al: positive surgical margin rate = 35% all D’Amico low-risk

These psm rates are mediocre to poor so it does not seem surprising that the corresponding rates of biochemical relapse were also mediocre to poor, since it is well known that biochemical relapse correlates strongly with surgical margin status.

Although many surgical margin rates and biochemical relapse rates superior to this have been published, they apparently were not considered because they did not include stratification by pre-op risk criteria (e.g. c-stage), which just happens to be less natural for inclusion in a paper on surgery.

Given this, I think the takeaway regarding surgery compared to BT should not be that BT is necessarily superior but, rather, that the skill and track record of surgeon is paramount in order to achieve outcomes comparable (or potentially even superior) to those shown for BT.

Post Edited (njs) : 6/23/2013 12:51:55 PM (GMT-6)

Posted 6/23/2013 7:59 PM (GMT 0)
Do we know how good the BT and IMRT practitioners are in the studies used in this survey? I think njs brings up an excellent point, but is there a way to also judge the collective skills for the doctors conducting the other treatment options?
Posted 6/23/2013 9:08 PM (GMT 0)
I thought this had some interesting takes on brachytherapy:

www.prostateseedinstitute.com/article5.aspx

And it fits into this discussion.

Sorry, still can't always make a link live.

david

I think I fixed you link. --PeterDisAbelard

Post Edited By Moderator (PeterDisAbelard) : 6/23/2013 3:30:39 PM (GMT-6)

Posted 6/24/2013 11:11 AM (GMT 0)
Throw in the other advantages of quick and easy procedure and much lesser SEs, and you wonder why this shouldn't be the first choice for everybody. ie brachy

I have to admit that I have wondered that every time I come on this board.
Posted 6/24/2013 11:24 AM (GMT 0)
Sometimes I wonder too, if it's easier to do BT than surgery as well. I get that surgery is a great option IF you have a very good surgeon, but what if that's not doable? If a guy lives in a rural area or doesn't have the resourses to go to one of the top guys? Is BT a better option in that scenario? I'm just thinking out loud here. I chose SBRT for myself based on the team I could assemble and thier results so far. I was having trouble finding a solid BT team in St. Louis and even the most expeirenced surgeons (which I had pretty much ruled out for my own reasons, but I looked) had mixed results here. As a G6, I had a lot of options, as do most G7's.  I didn't start out looking at SBRT, but I'm very glad that's where I ended up, but if I had not done my homework, and listened to my first urologist, I would have had surgery by now, and not by a "known" guy.  So, I wonder if sometimes the question isn't "what's the best treatment", as much as "who are the best people who do a particular treatment available to me". Not trying to argue, just throwing that out there. Not everyone has the resources to fly around looking for the best care. It is what it is.
Posted 6/26/2013 4:20 AM (GMT 0)
Just stumbled across this, which refers to a couple of studies contradicting the paper by Grimm:

www.drcatalona.com/quest/quest_article_v8n5.htm
Posted 6/26/2013 12:41 PM (GMT 0)
njs - there are tons of literature and studies out there and what I've tried to do is understand the data set behind whatever I read. In my own opinion the Grimm, et al stands strong. Can it be challenged, sure, but at the end of the day - for me - it's justified data that I included in my basket to make my decision on treatment. Everyone individually can, and should, make their own call on it and whatever else they are using to make their decision on treatment.

The article you provided a link to is from a study that is some 9 years old, meaning that the 10 year study results it describes was started 19 years ago. That dates the start of this data set by 19 years - and I think we all would agree that LDR BT has come a long way in that time frame.

Also Dr. Catalona is a surgeon and is known for developing the PSA test as a screening test for prostate cancer, as well as being one of the first surgeons to perform nerve sparing surgery in radical prostatectomy operations. This man has some great credentials and I'm sure he also has great success rates - and I also believe he views the world as, well, a surgeon. Which is the same push back others have used about Grimm and some of the other authors being radiation oncologists.
Posted 6/26/2013 12:58 PM (GMT 0)
One of the surgeons I considered had 1100 robotic surgeries under his belt. I was troubled when he told me that one could have an orgasm without an erection and that 85% of his patients were continent within a year. He told me flat out robotic surgery would be best for me and that radiation of any kind entailed me waiting for two years to see if I had picked the right treatment.

A lot of men just aren't being given the option of brachytherapy as far as I can see from this forum. I wasn't given this option at the large teaching hospital I went to.
Posted 6/26/2013 2:27 PM (GMT 0)
Brachytherapy seems to be equal or superior in cancer control and side effects are lower. Why have the large teaching hospitals not picked up on it? Recent papers seem to be the most definitive so maybe it will just take a few years. Maybe the early poor performance is holding it back. Academics are sometimes slow to change but not all. It can make someone's career to go against the tide.

Or are we missing some information?
Posted 6/26/2013 2:44 PM (GMT 0)
They buy expensive robots to perform surgery and have to pay for them is my guess.
Posted 6/26/2013 4:13 PM (GMT 0)
Treating Prostate Cancer is a multi-billion dollar a year INDUSTRY..Anything that upsets the status quo is going to get a lot of push-back..I learned early-on that the Urologists, Surgeons, Radiation Oncologists and Medical Oncologists all have staked out their turf and will fight to protect it...The PC patient finds himself wondering around on the battlefield, trying to stay alive.....
Posted 6/26/2013 4:24 PM (GMT 0)
Thomas,
The reason is pretty simple. 90% plus of all prostate cancer is DXed by urologists who are surgeons. They are unfamiliar with BT and when giving recommendations will go with what they know and how they were trained. Unless a patient does research and gets multiple opinions about his options he may not be aware that other options exist. I think that if oncologists DXed and recommended all treatments like they do in all other cancers you would see a shift in treatment modality towards AS and BT and away from surgery.
JT
Posted 6/26/2013 4:31 PM (GMT 0)
That's probably true, John.

Saw an interview with Scholz yesterday on Youtube. He was asked same question and didn't respond that surgeons or radiologists do what they do for unethical reasons. He was saying that surgeons like to cut, radiologists like to burn. But perhaps it's also true that he likes to manage.

Wish I still had the link. He talked about MRIs btw as a powerful screening tool.
Posted 6/26/2013 5:54 PM (GMT 0)
Makes sense John. It is men who get the shaft when doctors have to compete for dollars.
Posted 6/27/2013 11:08 AM (GMT 0)
I agree with the sentiments of Fairwind and John T, but I like the way Buddy comes right to the point.

It can be a battle to find the treatment that is truly best for the patient. It was in my case. I talked to several doctors who told me what treatment would be in their best interest, but only after much searching (of the soul, and in the medical field) did I come to a place where I truly felt that my best interest was first and foremost. Not everyone is fortunate enough to have that experience, but everyone should be.
Posted 6/27/2013 3:15 PM (GMT 0)
My RO at Vanderbilt, a major teaching hospital, does lots of brachytherapy. We talked about for my case, supplementing with the IMRT plan. For my specific case the added seeds wouldn't improve the expected outcome. One cannot generalize much about this wretched disease, it seems.

Vandy's docs seemed to give me a very balanced treatment discussion. I didn't feel any of them were pushing their specialty on me at all.

They're all about evidence-based decisions.
Posted 6/27/2013 3:40 PM (GMT 0)
Brachy does not appear to be the "first choice for everyone", as was stated earlier in this thread. I had invested in the first seed developments many years back (yes, it made me a lot of money, but it was all lost in two crashes, so no benefit from that today), so was motivated to want to know if they were useful for me.

My uro suggested that I investigate all options, as my insurance was willing to pay for some additional opinions. I sent everything to MD Anderson, and was refused for consideration of either seeds or Proton RT.

I am going to say that I do not see any treatment as the "best". If there was a "best" I would expect it to be useable for all cases.

Posted 6/27/2013 3:47 PM (GMT 0)
No doubt training, experience, and money play a role in the procedures recommended. I do not believe these are the sole motivators. In general, I am most concerned about these factors distorting the treatment plan in independent, dedicated treatment facilities. It is my impression that brachytherapy is usually done in these independent facilities. I am glad to hear Vanderbilt considers brachytherapy. If the favorable numbers hold up for brachytherapy I suspect it will appear at other major teaching hospitals.
Posted 6/27/2013 4:06 PM (GMT 0)
The thing about Brachy and any radiation treatment for that matter ,to my mind, is the fact that the SEs appear "long" after the treatment. You go along for 2-5 years with a declining PSA, you think you have it made, then, VIOLA! incontinence to a degree, some fecal incontinence, flow problems...even blockage. Radiation damage takes its' sweet appearing. At least in surgery your SEs are apparent right away. For those of us in physical occupations..,sheep farming and professional sheep shearing. BT seems ok since I would effectively be out of business if restricted from heavy activity for 6 months or longer. (I'm a sole proprietor) I'd be nervous, though waiting for the next shoe to drop with any radiation therapy. So, as we all well know, there is no good therapy from some points of view. All are better than being dead...I guess.
Posted 6/27/2013 5:04 PM (GMT 0)
sheepguy I like your last comment, "All are better than being dead.....I guess"!!!  Food for thought in more ways than one. . . .

Also I have to respectfully disagree with your comments about SE's appearing "long" after Brachytherapy.  There are now plenty of long term studies out that demonstrate that is no longer the case. 

The most recent study I have come across was presented during the European Society for Radiotherapy and Oncology (ESTRO) on April 19-23, 2013, in Geneva, Switzerland.  This study (over a time horizon of 10 years) was focused on the expected comparative costs and Quality Adjusted Life Year (QALY) gained across the various treatment modalities.

In the summary conclusion of this presentation then, "In intermediate and high risk prostate cancer, EBRT+BT is expected to provide the highest QALYs at acceptable or lower cost than monoradiation treatments and RP. In low risk prostate cancer, AS is preferred in terms of QALYs, while BT dominates EBRT and RP in terms of costs/QALYs."

In days long gone past radiation treatment had it's issues, but in today's world - in the hands of the right practitioner (as in all treatment approaches) - it's simply not the case any longer.

I have been planning on putting the results of this study in a new thread out here on HW and will be doing that soon.

Posted 6/27/2013 5:15 PM (GMT 0)
I hope you are right, Yooper. I see occasional postings here and there about BT patients who are experiencing those SE s I mentioned at 20 months , 30 months etc. However, that is probably about 6..less than 10 for sure..given the number of guys with BT I'll bet that's a tiny percentage. Still, when you see them they tend to stick with you without regard to any evidence to the contrary . If and when the time comes, I have a slowly rising PSA, I'll likely highly consider BT.
Posted 6/27/2013 5:24 PM (GMT 0)
sheepguy you're right about one thing for sure - and that is that no treatment is guaranteed - it just so much depends on each individuals situation and condition, as well as the practitioner chosen. There are guys that have had great success with all of the treatment options, and guys that have had some pretty bad results with all treatment options.

My own personal approach was to try and understand what the studies say as well as learn from the experiences of others, before making my decision on treatment.

As PeterDA so aptly stated above "I am going to say that I do not see any treatment as the "best". If there was a "best" I would expect it to be useable for all cases."

You mentioned "If and when the time comes..." - personally I hope that never comes and sorry but you ain't allowed in this club yet!

Best to you.
Posted 6/27/2013 9:19 PM (GMT 0)
Brachy does not appear to be the "first choice for everyone", as was stated earlier in this thread.

Pretty sure that nobody made the statement that brachy WAS the first choice for everyone. The conjecture was...why in the heck isn't it?
Posted 6/27/2013 10:09 PM (GMT 0)
GOP,

I was refering your comment:
Throw in the other advantages of quick and easy procedure and much lesser SEs, and you wonder why this shouldn't be the first choice for everybody.
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