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CR's take on PC treatment rsults --AS does raise death rate; incontinence is very higth for SUR, etc.

JohnK11
Posts: 23
Joined: Nov 2009

Consumer's report on Health (10/10) take on prostate cancer
treatment --AS (Active Surveillance) vs. SUR (surgery) vs
RAD (external radiation) vs. SEEDS (Radiative seeds implant)

(Hope this has not duplicate a previous post)

Synopsis :
(1) for low-risk and intermediate risk --10 year death rate
is higher for AS by about 2% (vs. SUR) to 1% (vs. RAD)
(2) 1/2-2/3 of AS does not need further treatement within 5 years.
(3) 2-year urinary leakage (> 1 leak per day) is 14%/7%/10% for
SUR/RAD/SEEDS
(4) 2-year BM problems (frequent, urgent, bloody, or painful)
is 1%/11%/8% for SUR/RAD/SEEDS
(5) see the newsletter for recommendations

The October 2010 issue of "Consumer's report on Health"
newsletter contains an interesting (and to me surprisingly
detrimental) take on the effect of Prostate cancer treatment
and on AS. While I often view some of Consumer's report's
result as perhaps somewhat unreliable, it is at least honest.

The 10-year death rate is based on an observations study
published in 2010 of 6849 Swedish men diagnosed with localized
prostate cancer (treatment in the 1990's, so, the results might
not reflect what one might get today).
For low-risk (Gleason 6, low %, PSA <10) and intermediate
risk (localized) cases, the 10 year death rate is
AS 3%/5%, SUR <1%/3%, RAD 2%/4%, SEEDS probably similar to RAD.
Thus, while AS saves you from side effects (see below),
it does raise the anxiety level, and DOES COST higher death rate--
2% extra compared to SUR, and 1% compared to RAD.
Note that for people who choose AS, 1/2-2/3 does not need further
treatment within 5 years (this means perhaps 40% does need further
treatment within 5 years, and for those people, their 10-year death
rate is higher than if they have chosen SUR/RAD at the beginning
--perhaps up to 5% vs. SUR). I don't know the statistical uncertainty
in this, and whether other studies back these results up.

The 2-year long term adverse effect is based on a 2008 study on
survey on 1201 men. The rates for SUR/RAD/SEEDS for 3 major effect are
poor sexual function --53%/58%/46%
urinary leakage (>1 per day) 14%/7%/10%
BM problems 1%/11%/8% (frequent, urgent, bloody, or painful)
They also note that Robotic have similar results as Open, but the
Robotic clients are 3-4 times less satisfied (they expected better
results based on marketing hype--note that Robotic does have
faster recovery, and less liklihood of need for blood transfusion.
However, for those case with cancer that has spread, Open is probably
more effective in removing nearby cancer (like my case--I regretted
not having chosen Open, since my PSA DID NOT drop after robotic surgery)
I wish for a larger sample for this study, though.

Beau2
Posts: 228
Joined: Sep 2010

Thank you for the post.

Most of it makes sense; however, I was not aware of the very high rate of side effects for RAD and SEEDS. The BM side effects of RAD/SEEDS seems quite high compared to SUR.

bdhilton
Posts: 752
Joined: Jan 2010

Yes I would agree that Open is probably more effective in removing nearby cancer and this is why I selected this procedure over robotics. I also agree that statically open has less long term side effects than radiation….I also agree that robotics is “marketed” for a “better results” than open and has a very high rate of failure (I have read studies citing reoccurrence as high as 70% with robotics)…However, at the end of the day statistics are just statistics and you need to select your process based on your own research and “gut”…Best to all fighting this beast…

JohnK11
Posts: 23
Joined: Nov 2009

Re : 3% death rate (AS) is statistically different from
<1% death rate (SUR) ?? (6 sigma ??)

While I would not know for sure, one can estimate the number
if one assume that the 6849 cases are roughly divided into
4 equal parts --i.e., 1700 per part (it is not likely to be
more than a factor of 2 off, I would guess).
In that case, 3% would be 51, and <1% would be around 10.
That is at least a 6 sigma effect, so it is significant.
Again, I wish there were other studies that confirm these
findings.

I also agree that European studies are likely to be easier to
do (in addition to national health services and record-keeping,
people there are more agreeable to being monitored,
and less "privacy" concerned).

buzzz
Posts: 26
Joined: Aug 2010

I was so disappointed in Consumer Reports for not even mentioning that HIFU exists that I cancelled my subscription. I thought they were the open news source, and the least they could do is mention it. It makes me wonder what else is out there that we don’t get to find out about.

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Kongo
Posts: 1167
Joined: Mar 2010

I don't think they used six sigma to determine these statistics, I suspect the used some form of simple regression analysis and since all the variables they discuss are somewhat defined, I would guess its more a least squares type of form fit but it is unclear here as to whether or not the small differences are within one, two, or perhaps even three standard deviations. Sig Sigma is more about looking at data to find find the source of defects in manufacturing processes, where 6 standard deviations (sigmas) equate to about 99.9999...and so on of the possibilities.

What we really want to know from these types of studies is how the percentages translate to extended life. If, for example, the studies showed that "on average" surgery or radiation extended your life say 4.3 months over a 10 year period than AS then I think a lot of men would look at their treatment options and risk of side effects in a whole other perspective. What we tend to bet on with the way these statistics are shown is whether we're going to end up in the 3% or the 1% group. Good luck with that!

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Kongo
Posts: 1167
Joined: Mar 2010

John, thanks for posting the study and I appreciate the emphasis you noted that the Swedish study apparently looked at a lot of men treated in Sweden in the 1990s and its relevance today to men living in the United States is uncertain.

The study also confused me when it referred to the number of leaks per day versus the more standard urinary toxicitiy grades we usually see in studies. I'm not sure what "leaks per day" means, is it a drop, a dribble, a quart, complete incontinence, what? Maybe the complete study defines what that is. Same confusion with the way they described BM difficulties as "bloody, frequent, urgent, painful." I just don't know what that means with respect to how bloody, how frequent, how urgent, or how painful, and for how long and so forth. Most studies cite rectal toxcicity by grade and you can look up the definition and have a pretty good idea just what they're talking about.

The overarching statistic that I noticed was that for men with low grade cancer (the condition most men are diagnosed with today) the long term survival between AS, radiation, and surgery are essentially the same although both surgery and radiation add some small acutarial increase in longevity...probably a few to several months over a ten year period.

Even with different and improved methods of surgery and radiation that we have today in 2010, those long term statistics haven't changed much.

The more recent survey John cited comparing open versus robotic surgery and side effects between surgery, radiation, and seeds seems to have the same confusing jangle of terminology so maybe it's just the way Consumer Reports identifies thses effects and they are defined elsewhere. I think there is danger in lumping the several types of radiation available today into "radiation." That may have been appropriate in 1990 but 20 year later there's a big difference. At least with the type of radiation I chose (SBRT with CyberKnife), the available data for urinary, rectal, and sexual side effects are nowhere near as high as the study cited under "radiation."

The study also does not indicate the median age of the men with respect to the sexual function scores and doesn't seem to indicate what their baseline before treatment was. A study I posted lost week about AS indicated that 49% of men had some level of sexual dysfunction BEFORE TREATMENT with a median age of 64.

As far as open versus robotic surgery, there are no studies that I am aware of that show that either one has an advantage over the other either in terms of long term survival or rates of cancer recurrence. The point bdhilton and John make about open surgery having a greater chance of getting more cancer at the margins than robotic (assuming you're under the care of a highly skilled surgeon) makes a lot of sense to me but I just don't recall reading any studies where open surgeries have fewer BCE than robotic...but given the relatively short time since robotic surgery has been used (Da Vinci was aprroved in 2006) it is not surprising that that data isn't there.

bdhilton
Posts: 752
Joined: Jan 2010

I totally agree that “prostate surgery is skill dependent” as with any other procedure… the goal of any treatment is to cure the patient of his cancer and preserve his quality of life…. They all have risk and some are statically better than others but as Trew says “we are all snowflakes”…

"I like to say that it's not the pair of scissors someone's using but the person using the scissors."

With regards to what has better “results” from a surgery stand point,a “JAMA Study Sounds a Cautionary Note…”

‘…A multi-center study in the October 2009 issue of the Journal of the American Medical Association (JAMA) [PubMed Abstract] looked at the outcomes of about 2,000 men who had their prostate cancer treated with minimally invasive surgery between 2003 and 2007 compared with approximately 6,900 men who had open surgery. All the men in the study were 65 or older. The minimally invasive surgery group had shorter hospital stays (a two- versus three-day average stay) and fewer surgical complications when compared with men treated with open surgery.

However, 18 months after receiving treatment, the minimally invasive surgery group had a greater risk of incontinence and erectile dysfunction when compared with men treated with open surgery.

In addition, after the study's authors adjusted for patient and tumor characteristics, men in both groups required similar amounts of additional cancer therapy (such as chemotherapy, hormone therapy, or radiation) -- which, the authors note, correlates to cancer control and cure rates. These data suggest that claims of "superiority" of minimally invasive surgery compared to open surgery made by some must be viewed with caution…”

http://www.mskcc.org/mskcc/html/95645.cfm

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Kongo
Posts: 1167
Joined: Mar 2010

I recall reading the JAMA bdhilton quoted study when I was doing my research on treatment options and it led me to conclude that if I were to pursue surgery (I ended up with another choice) that I would probably have avoided the robotic procedure as having higher potential risk of ED and incontinence issues and to me, the shorter hospital stay didn’t seem like that much of an advantage.

But there are other factors which I now think need to be taken into perspective. The study time frame looked at men with minimally invasive surgery between 2003 and 2007. To be fair, the Da Vinci procedure only began to come into widespread use in 2006 after it received FDA approval for the treatment of prostate cancer. We have all read the statistics and listened to the advice of those who have had this procedure that it takes a surgeon about 250 procedure to become completely proficient in mastering the technique and I suspect that the study included many men who had robotic surgery by physicians who were still on the upslope of the learning curve because the procedure was still relatively new. I would imagine that as more surgeons become adept at using Da Vinci that the disparity in ED and incontinence side effects between open and robotic RP would decrease over time.

Interestingly, the study shows no real difference between open and robotic RP in the long term rates of cancer recurrence. Most studies I have read show that 30-35% of men who have RP by any means will experience a rising PSA at some point and, depending on when it occurs and at what level, will require further treatment.

I think that the age of the men in the study is also worth noting. Everyone in the study was older than 65 and although the study doesn’t mention the median age, since most surgeons decline to do surgery on men over 70, you would think that this cohort was comprised of men between 65 and 70. Disregarding the virile posters on this forum, we all know that as men grow older they have increasing incidences of both ED and urinary issues. Without taking into account pre-existing ED and urinary difficulties BEFORE treatment, post treatment statistical comparisons really don’t have much validity in my mind.

MCinNC
Posts: 32
Joined: Sep 2010

You mentioned reading studies showing "30-35% of men who have RP by any means will experience a rising PSA at some point and, depending on when it occurs and at what level, will require further treatment."

What is your understanding of the comparable numbers for radiation type treatments? Are they still comparable to the RP #s?

Thanks.

Mac

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Kongo
Posts: 1167
Joined: Mar 2010

Mac,

That's a great question and I wish there was an easy answer but this is one of those areas where the expression, "it's complicated" really fits.

First there are differences between the urological societies as to what actually constitutes a failure since men retain a prostate after radiation and even irradiated prostates generate some PSA. This confusion about what constitures a failure makes it extremely difficult to compare studies on failure rates because we're not always sure what definition of failure the authors are using. Some studies blatantly choose a more relaxed definition to show that a certain treatment may have higher success rates than otherwise.

Typically, after radiation, PSA declines to some low steady point known as a nadir. The latest ASTRO definition defines failure as nadir +2 or the lowest steady PSA reading plus 2 ng/ml rise that continues to rise.

For EBRT, the most common radiation before 2000 shows about a 20% failure rate but there have been significant improvements in how radiation is applied since then and it may be too early to tell if those statistics improve with IMRT or SBRT. Seeds seem to have a slightly lower failure rate, and HDR brachy comes in at about 15% in the studies I have read. Some of the newest forms of radiation, such as SBRT, report 0% recurrence at up to four years but that is not long term.

Confusion reigns in this area because of the conflicting definitions, whether or not hormone therapy was used in conjunction with treatment (as is common with HDR brachy) and so forth.

Like a failure after an RP, the recurrence of measurable cancer after radiation is most often because of metastatic features of the disease. Few radiation failures show cancer growing again in the prostate but it is certainly possible for that to happen.

Often a failure after radiation can be addressed with AS. It all depends on the PSA velocity, but it’s important to keep in mind that prostate cancer outside the prostate grows much faster than it does inside the prostate.

Also, like RP the more serious the grade and Gleason score, the more frequent the failure.

Men with low risk cancer, such as what you have described in your case, have a much lower rate of recurrence than the overall group of patients that choose radiation treatment regardless of the method the radiation is delivered.

Dosage is another factor that affects failure rates. Generally the higher the dosage the less the failure rates, but higher dosage increases the risk of toxcicity after effects. (CyberKnife alleviates that somewhat because of how its dosage is delivered)

Again, that’s a great question and I don’t really think I’ve given you an adequate explanation. As you explore various forms of radiation with specialists, I would be very aggressive in asking the doctors to explain what radiation failure means for that treatment option, and how you as a relatively young man with low risk cancer fit into the scheme of things.

JohnK11
Posts: 23
Joined: Nov 2009

Re : failure rate

As the previous poster(s) said, a lot depends on the definition.
Nevertheless, let me give you my take (much of it based on what
I read in the various boards, with my uro, etc.) --I am not
a doctor (except outside medicine) so, this is just my opinion.

(A) The key factor is whether your cancer is confined to your
prostate, or it has spread before treatment. Localized cancer,
those that the CR addressed (although there is always a chance
that the biopsy/examination did not detect the spread), can be "cured"
with SUR/RAD/SEEDS/HiFu/etc. to various degrees. Obviously,
a good surgeon who removed all the prostate will "cure" the cancer;
I would guess that there is a stronger likelihood that RAD/SEEDS
would not get all the cancer, but that also depend on the skill
of the doctor.
For most cases, initial treatment (SUR/RAD/SEEDS/etc.) results
in undetectable PSA, and for some, it will remain low for the rest
of their lives. Other will see a resurgence after 1,2, 3, or more years,
and would require additional treatment, such as SRT, hormone, etc. They
could expect many more years of reasonable QOL (aside from those induced
by the first treatment) before failure of hormone, requiring more
drastic further treatments (chemo, etc.)

failure for SUR, it is obvious to me that there was hidden metastatis
(note, the surgeon could also not be good enough, or there was
effort to "spare the nerves for ED prevention purposes" and thus
some prostate, perhaps cancerous, remained).

Note that 10-year death rate due to localized prostate cancer is low--
If we can believe CR, it's 1-3% for SUR, and 3-5% for RAD.

(B) If the cancer have spread before initial treatment, then all bets are off.
Unfortunately, in some cases, you might not know that until the first PSA test after
treatment (as is my case--all looks okay--even though my right seminal vesicles
were invaded, perhaps portending dire consequences--until my first PSA 6 weeks
after surgery, when PSA showed up at 7, same as just before surgery. with doubling
rate of 2+ months based on retest after a few weeks--fortunately,
hormone seems to keep it at bay so far--my PSA has been <.1 for the last 8 months,
and hopefully for many years--I still live an active life, work every
weekday, and play singles tennis, though not as rigorously as before)

If the spread is ONLY nearby (e.g., seminal vesicles), surgery might be able to
remove it (I would guess more effectively than RAD or SEEDS, maybe people
more knowledgeable than me can comment). The skill of the surgeon then becomes
critical; I would also believe strongly that open surgery would be more
effective in removing nearby cancer than Robotics (unfortunately, I chose
Robotics)--so, people with high Gleason --anything at or above 4+3=7 (my case)
should probably chose Open, and take the hit on longer recovery (though
long term side effects are comparable, I believe). Experienced surgeon is a must.

If the PSA went to 0, and the rise after a while (months or years), SRT
is usually taken, with the assumption that nearby cancer might be removed
by that, but that is much less certain than initial treatment--so success
rate would be lower. Beyond that, hormone and stronger efforts are available.
So, the chance of a rapid deterioration in months are unlikely, unless
the PSA doubling time is very short (my opinion).

If the spread is far away (bone, far away lymph nodes, etc.) no initial treatment
will impact that. Furthermore, any diagnostics when your PSA is low (below
20-40) will unlikely find far-away cancer, since it is likely to be too small
(I think I wasted the effort in bone scan, CT scan, and MRI/prostascint scan,
since at that time, my PSA was only 7). SRT would not be indicated--though
it would be impossible at that time to know of far away metastasis.
If, eventually, a cluster of cancer is found (bone, etc.), further treatment
can be done, but with the knowledge that it is unlikely that the found
cluster is the ONLY metastasis (though, it is the majority of the metastasis,
it would slow down the progress of the cancer).

In my case, since PSA remain at 7 6 weeks after prostate removal surgery,
it it obvious that much of the spread is far away--the surgeon would have
noticed nearby cancer--so, I am not thinking of SRT at all. So, hormone for
now, and more drastic (with much worse side effect) if needed later.

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Kongo
Posts: 1167
Joined: Mar 2010

John,

I appreciate your perspective but at the heart of your "cure" argument I seem to see some French deconstructionists lurking. What you seem to be suggesting is that if the cancer is fully contained in the prostate and an expert surgeon successfully removes it then tada, you're cured. It's kind of like saying if they get all the cancer they get all the cancer.

While I for one certainly would like to believe that prostate cancer can be "contained" in the prostate, I fear that just isn't the case at the microscopic level. Given that the histology of the most common forms of prostate cancer is 52 years, when it reaches a level where we suspect its presence through PSA testing and actually see it in a biopsy, it has been growing in our prostates for several years. As the cancer clusters in the prostate gland begin to grow they inevitably slough off cells that work their way into the bloodstream. Most of these get sucked up by the lymph nodes and the body's own immune system does a pretty good job in dealing with them but sooner or later, given the millions of these cells moving around, some of them are going to find a home they like either in the lymph nodes themselves, seminal vesicles, bladder, liver, lungs, or bone. Prostate cancer is, by definition, a malignant tumor which means it spreads.

We have all heard from men in this forum who were diagnosed with a low risk prostate cancer, a Gleason 6, a PSA less than 10, and after a RP with negative margins see a PSA rise indicating that the surgeon either cut across a margin that was actually positive and didn't realize it, or that the cancer is growing somewhere else even though it cannot be detected by any of the scans we have today. Or, an even scarier scenario in my opinion, is that the very act of surgery itself releases cancer cells into the bloodstream as the surgeon begins cutting away the prostate from its surrounding nerves, bladder, and penile bulb. Since prostate cancer seems to like to exist in the peripheral zones and near the nerves, this is a likely scenario in my mind.

About 30-35% of men who have their prostate removed will see a recurrence evidenced by a rising PSA. Perhaps those who don't really did have it all contained within the capsule and nothing leaked out during surgery or, a more plausible explanation in my mind, is that the cancer that is migrating is also slow growing and hasn't yet reached the critical mass necessary to be detected but that if we live long enough, it would be.

Your perspective closely parallels that put forward by Dr. Walsh in his book where he basicaly tries to make a case that for low risk cancers, surgery remains the "gold standard" for a cure because it's "contained" and removal of the prostate makes it all go away. AS is considered an OK choice for low risk cancer if you're willing to roll the dice. Dr. Walsh does not like radiation for low risk prostate cancer. In my opinion, Dr. Walsh's book makes a poor case for surgery because it fails to adequately explain the relatively high percentage of recurring cancer. Otherwise, if you know for sure the cancer is out of the prostate, why are you bothering to remove it at all?

Good discussion here and there's plenty of room for different positions amongst us amateurs since there is a raging debate about the same thing by learned experts.

I hope that in your own case, the HT treatment works.

BRONX52
Posts: 156
Joined: Apr 2010

Since being diagnosed and treated for PC I have read/researched as much as I could regarding radiation, surgery, hormone and chemotherapy treatments, as well as other non conventional treatments. I've spoken with several different physicians of various specialties and also to friends and relatives who have had to deal with this disease. What I find amazing about this whole thing is that treatment results are all over the map. Some people with very favorable stats such as gleason 6, low psa, extended doubling times etc; are not having the desired results regardless of the treatment, while others do just fine. Then again, people with gleason 7 and higher are doing better than predicted while others fare poorly. This can certainly be overwhelming for those pondering which treatment might be best for them. It also has people second guessing the treatment that they've already had. What works for one may not work for another even when their pre-treatment stats are the same. So what do we do? Well, I for one, have chosen not to look back, but instead choose to look ahead. There is no reason to pile on additional stress (we have enough of that already) by constantly asking ourselves "what if", and more stress can cause additional medical problems! Once you've done all of the research,consults etc; you and only you get to decide which form of treatment is best. Here on this forum, we're all basically in the same battle with the same enemy. We may use different tactics to win the war but we are fighting the same war. Sorry for rambling on but I recently noticed some posts seem like they are turf wars ie: "my treatment is better than yours". Let's just support all of our brothers on this forum regardless of what treatment they've received and don't be drawn into these tit-for-tat threads. Thanks for listening---Dan

MCinNC
Posts: 32
Joined: Sep 2010

With all its faults and aggravations, this forum is still a super tool for someone going through this wrenching decision making process.

I agree with Bronx that everything about the data and advice you get can be mixed up. The treatments vary widely. The data is all jumbled up and often compares apples to oranges. And who would have thought that we, as lay people, are left to make this life changing decision about treatment with very little real help from the experts, who are consumed by their particular part of the field. Where are the medical experts who can rightfully claim a working knowledge of all treatment options and give an educated opinion about what makes sense for the particular patient? Few and far between.

While we won't agree with all that is said on this board, I for one appreciate the posters putting it out there. It gives me a much better perspective upon which to make my own decisions.

And absolutely, while we may disagree on some things, it is obvious that we are all in this together.

bdhilton
Posts: 752
Joined: Jan 2010

Kongo,

Your comment that “….Dr. Walsh's book makes a poor case for surgery because it fails to adequately explain the relatively high percentage of recurring cancer…” Is interesting to say the least….

The purpose of the site is to support each other not promote a particular treatment selection as the “best” ….and worse “scare tactics” as represented in several recent postings within this tread…

I truly hope for the best for you and you should do the same without this mantra of CyberKnife and how bad “surgery” is…. If you are so insecure of your choice (and that is how I read your threads and I am educated to make such a comment) then seek professional help…

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

Nice post, bd. As usual your incisive commentary and keen insight adds greatly to the discussion and gives us all much to ponder.

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