Surgery Vs Radiation in High Risk Men

That link isn't working, Pratoman. Could you post the name of the study? I do remember seeing it.

Here is a 2021 review on this topic:

Characterizing Surgical and Radiotherapy Outcomes in Non-metastatic High-Risk Prostate Cancer: A Systematic Review and Meta-Analysis (2021, Full Text)

Abstract
Background
Identifying the optimal management of high-risk non-metastatic prostate cancer (PCa) is an important public health concern, given the large burden of this disease. We performed a meta-analysis of studies comparing PCa-specific mortality (CSM) among men diagnosed with high-risk non-metastatic PCa who were treated with primary radiotherapy (RT) and radical prostatectomy (RP).

Methods
Medline and Embase were searched for articles between January 1, 2005, and February 11, 2020. After title and abstract screening, two authors independently reviewed full-text articles for inclusion. Data were abstracted, and a modified version of the Newcastle-Ottawa Scale, involving a comprehensive list of confounding variables, was used to assess the risk of bias.

Results
Fifteen studies involving 131,392 patients were included. No difference in adjusted CSM in RT relative to RP was shown (hazard ratio, 1.02 [95% confidence interval: 0.84, 1.25]). Increased CSM was found in a subgroup analysis comparing external beam radiation therapy (EBRT) with RP (1.35 [1.10, 1.68]), whereas EBRT combined with brachytherapy (BT) versus RP showed lower CSM (0.68 [0.48, 0.95]).All studies demonstrated a high risk of bias as none fully adjusted for all confounding variables.

Conclusion
We found no difference in CSM between men diagnosed with non-metastatic high-risk PCa and treated with RP or RT; however, this is likely explained by increased CSM in men treated with EBRT and decreased CSM in men treated with EBRT + BT studies relative to RP. High risk of bias in all studies identifies the need for better data collection and confounding control in the PCa research.

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It is noteworthy that the first prospective, randomized study comparing RP vs RT has begun. This kind of gold-standard comparison has not been done and retrospective studies have come down on both sides of the issue, whether for all-risk or high-risk men. However, it will be some time before we have results, assuming this Scandinavian study can meet its enrollment goal.

Characteristics of Patients in SPCG-15—A Randomized Trial Comparing Radical Prostatectomy with Primary Radiotherapy plus Androgen Deprivation Therapy in Men with Locally Advanced Prostate Cancer

"Abstract
Background
There is no high-grade evidence for surgery as primary treatment for locally advanced prostate cancer. The SPCG-15 study is the first randomized trial comparing surgical treatment with radiotherapy.

Objective
To describe the baseline characteristics of the first 600 randomized men in the SPCG-15 study. The study will compare mortality and functional outcomes.

Design, setting, and participants
This study is a Scandinavian prospective, open, multicenter phase III randomized clinical trial aiming to randomize 1200 men.

Intervention
Radical prostatectomy with or without consecutive radiotherapy (experimental) and radiotherapy with neoadjuvant androgen deprivation therapy (standard of care).

Outcome measurements and statistical analysis
Cause-specific survival, metastasis-free survival, overall survival, and patient-reported bowel function, sexual health, and lower urinary tract symptoms were measured.

Results and limitations
The distribution of characteristics was similar in the two study arms. The median age was 67 yr (range 45–75 yr). Among the operated men, 36% had pT3a stage of disease and 39% had pT3b stage. International Society of Urological Pathology grades 2, 3, 4, and 5 were prevalent in 21%, 35%, 7%, and 27%, respectively. Half of the men (51%) in the surgery arm had no positive lymph nodes. The main limitation is the pragmatic design comparing the best available practice at each study site leading to heterogeneity of treatment regimens within the study arms.

Conclusions
We have proved that randomization between surgery and radiotherapy for locally advanced prostate cancer is feasible. The characteristics of the study population demonstrate a high prevalence of advanced disease, well-balanced comparison groups, and a demography mirroring the Scandinavian population of men with prostate cancer at large.

Patient summary
This study, which has recruited >600 men, compares radiotherapy with surgery for prostate cancer, and an analysis at the time of randomization indicates that the study will be informative and generalizable to most men with locally advanced but not metastasized prostate cancer."

Post Edited (DjinTonic) : 6/14/2022 8:29:07 AM (GMT-6)

RobLee said...
Five year survival, even ten year, is essentially meaningless in the case of prostate cancer, because stage IV is such a slow death (sorry). I hate when stats show 99 or 100% survival from PCa, makes it sound like a big nothingburger. Gives the wrong idea to people. It's no wonder everyone calls it "the good cancer".

One of the problem with newer RT modalities is that the outcomes are both (1) relatively short and (2) for that reason use a poor outcome metric: BCR rates. For example, the "longer" SBRT studies are usually 15 years, which is not a long time, especially if you are a 50-year old wondering what may happen after 15 years. Even radiation oncologists lament that they are initially limited to the metric of biochemical recurrence, when the outcome we are interested in is prostate-cancer-free survival. That takes decades of time, so a better stand-in is metastasis-free survival. I hope we begin to see this metric used in studies of newer radiation modalities in place of BCR rates.

On the one hand, when truly long-term comparisons of RP vs RT come out in favor of RP, proponents of RT are very quick to point out that the new RT modalities are much improved (e.g. beam focus) and shouldn't be compared to older RT technologies. OK, but the cost of looking at new technologies only is relatively short-term RT studies (with lower numbers) that look at BCR rates. On a portion of men encountering BCR go on to clinical recurrence, and there is no way of knowing whether those demonstrating BCR after, say, 10 years, will demonstrate the same proportion of men going on to clinical recurrence.

SBRT studies are approaching 20 years in coverage, but the ideal radiation doses and schedules are still being worked out for different risk categories.

Djin

Post Edited (DjinTonic) : 6/14/2022 8:47:16 AM (GMT-6)

Mumbo said...
double https:// will get you every time. The url link could be improperly done since nothing happens when I click it also.

Good catch Mumbo. The link works for me, taking me to the abstract.

BTW, just to rattle the chains of primary RT fans, I will quote the "take home message" from the article: While prospective studies are needed, these data suggest that men with HR/VHR prostate cancer may have reduced prostate cancer–specific mortality with radical prostatectomy.

RobLee said...


BTW, just to rattle the chains of primary RT fans, I will quote the "take home message" from the article: While prospective studies are needed, these data suggest that men with HR/VHR prostate cancer may have reduced prostate cancer–specific mortality with radical prostatectomy.

We know for certain that a cancer cell surgically removed from the body will never again be a problem. Do we know for certain that a cancer cell exposed to radiation will never again be a problem?

the cancer cells you have to worry about are the ones that are missed

DjinTonic said...
That link isn't working, Pratoman. Could you post the name of the study? I do remember seeing it.

Sorry Djin, Mumbo, I fixed the link.

I almost always check a link after I post because I know about the double https. Of course this time I did not 🙄

RobLee said...

BTW, just to rattle the chains of primary RT fans, I will quote the "take home message" from the article: While prospective studies are needed, these data suggest that men with HR/VHR prostate cancer may have reduced prostate cancer–specific mortality with radical prostatectomy.

HAHA. That's a little troll-like but still funny. One month a study shows the "triple play" is best for advanced cases, another month a study shows it's surgery. Here's my take after well over a decade on this site and reading literally hundreds of "studies". That is that for almost every PCa patient either surgery or some sort of radiation is likely to be effective -- even curative. So a patient's choice is not likely to be "wrong" as long as he gets treatment. His choice depends on many factors including his personality, his penchant for needing definitive pathology, his tolerance for side effects, etc.

My clear bias remains toward radiation for all of the reasons outlined in Dr. Scholz' videos, especially quality of life. But I understand that others make different choices. I just want to continue to lobby for men to make informed choices.

Jim

Mt cancer is only in my lymph nodes.
They extend from my lower abdomen to the right side of my neck.
So many metastatic nodes that they refuse to do radiation.

mel -- ok let's say radiation and surgery are equal.

now let's talk SEs

This thread has gone off-track. Let's keep the focus on HIGH-RISK prostate cancer.

Sr Sailor said...
This thread has gone off-track. Let's keep the focus on HIGH-RISK prostate cancer.

What sailor said. Please.

A part of me was hesitant to post the study. But I thought it might help someone.
Let’s keep it on track and away from getting personal in any way shape or form.

My husband was in the SWOG S1802 trial. He was in the SBRT arm. He quality of life is still very good. Very thankful.