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What am I missing about this study.... re mets after BCR...

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Posted 1/31/2018 1:54 AM (GMT 0)
urologytimes.modernmedicine.com/urology-times/news/few-prostate-ca-patients-bcr-develop-metastasis?page=0,0

"Hamburg, Germany—Fewer than 20% of patients with biochemical recurrence after radical prostatectomy (RP) develop metastasis, and a smaller proportion die as a result of prostate cancer."
Posted 1/31/2018 6:08 AM (GMT 0)

Pratoman said...
urologytimes.modernmedicine.com/urology-times/news/few-prostate-ca-patients-bcr-develop-metastasis?page=0,0

"Hamburg, Germany—Fewer than 20% of patients with biochemical recurrence after radical prostatectomy (RP) develop metastasis, and a smaller proportion die as a result of prostate cancer."

I guess you are not missing anything. BCR is not the end, at least not usually.
"Recent studies show similar survival rates for patients with and without biochemical recurrence at 10 years................. Included were patients with biochemical recurrence defined as a serum PSA level ≥0.2 ng/mL on two consecutive measurements. Patients who received neoadjuvant or adjuvant treatment were excluded. Univariate and multivariate regression analyses were performed to identify predictors of oncologic outcomes.

In the database, 1,189 had biochemical recurrence within a median follow-up of 132.6 months. The median time to biochemical recurrence was 37.9 months. about 60% of these patients had extraprostatic disease, about 80% had a Gleason score ≥6, 5% had a Gleason score ≥8, and 35% had positive surgical margins.

Of the 1,189 patients with biochemical recurrence, 15.9% developed metastatic disease and 11.1% died from prostate cancer......................Univariate analysis showed the worst metastasis-free survival and cancer-specific survival in the group that experienced biochemical recurrence within 12 months after surgery.".

Pretty good news for most of us, even for some of us high risk guys. What is it you think you are missing?(more info on your thinking, please!)
Posted 1/31/2018 7:42 AM (GMT 0)
Those numbers are better than what Johns Hopkins' reported. There, 34% of recurrent patients developed metastatic disease within the study period. The 5-year metastasis-free survival among recurrent patients was 63%. The median time from recurrence to detected metastases was 8 years. 43% of the men with metastases died of PC within the study period. They died a median of 5 years after mets were discovered.Of course, that was 1999 - survival times would be appreciably longer now.

/jamanetwork.com/journals/jama/fullarticle/189741

I think one big difference between the two studies was that in the JH study "Men with a PSA elevation following surgery who received postoperative radiation to the prostatic bed and demonstrated a biochemical response for longer than 24 months were considered to have local recurrences only and cured by the combination of surgery and radiation, and thus were not included in this analysis." whereas in the Hamburg study, only those who had received adjuvant treatment were excluded (which was also true in the JH study). Including the men who'd had salvage radiation makes an enormous difference.

MSK has a nomogram that calculates the percent who will survive prostate cancer for 5, 10 & 15 years after BCR. I'm sure the number for you would be at least 98%. This includes patients who had salvage radiation (42% did) and ADT (48% did).

/www.mskcc.org/nomograms/prostate/biochemical_recurrence

So the message I hope you're receiving is that BCR after prostatectomy is not a death sentence, and salvage radiation can be curative for most recurrent men. Also, PC is a very slow disease in early stages. It takes awhile for those micrometastases to prepare the soil so they can thrive.
Posted 1/31/2018 12:14 PM (GMT 0)
Acknowledge: "Prostate cancer is one of the most common, and least lethal, of all cancers."
Posted 1/31/2018 12:17 PM (GMT 0)
Ok, guys help me understand what I think I’m not understanding with the results I get from the MSK prediction tool in Tall’s link. I meet with my RO today to put into motion my salvage therapy plan so I know the results of the tool won’t apply to me but I ran my numbers through the tool as if I wasn’t going to get salvage treatment and based on my numbers I read the results as saying I have a 95% chance of dying from prostate cancer in five years. I know I have to be reading this wrong, right?

Most of my info is in my sig but here’s what I inputted into the tool.

No to all 4 disqualifying conditions
Pre-treatment PSA = 15.1
Extra capsular extension = yes
Lypth node = no
Seminal invasion = no
Primary Gleason = 4
Secondary Gleason = 3
Margins = yes (apical)
Age at biochemical recurrence = 55
Time to bio chemical recurrence = 70 months (Jan 15th 2018)
PSA at bio chemical recurrence = .2
PSA doubling time = 14.1

Thanks in advance guys!

Mike
Posted 1/31/2018 1:24 PM (GMT 0)

Crazyick said...
Ok, guys help me understand what I think I’m not understanding with the results I get from the MSK prediction tool in Tall’s link. I meet with my RO today to put into motion my salvage therapy plan so I know the results of the tool won’t apply to me but I ran my numbers through the tool as if I wasn’t going to get salvage treatment and based on my numbers I read the results as saying I have a 95% chance of dying from prostate cancer in five years. I know I have to be reading this wrong, right?

Most of my info is in my sig but here’s what I inputted into the tool.

No to all 4 disqualifying conditions
Pre-treatment PSA = 15.1
Extra capsular extension = yes
Lypth node = no
Seminal invasion = no
Primary Gleason = 4
Secondary Gleason = 3
Margins = yes (apical)
Age at biochemical recurrence = 55
Time to bio chemical recurrence = 70 months (Jan 15th 2018)
PSA at bio chemical recurrence = .2
PSA doubling time = 14.1

Thanks in advance guys!

Mike

I actually hadn't seen this particular calculator from MSK before...and there's clearly something odd goin g on. There's either an issue with their model - or there's an issue with the data being fed into it. I just had my prostate removed in December. Just for kicks - I plugged in my #'s of 3+4, PSA of 2.7, no to EVERYTHING which I am --- my results come back at 98-99% chance of death in 5 years for literally every tweak of the data. I can even change it to a Gleason 6...and 93% are dead at five and 99% @ 10...clearly very, very incorrect.
Posted 1/31/2018 1:42 PM (GMT 0)
Thanks for the responses.
I should hve cut off my quote at "develop metastasis" . Death is not something I'm thinking about. What amazed me is the statement that only 20% of men with BCR will go on to develop mets. Without further treatment. And even in the JH study referred to by TA, it's only 34%.
But I'm focusing on the odds without Salvage.

So that means men with BCR who choose to forego further treatment, have an 80% chance of no kets, thus keeping PC in the rear view mirror.

I'm sure I'm missing something, because with those odds, not only is overtreatment a problem, it's massive, in the recurrence setting. And many more men would choose to play the odds and forego treatment.

So I ask again, what am I missing
Posted 1/31/2018 1:55 PM (GMT 0)

Erichardson234 said...

Crazyick said...
Ok, guys help me understand what I think I’m not understanding with the results I get from the MSK prediction tool in Tall’s link. I meet with my RO today to put into motion my salvage therapy plan so I know the results of the tool won’t apply to me but I ran my numbers through the tool as if I wasn’t going to get salvage treatment and based on my numbers I read the results as saying I have a 95% chance of dying from prostate cancer in five years. I know I have to be reading this wrong, right?

Most of my info is in my sig but here’s what I inputted into the tool.

No to all 4 disqualifying conditions
Pre-treatment PSA = 15.1
Extra capsular extension = yes
Lypth node = no
Seminal invasion = no
Primary Gleason = 4
Secondary Gleason = 3
Margins = yes (apical)
Age at biochemical recurrence = 55
Time to bio chemical recurrence = 70 months (Jan 15th 2018)
PSA at bio chemical recurrence = .2
PSA doubling time = 14.1

Thanks in advance guys!

Mike

I actually hadn't seen this particular calculator from MSK before...and there's clearly something odd goin g on. There's either an issue with their model - or there's an issue with the data being fed into it. I just had my prostate removed in December. Just for kicks - I plugged in my #'s of 3+4, PSA of 2.7, no to EVERYTHING which I am --- my results come back at 98-99% chance of death in 5 years for literally every tweak of the data. I can even change it to a Gleason 6...and 93% are dead at five and 99% @ 10...clearly very, very incorrect.

I was tweaking my numbers too to no real avail. I agree it has to be an error with how the calculator is presenting the results. But I will say it was an eye opener when I plugged in my stats at 4am and saw the results lol
Posted 1/31/2018 1:55 PM (GMT 0)
Thanks for posting that link. I found similar studies, which led me to ask what the definition of metastasis is. I know that it means that it's no longer local to the prostate but does it include spread to the local lymph nodes or does it have to be distant? And I wonder how they determine if it's metastasized or not? I mean, without imaging studies showing bone or lymph involvement?

TA described differences between studies in what they considered local involvement, so there's some noise in that.

Bottom line, though, is good news for those of us still in early stages of BCR.

By the way, I think according that that MSK tool I should have died about 5 years ago smile
Posted 1/31/2018 1:55 PM (GMT 0)
Hey, Mike and Erichardson,

Yeah, I saw this kind of stuff last summer and posted on it (see Bobbiesan post 7/6/2017) in another thread:

/www.healingwell.com/community/default.aspx?f=35&m=2028303&p=2

My guess is that it is a web application flaw wherein the nomogram displays text trying to explain the "percents" it is showing, but gets it wrong (reversed) in the text. That is, the little nomogram table may show "95% at 5 years", and it means you have a "95% chance of being alive". But the text below the little table says you have a 95% of being dead. Clearly wrong. You can prove this by entering a made-up, very optimistic case like 3+3=6, preop psa = 4.0, 48 month doubling, etc., run the nomogram calculator, and see the the nomogram text tell you the guy has no chance at all.

At least I hope it's just their web app, and not their underlying dataset!

Robert
Posted 1/31/2018 2:01 PM (GMT 0)
When I did it, the risk of dying in five years came out 3%. At least for my attempt, the percentage on the last page is the chance of dying from prostate cancer. Maybe somehow yours aregetting reversed?
Posted 1/31/2018 2:22 PM (GMT 0)
"men with BCR who choose to forego further treatment"
I do not see where the nomogram makes that distinction??
Posted 1/31/2018 3:34 PM (GMT 0)
By the way, I posted this previously, but there is hope even for those of us who have failed twice -- surgery and SRT. This paper shows a 83% PC specific survivability 6.1 years after the second BCR. But it depends on how aggressive the cancer is, with time to second BCR (< or > 1 year) most important. Depending on aggressiveness, 6 year PC survivability rates ranged from a low of 65% to a high of 89%

/www.ncbi.nlm.nih.gov/pubmed/28581200
Posted 1/31/2018 3:58 PM (GMT 0)

reachout said...
By the way, I posted this previously, but there is hope even for those of us who have failed twice -- surgery and SRT. ...


reachout, there is a tremendous amount of hope even for those who have failed twice. Don't get me wrong; there are men who die every day from PC, but...

Remember: "There are more people making a living from prostate cancer than there are dying from it."
Posted 1/31/2018 6:48 PM (GMT 0)
Crazyick-
When I put in your numbers, it shows a 46% chance of dying within 5 years.

Erichardson234-
When I put in your numbers (i put in 3 yrs to BCR), it shows a 1% chance of dying within 5 years.

Pratoman-

Pratoman said...
So that means men with BCR who choose to forego further treatment, have an 80% chance of no mets, thus keeping PC in the rear view mirror.

What you are missing is what I tried to explain and obviously failed to communicate, is that only the JH study excluded men who had salvage therapy. The JH study said that after BCR, the chance of no mets was 63% in their 5.3 years of median f/u. That's not surprising because it takes a median of 8 years for mets to become detectable.

Reachout-
When these studies talk about metastases, they are talking about distant mets (M1) discovered via bone scan/CT. They are not talking about local spread (T4) or pelvic lymph nodes (N1). When I put your numbers in the nomogram, it shows a 1% risk of dying within 5 years.

I wonder if it's a browser error for some of you guys. I use Chrome as my browser.

Cigafred-
I wrote that about the JH study - not the nomogram. What I wrote was a direct quote from their study. I'm sure you can find it with the find command. For the nomogram, they included men with salvage therapy, just as in the Hamburg study. Methodology is in the full text of the Stephenson nomogram study that they link.
Posted 1/31/2018 7:46 PM (GMT 0)
Thanks Allen! I’m not sure why there’s a difference in percentage with what we both imputed but I’ll take 46% over 95% any day!! 😊

Mike
Posted 1/31/2018 8:47 PM (GMT 0)
OK, this shouldn't be that hard. I put in Crazyick's numbers and got the same 95% chance of dying in five years that he got. TA gets 46%.

I put in my numbers again and I get 46% at 90% at 20 years, TA gets 1%. My inputs were all No's for disqualifying, 5.6 before surgery, all No's after surgery, Pattern 4 and 3, 67 when BCR was detected, 28 months to BCR, and 0.2 at BCR. For doubling time I put in 89 months, which was the doubling time when I had SRT, and that is how I got the 46% and 90%. If I put in 9 months, which is my most recent doubling time, I get 68%, 98%, and 99% at 5, 10, and 15 years, meaning I should be dead by now.

As a sanity check, I put in a really vanilla case. Gleason 3+3, PSA of 4 at surgery, 48 months to BCR, .2 at SRT, and 48 month doubling. I still get 34%, 79%, and 91%. Seems way too high.

Oh well ..., I'll take TAs result as well. smile

Edit. If you look at the source article they get this nomogram from there is a survivability curve as Figure 1. That curve's 25% PC mortality doesn't hit 25% until about 12 or 13 years, which seems correct. So for some reason the nomogram gets the wrong answer, but only for some people. ???
Posted 1/31/2018 8:49 PM (GMT 0)
reachout - were you using the Chrome browser?
Posted 1/31/2018 9:01 PM (GMT 0)

Tall Allen said...
reachout - were you using the Chrome browser?

Let me check. Yes I am using Version 63.0.3239.132 (Official Build) (64-bit) on Windows 10. Funny, when I checked the version it updated itself to version Version 64.0.3282.119 (Official Build) (64-bit). I did a quick check on the nomogram and this time it gave me lower numbers. So it is probably something to do with the way the browser encodes the data on specific OSs. Maybe rounding errors in an ill conditioned regression equation or something.
Posted 1/31/2018 9:29 PM (GMT 0)
Hmm. Mine is also Chrome version 63.0.3239.132 (Official Build) (64-bit) but on Mac OS 10.11.6. I just tried it on my iphone - it seems to work fine on it. Somehow their html code must be treated differently on the various platforms. Maybe contact them and let them know they are scaring patients.
Posted 1/31/2018 10:11 PM (GMT 0)
Allen/reachout I inputted my stats on both an iPhone and iPad. Im going to try on my win 10 system next and see if the results mirror my IOS platform turn

Mike
Posted 1/31/2018 10:28 PM (GMT 0)

Crazyick said...
Allen/reachout I inputted my stats on both an iPhone and iPad. Im going to try on my win 10 system next and see if the results mirror my IOS platform turn

Mike

Just keep trying until you find one that says you shouldn't be already dead smile
Posted 1/31/2018 11:11 PM (GMT 0)

reachout said...

Crazyick said...
Allen/reachout I inputted my stats on both an iPhone and iPad. Im going to try on my win 10 system next and see if the results mirror my IOS platform turn

Mike

Just keep trying until you find one that says you shouldn't be already dead smile

Lol amen brother!!
Posted 2/1/2018 3:24 AM (GMT 0)
Ok TA, I got it. I saw this in the study...

"To accomplish this goal, they assessed data from 4,754 men who underwent RP between 1992 and 2005 at Martini-Klinik, Hamburg. Included were patients with biochemical recurrence defined as a serum PSA level ≥0.2 ng/mL on two consecutive measurements. Patients who received neoadjuvant or adjuvant treatment were excluded. Univariate and multivariate regression analyses were performed to identify predictors of oncologic outcomes."

And took it to mean no SRT, but apparently it excluded men who had ART, but not SRT
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