Why salvage radiation is bad.

"Surgery is overwhelmingly the most prevalent initial choice of treatment.
A quarter to a third of men electing surgery have a recurrence afterwards, about 2/3 of which are local."

I did not know surgery had such a high recurrence rate. To me this mystifies the notion "you can have radiation later if surgery fails" regarding who started it. I'm assuming perhaps this was an adage years ago before radiation became much more precise?

Squirm said...
"Surgery is overwhelmingly the most prevalent initial choice of treatment.
A quarter to a third of men electing surgery have a recurrence afterwards, about 2/3 of which are local."

I did not know surgery had such a high recurrence rate. To me this mystifies the notion "you can have radiation later if surgery fails" regarding who started it. I'm assuming perhaps this was an adage years ago before radiation became much more precise?

I also am a little surprised at that failure rate, especially since I suppose it is based on all surgeries, including for low/med risk? Of course, what I may not have been considering is that this is apparently referring BCR, or simply a PSA rise.

I had been encouraged by such studies as this one, which has been mentioned several times around here, including by me:
www.renalandurologynews.com/study-supports-surgery-for-high-risk-prostate-cancer/article/338483/

article said...
In a study of 30,379 men (mean age 62.5 years) who underwent RP for Gleason 8-10 non-metastatic PCa, Naveen Pokala, MD, and colleagues at the University of Missouri-Columbia School of Medicine in Columbia found that the overall survival rates at 5, 10, 15, 20, and 25 years were 92.8%, 78.6%, 59.5%, 38.6%, and 20.0%, respectively. Cancer-specific survival rates were 96.4%, 89.5%, 82.0%, 72.9%, and 68.8%, respectively, the researchers reported online ahead of print in the World Journal of Urology.

“This is the first study to demonstrate excellent 20-year cancer-specific survival of men with Gleason 8-10 prostate cancer,” the authors wrote.

A total of 52.8% of patients had T2 disease, 73% had node-negative disease, 80.2% underwent lymph node dissection, and 12.9% had adjuvant radiation therapy. The study showed that pelvic lymph node dissection did not significantly affect overall survival.

And these were the high risk guys, G8-G10 and almost 1/2 were at least T3, but still with 90% having a 10 year, and 73% a 20 year cancer-specific survival rate. And only 13% had ART. Did any have SRT, or are they including that with ART? They don't say about SRT. It says "those who underwent other modalities of treatment were excluded", but does that mean as primary treatment? Would SRT have been excluded?

So then what's with the 1/3 failure rate? Well, I guess this means that even if 1/3 do have a BCR, regardless, 20 years later 73% of them still would not have died of PC and 39% of them would not have died of PC, heart attack, stroke or anything else. Pretty good considering 20 years would put the average age at 82.5 years. Raise that to 60% not dead from any cause at 15 yrs or age 77.5. Average male life span in USA is what, 76 years? Seems like 50% should have been dead from something by age 77. So, again, not bad. I would love to know how many had SRT, and I hope most had an OK quality of life.

So with survival figures like that, I was surprised at the 1/3 failure rate. But I guess it just shows BCR does not have to be the end of the road. Since if the figure is 1/3 failure, I think we can reasonably figure at least 1/3 of these long term survivors had BCR.

Post Edited (BillyBob@388) : 1/20/2015 8:52:15 PM (GMT-7)

my uro told me I had a 60% chance of the cancer being out of the capsule. he said he could therefore not recommend surgery. he said once the target (prostate) was removed I had a greater likelihood of permanent SEs and "i just couldn't do that to you" unless I insisted.

I've been a broken record about avoiding surgery when there was a strong likelihood that the cancer is not contained but I understand the desire to "just get it out".

ed

Many thanks to Tall Allen for posting this, and his wonderful multiple contributions on many subjects.

I had surgery and enjoyed undetectable PSA for only 7 months, when my PSA became a detectable 0.07. Had blood taken for a second PSA test this past Monday, and on the 21st meet with my surgeon who has already sent me to meet with a RO ......

No one takes surgery / radiation or any treatment for ANY type of cancer lightly, given the unpredictability of the outcome or the side effects. The best you can do is learn about your choices and ask questions so you make decisions that are best for you. If you have good doctors, they can help you decide on what is your best bet.

F8 said...
my uro told me I had a 60% chance of the cancer being out of the capsule. he said he could therefore not recommend surgery. he said once the target (prostate) was removed I had a greater likelihood of permanent SEs and "i just couldn't do that to you" unless I insisted.

I've been a broken record about avoiding surgery when there was a strong likelihood that the cancer is not contained but I understand the desire to "just get it out".

ed

Makes sense to me. Why undergo the risk and associated side effects of prostate surgery when there is a high chance of having to undergo additional radiotherapy.

Caspar:

Excellent points.

I wish the subject title of this thread was a more judicious one!

I could take almost any tx., I imagine, and post "Why XXX is BAD>"

I can even do "Why XXX is Good"

Obviously, it depends on each patient's situation.

Each tx. has its own positives and negatives.

Hindsight is wondrful, but unfortunately with PC we always have incomplete information -- never much certainty (with maybe a few exceptions)



Mel

Casper, I'm not sure I backpedaled at all. SRT is bad. Period. It may be the only choice we have, however. But that doesn't make it good. It just makes this therapy with potential to endanger our quality of life what we have to live with. There is incredible ignorance among patients and urologists about the risks involved, and I welcome the opportunity to provoke spirited discussion.

Also, if you have seen studies that seem to be in conflict, please post them. I love that kind of interaction. Vaguely pointing to mysterious studies that you assume to be out there benefits no one, and does a disservice to all.

- Allen

Michael_T said...
Other than ordering a bone scan, my uro didn't seem to think at all about the chances that it had moved beyond the mothership. He told me he recommended surgery for high risk guys like me. When I asked him what he would have recommended if I wasn't high risk, the answer was that he would still recommend surgery. The reason? Because you could have radiation after surgery, but not vice versa.

That's why I think the info in this thread is important. Not because surgery is bad--it makes a ton of sense when the cancer is likely to be contained. But because so many uros imply that surgery comes with a "get out of jail free" card in the form of SRT.

Yes, I agree. Surgeon's using SRT as an encouragement to choose surgery should explain about the possible- or even likely- negatives.

If we go the other way, RT that needs some type of salvage- are we better off? (don't know, just asking) But either way, the obvious message for me is: If you can actually determine which approach gives you the better odds of long term lack of recurrence, better choose that. Because your first shot is your best shot.

I thought this was interesting looking at a different type of salvage, i.e. SRP:
www.indianjurol.com/article.asp?issn=0970-1591;year=2014;volume=30;issue=4;spage=429;epage=433;aulast=Kaffenberger
Also this which is similar:
www.ncbi.nlm.nih.gov/pubmed/23000849

Post Edited (BillyBob@388) : 1/22/2015 3:37:56 PM (GMT-7)

InTheShop said...

F8 said...
my uro told me I had a 60% chance of the cancer being out of the capsule. he said he could therefore not recommend surgery. he said once the target (prostate) was removed I had a greater likelihood of permanent SEs and "i just couldn't do that to you" unless I insisted.

I've been a broken record about avoiding surgery when there was a strong likelihood that the cancer is not contained but I understand the desire to "just get it out".

ed

My path report had a small chance that it was outside the capsule, which was a factor in my decision to do radiation. My surgeon didn't try to sell my on surgery. It's one of the things I liked about the clinic I found myself in - they treated cancer and didn't try to sell anyone kind of treatment. They just presented the facts, the options, risks and stayed around to answer all my questions. The day of my appointment with them I met with both a surgeon and an RO. The two had a short hallway conversation after talking to me to make sure they were make the best recommendation to me.

The conversation ended with, we think radiation is the best but it's up to you.

I simply don't understand why some surgeons are so set against sending people over for radiation.

Andrew

You don't? I don't want to sound like a cruel cynic who is unfairly accusing surgeon's of being poor humanitarians, because I'm not. I'm sure the majority of surgeons(I just retired from 36 years of working side by side with all kinds of surgeons, daily) and all other docs desire to be literally life savers for their patients. But when it come to trying to get unbiased information, human nature just has to be considered. And sadly, even if subconsciously, for all humans, the impulse that must be overcome is "If a man has a hammer, everything looks like a nail".

So just to use an admittedly very extreme example to make my point: Let's say your surgeon has spent 12 years after high school, and has maybe who knows how many, many thousands of debt for his schooling, and is paying $100,000+ a year for malpractice insurance. And he is finally a well established surgeon and authority in the community and is a super powerful big shot at his hospital due to all the business he brings in, and is finally grossing 0.5 to 1 million a year. Now say he becomes convinced that all new studies jave proved that primary RT is hands down the best treatment for all PC, low risk and HR? Everything he is reading shows that the curerate is higher and the SEs are lower. So, there is no longer really any way he can justify recommending any surgery to his patients, because what is best for them is to go to the RT guy?

Surely this would at the very least cause all of us some difficulties, as the above is going to wipe out out huge income and power. Most likely, for many, it would just manifest itself as a refusal to see the facts with no bias. There might be a tendency- even if not conscious- to not see the evidence. Because this great news for PC patients would be terrible news for his practice and his and his families life style. There might be a tendency to some how see the facts that support the surgery. I mean, is it realistic to expect the majority of surgeons to tell most of their patients that they don't need surgery? They instead need what the other guy is selling? All purely hypothetical, of course. But, I think the principle is a danger to any man's advise giving. And it could apply just as well to the RT guys advice.

Post Edited (BillyBob@388) : 1/22/2015 3:52:47 PM (GMT-7)

Casper,

I'm surprised you can not tell the difference between an internet hack that does not know is arse from a hole in the ground to a very intelligent researcher who presents the best and most current literature. I have worked with hundreds of physicians and you give them too much credit. The best physicians I know would hold Allen and what he does in high regard.
Allen does us a great service.

Paul

There have been a few too many vague and implied insults in the posts here. I see the discussion as beaten to death.

I'm closing this, as the value added has been exhausted.