Question about Surgery and advanced stage PCa

Do docs generally not suggest surgery if your PCa is Gleason 8 or greater AND you have lymph involvement and/or mets?

If so, why?

Used to be they would 1st check the lymph nodes during a prostatectomy. And if they came back positive, they would cancel the prostatectomy. I discussed that with my surgeon- department head at Vanderbilt- and he told me that based on current knowledge that was considered old-fashioned thinking.I have seen some Studies since then That compared men whose surgeries were canceled and placed on HT if they had positive lymph nodes to men who had their prostate removed anyway. In those studies the men who had the prostatectomies even though their cancer had obviously left the prostate bed, did much better in long-term follow-up. (Sorry I don't have a link for the study at the moment)

So maybe there is some advantage to removing ground zero for prostate cancer cells (that is, the prostate itself) even if it has already spread a bit? But I'm not sure if modern radiation techniques might not accomplish the same thing or better. I just read a study by to Tewari(sp?) where he compared G8-10s with either conservative treatment (Really? Conservative treatment for G8-10s?) to radiation and surgery. No surprise that the conservative treatment had by far the poorest results, but it surprised me that the surgery did better than the radiation. Significantly better overall long-term survival and lower prostate cancer specific death rates long term.(Why would surgery have better overall survival? Lower death rates even for those who did not die from prostate cancer? Dead from other than PC was 27% for conservative, 25% RT and 9% surgery! ? ) However, I think this study was kind of old, based on treatments in the 80s and late 90s. I suspect that radiation techniques have advanced quite a bit since then, and those results might not be valid for today. Although there is the possibility that surgical techniques have also advanced quite a bit. Regardless, I was surprised by the results of that study. Surprised by the idea that surgery could actually be the preferred primary treatment for G8-10. My intuition would've said that so many of those would've already escaped and become systemic that radiation/HT would be the hands-down winner. But maybe it gets back to that whole debulking concept? I really don't know, all of the above is just food for thought/discussion.

Tudpock18 said...
BillyBob, could you please provide a link to the Tewari study that you quoted. Some of the numbers you show don't seem to make any sense out of context, e.g. age of participants, Gleason scores, type of radiation treatment compared, etc. The devil is always in the details...

Thanks,

Jim

Sure, I'll try. Here's for the abstract:
www.ncbi.nlm.nih.gov/pubmed/17296374

I have a copy of the full report on my computer. But I can't figure out where I got it, where the link is. The only one I can find a link to you have to pay for it. And I know I did pay not for it.

OK, here is a link. When I clicked on it, it does not take me to a web page but just downloads the PDF file directly to my computer. If that doesn't work for you, I can copy some segments from the PDF file that I have.
r.search.yahoo.com/_ylt=A86.JyIDgF9VlBwAggMnnIlQ;_ylu=X3oDMTByYnR1Zmd1BGNvbG8DZ3ExBHBvcwMyBHZ0aWQDBHNlYwNzcg--/RV=2/RE=1432350852/RO=10/RU=http%3a%2F%2Fwebdoc.nyumc.org%2Fnyumc%2Ffiles%2Furology%2Fattachments%2Ftewari_j_urol.pdf/RK=0/RS=IOdbQ8Inmg_R_pKLdtN3YvstXso-

I think this could account for at least some of the surprising results:

Somebody said...
Table 1 shows the study population. Patients treated with RT were older than men treated conservatively or with RP (mean􏰁SDage68.0􏰁5.8vs60.0􏰁5.7and62.9􏰁6.2)and they also had more comorbidities (RT, conservative manage- ment and RP Charlson scores 1.81 􏰁 1.51, 1.44 􏰁 1.26 and 1.23 􏰁 1.21, respectively). Black patients represented 57.6% of the study group and they were less likely to undergo RP than white patients (20.0% vs 31.0%)

Somebody said...
................In diseases such as high grade prostate cancer, for which randomized studies are nonexistent or do not include all treatment groups, it is appropriate to resort to observational studies and attempt to decrease their inherent biases to help patients and clinicians assess and compare treatment risks more accurately. With this aim in mind we used propensity scoring methodology, a valid statistical approach that has been used in several such studies,3– 6 enabling us to compare all 3 treatment modalities. We noted that for a given quintile the overall risk of death in patients undergoing RP was 68% lower than in those with conservative treatment and 54% lower than in those with RT.
Our study strengths are its large database, intent to treat analysis, propensity score modeling, representation of black race, single institution setting, capture of comorbidity and adjustment for baseline confounders. Therefore, the findings are a useful addition to the existing literature.

Post Edited (BillyBob@388) : 5/22/2015 1:36:35 PM (GMT-6)

alephnull said...
Do docs generally not suggest surgery if your PCa is Gleason 8 or greater AND you have lymph involvement and/or mets?

The Gleason score isn't the critical factor so much as the positive nodes(N1) or mets (M1). If you know before treatment that you are N1, there's no point in going through surgery, but some recent studies show there might be an advantage to whole pelvic radiation (WPRT).

ADT and radiation for first-line treatment of node-positive (N1) prostate cancer

For distant mets (M1) the cancer is most likely to be systemic, and hormone therapy is the best management strategy - with docetaxel if there are multiple mets. If there's only one or just a few mets, you can try playing whack-a-mole with it with WPRT +SBRT spot radiation, but odds are low. There may be an advantage to de-bulking (possibly slowing it down) but that hasn't really been proven.

- Allen