Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests

bdhilton

Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests
ScienceDaily (Sep. 27, 2010) — In one of the first studies to focus exclusively on the outcomes after treatment for patients with high-risk prostate cancer, researchers have found that surgery provides high survival rates. Collaborating researchers at Mayo Clinic and Fox Chase Cancer Center in Philadelphia discovered that patients with the most aggressive forms of prostate cancer who had radical prostatectomy procedures had a 10-year cancer-specific survival rate of 92 percent and an overall survival rate of 77 percent.


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The cancer-specific survival rate for patients who had radiation therapy alone was 88 percent and the overall survival rate was 52 percent. The findings were presented September 27 at the North Central Section of the American Urological Association's 84th Annual Meeting held in Chicago.

"It's long been believed that patients with aggressive prostate cancer are not candidates for surgery," says Stephen Boorjian, M.D., a Mayo Clinic urologist. "We found that surgery does provide excellent long-term cancer control for this type of prostate cancer. In addition, by allowing the targeted use of secondary therapies such as androgen deprivation, surgery offers the opportunity to avoid or at least delay the potentially adverse health consequences of these treatments."

Of the 1,847 patients with aggressive prostate cancer (as defined by the National Comprehensive Cancer Network) included in the study from 1988 to 2004, 1,238 underwent surgery at Mayo Clinic and 609 were treated with radiation therapy at Fox Chase Cancer Center. Of the 609 receiving radiation therapy, 344 also received androgen deprivation therapy.

Researchers analyzed their cancer-specific and overall survival rates. The cancer-specific survival rate was equal for those who had surgery and those treated with radiation plus hormone therapy (92 percent). However, the overall survival rate was significantly better for those who had the surgery (77 percent) than those who had radiation plus hormones (67 percent) or those who had radiation alone (52 percent).

"Patients with radiation and hormone therapy were 50 percent more likely to die than patients who had surgery," says Dr. Boorjian. "This was true even after controlling for patient age, comorbidities and features of the tumors. These results suggest that use of hormone therapy in patients who received radiation therapy may have had adverse health consequences.

"We want to stress that surgery provides excellent long-term control for high-risk prostate cancer patients," says Dr. Boorjian. "Limiting the need for hormones may avoid adverse health consequences. Further studies evaluating the differing impacts of treatments on quality of life and non-cancer mortality are necessary before we can determine the best approach for patients with aggressive prostate cancer."

Funding for the study was provided by the National Cancer Institute. Collaborators include R. Jeffrey Karnes, M.D; Laureano Rangel; Eric Bergstralh, Ph.D.; and Michael Blute, M.D., all of Mayo Clinic; and Rosalia Viterbo, M.D.; Eric Horwitz, M.D.; and Mark Buyyounouski, M.D., all of Fox Chase Cancer Center.

Kongo

Another View
Monday, 27 September 2010
Department of Surgery, Memorial Sloan-Kettering Cancer Center, Sidney Kimmel Center for Prostate and Urologic Cancers, New York, NY 10065, USA.



To summarize the presentations and debate regarding the optimal treatment of localized high-risk prostate cancer as presented at the 2009 Spring Meeting of the Society of Urologic Oncology.

The debate was centered on presentations arguing for radical prostatectomy (RP) or radiotherapy as the optimal treatment for this condition. The meeting presentations are summarized by their respective presenters herein.

Dr. James Eastham presents the varied definitions for "high-risk" prostate cancer as strongly influencing which patients end up in this cohort. Based upon this, between 3% and 38% of patients with high-risk features could be defined as "high-risk". Despite that, these men do not have a uniformly poor prognosis after RP, and attention to surgical principles as outlined improve outcomes. Disease-specific survival at 12 years is excellent and up to one-half of these men may not need adjuvant or salvage therapies, depending on their specific disease characteristics. Adjuvant or salvage radiotherapies improve outcomes and are part of a sequential approach to treating these patients. Dr. Anthony Zietman presented radiotherapy as the gold-standard based upon large, randomized clinical trials of intermediate- and high-risk prostate cancer patients. Compared with androgen deprivation alone, the addition of radiotherapy provided a 12% cancer-specific survival advantage and 10% overall survival advantage. Dose escalation seems to confer further improvements in cancer control without significant escalation of toxicities, with more data forthcoming.

There are no randomized trials comparing RP to radiotherapy for any risk category. In high-risk prostate cancer patients, both approaches have potential benefits and cumulative toxicities that must be matched to disease characteristics and patient expectations in selecting a treatment course.

Written by:
Eastham JA, Evans CP, Zietman A.

Reference: Urol Oncol. 2010 Sep-Oct;28(5):557-67.
doi: 10.1016/j.urolonc.2009.12.012

PubMed Abstract
PMID: 20816616

mrspjd

here's the critical info that was left out
Here's the critical info that was left out of the thread posters article entitled "Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests"
ScienceDaily (Sep. 27, 2010)

1) the reason the % was higher for RP in advanced stage PCa, was that many in that group required (due to postive margins and rising PSA post RP) & went on to have adjuvant & salvage RT, some w/HT, others, without, thereby increasing the %, but not significantly;

2) by needing both RP AND RT, the toxicity of their side effects from all tx modalities were increased;

3) toxicity of side effect compounded by the RP (especially incontinence & ED) AND RT AND hormones, affected quality of life issues for most who needed the adjuvant tx;

4) that is why Dr Boorjian states "Further studies evaluating the differing impacts of treatments on quality of life and non-cancer mortality are necessary BEFORE we can determine the best approach for patients with aggressive prostate cancer."

If you're going to post studies, please include all the so called "facts." BTW, is this some sort of marathon posting binge of any & all "studies" that seems to hint at supporting RP surgery as best tx for any & all stages of PCa...give me a break...the CSN site was down this am from overload...might it be from obsessive lengthy postings from one very determined poster?

mrspjd

mrspjd said:

here's the critical info that was left out
Here's the critical info that was left out of the thread posters article entitled "Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests"
ScienceDaily (Sep. 27, 2010)

1) the reason the % was higher for RP in advanced stage PCa, was that many in that group required (due to postive margins and rising PSA post RP) & went on to have adjuvant & salvage RT, some w/HT, others, without, thereby increasing the %, but not significantly;

2) by needing both RP AND RT, the toxicity of their side effects from all tx modalities were increased;

3) toxicity of side effect compounded by the RP (especially incontinence & ED) AND RT AND hormones, affected quality of life issues for most who needed the adjuvant tx;

4) that is why Dr Boorjian states "Further studies evaluating the differing impacts of treatments on quality of life and non-cancer mortality are necessary BEFORE we can determine the best approach for patients with aggressive prostate cancer."

If you're going to post studies, please include all the so called "facts." BTW, is this some sort of marathon posting binge of any & all "studies" that seems to hint at supporting RP surgery as best tx for any & all stages of PCa...give me a break...the CSN site was down this am from overload...might it be from obsessive lengthy postings from one very determined poster?

more info
This today from urotoday.com

Monday, 27 September 2010
Department of Radiation Medicine, Georgetown University Hospital, Washington, DC, USA.

Clinical data suggest that large radiation fractions are biologically superior to smaller fraction sizes in prostate cancer radiotherapy. The CyberKnife is an appealing delivery system for hypofractionated radiosurgery due to its ability to deliver highly conformal radiation and to track and adjust for prostate motion in real-time. We report our early experience using the CyberKnife to deliver a hypofractionated stereotactic body radiation therapy (SBRT) boost to patients with intermediate- to high-risk prostate cancer. Twenty-four patients were treated with hypofractionated SBRT and supplemental external radiation therapy plus or minus androgen deprivation therapy (ADT). Patients were treated with SBRT to a dose of 19.5 Gy in 3 fractions followed by intensity modulated radiation therapy (IMRT) to a dose of 50.4 Gy in 28 fractions. Quality of life data were collected with American Urological Association (AUA) symptom score and Expanded Prostate Cancer Index Composite (EPIC) questionnaires before and after treatment. PSA responses were monitored; acute urinary and rectal toxicities were assessed using Common Toxicity Criteria (CTC) v3. All 24 patients completed the planned treatment with an average follow-up of 9.3 months. For patients who did not receive ADT, the median pre-treatment PSA was 10.6 ng/ml and decreased in all patients to a median of 1.5 ng/ml by 6 months post-treatment. Acute effects associated with treatment included Grade 2 urinary and gastrointestinal toxicity but no patient experienced acute Grade 3 or greater toxicity. AUA and EPIC scores returned to baseline by six months post-treatment. Hypofractionated SBRT combined with IMRT offers radiobiological benefits of a large fraction boost for dose escalation and is a well tolerated treatment option for men with intermediate- to high-risk prostate cancer. Early results are encouraging with biochemical response and acceptable toxicity. These data provide a basis for the design of a phase II clinical trial.

Written by:
Oermann EK, Slack RS, Hanscom HN, Lei S, Suy S, Park HU, Kim JS, Sherer BA, Collins BT, Satinsky AN, Harter KW, Batipps GP, Constantinople NL, Dejter SW, Maxted WC, Regan JB, Pahira JJ, McGeagh KG, Jha RC, Dawson NA, Dritschilo A, Lynch JH, Collins SP.

Reference: Technol Cancer Res Treat. 2010 Oct;9(5):453-62.

PubMed Abstract
PMID: 20815416

mrspjd

mrspjd said:

here's the critical info that was left out
Here's the critical info that was left out of the thread posters article entitled "Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests"
ScienceDaily (Sep. 27, 2010)

1) the reason the % was higher for RP in advanced stage PCa, was that many in that group required (due to postive margins and rising PSA post RP) & went on to have adjuvant & salvage RT, some w/HT, others, without, thereby increasing the %, but not significantly;

2) by needing both RP AND RT, the toxicity of their side effects from all tx modalities were increased;

3) toxicity of side effect compounded by the RP (especially incontinence & ED) AND RT AND hormones, affected quality of life issues for most who needed the adjuvant tx;

4) that is why Dr Boorjian states "Further studies evaluating the differing impacts of treatments on quality of life and non-cancer mortality are necessary BEFORE we can determine the best approach for patients with aggressive prostate cancer."

If you're going to post studies, please include all the so called "facts." BTW, is this some sort of marathon posting binge of any & all "studies" that seems to hint at supporting RP surgery as best tx for any & all stages of PCa...give me a break...the CSN site was down this am from overload...might it be from obsessive lengthy postings from one very determined poster?

# 5 (continued)
I had read the actual study that is summarized in the science magazine article posted in the first/initial thread quite a while ago. Forgot to mention one other reason for RP APPEARING to have better % in tx of advanced PCa (unclear if defined by volume & capsular containment or ECE & locally advanced--assuming non-mets???):
5) the methods used for RT as PCa tx between 1988-2004 were not as effective in treating PCa as are the IMRT/IGRT (Intensity Modulated/Image Guided) & SBRT modalities used today. External beam (EBRT), used in the original study was, at the time, hit or miss, with high side effect toxicity common. Today EBRT has evolved and is evolving into equipment that is better able to accurately distribute rad dosing to critical areas. In addition to the prostate, prostate bed, seminal vesicles and nodes can be targeted by imaging systems used today to tx most T3 locally advanced PCa. These newer guidance/tracking and dosing systems have made RT, especially when combined with HT, an effective and successful tx for intermediate risk locally advanced PCa, without the add'l potential side effects of RP, and with comparable life expectancy and PCa free survival as RP alone.

Kongo

mrspjd said:

# 5 (continued)
I had read the actual study that is summarized in the science magazine article posted in the first/initial thread quite a while ago. Forgot to mention one other reason for RP APPEARING to have better % in tx of advanced PCa (unclear if defined by volume & capsular containment or ECE & locally advanced--assuming non-mets???):
5) the methods used for RT as PCa tx between 1988-2004 were not as effective in treating PCa as are the IMRT/IGRT (Intensity Modulated/Image Guided) & SBRT modalities used today. External beam (EBRT), used in the original study was, at the time, hit or miss, with high side effect toxicity common. Today EBRT has evolved and is evolving into equipment that is better able to accurately distribute rad dosing to critical areas. In addition to the prostate, prostate bed, seminal vesicles and nodes can be targeted by imaging systems used today to tx most T3 locally advanced PCa. These newer guidance/tracking and dosing systems have made RT, especially when combined with HT, an effective and successful tx for intermediate risk locally advanced PCa, without the add'l potential side effects of RP, and with comparable life expectancy and PCa free survival as RP alone.

Good Points
mrspjd:

Good points. In addition to the advances in radiation treatment after the timeframe of this study, surgery has also seen technological improvements in the form of robotic assist in the removal of the prostate. Given the time frame, the study obviously does not address the difference between robotic and open, but if I were to chose surgery for an advanced prostate cancer diagnosis I think I would go the open route because there is probably a good chance that the surgeon would also need to remove the nerves and perhaps the seminal vesicles as well.

My personal opinion is that a T3 or later diagnosis is strongly indicative that there are tumors outside the prostate, at least in the margins, and perhaps elsewhere as well. In such a situation I don't understand the reasoning behind removing the prostate. Sure, you will get the source but the strong possibility is that the surgeon is going to be cutting across margins and may well end up taking your nerves and who knows how much around the bladder connections...so the risk of adverse side effects goes up. Since prostate cancer grows much faster outside the prostate than within the prostate, it seems to me that the area of concern would be addressing the cancer that has moved out, not what may still be inside the prostate.

Even the surgeons I consulted with were all in agreement that if there was evidence that the cancer had moved outside the prostate, surgery was not a good option.

Early in my research when I was considering surgery I read about a procedure where nerves from the ankle are removed and grafted to replace those damaged or removed during RP. I haven't seen any posts by anyone who had that done. Since the nerve sparing procedures we all hear about involve trying to save nerves that are about the size of a human hair, I can easily understand how easily they could be damaged in the surgical process and perhaps if they were transplanted from another source it would be easier since the "nerve sparing" techniques that Dr. Walsh pioneered is difficult to perform and has varying degrees of success.

bdhilton

mrspjd said:

here's the critical info that was left out
Here's the critical info that was left out of the thread posters article entitled "Surgery Found Effective for Patients With Aggressive Prostate Cancer, Study Suggests"
ScienceDaily (Sep. 27, 2010)

1) the reason the % was higher for RP in advanced stage PCa, was that many in that group required (due to postive margins and rising PSA post RP) & went on to have adjuvant & salvage RT, some w/HT, others, without, thereby increasing the %, but not significantly;

2) by needing both RP AND RT, the toxicity of their side effects from all tx modalities were increased;

3) toxicity of side effect compounded by the RP (especially incontinence & ED) AND RT AND hormones, affected quality of life issues for most who needed the adjuvant tx;

4) that is why Dr Boorjian states "Further studies evaluating the differing impacts of treatments on quality of life and non-cancer mortality are necessary BEFORE we can determine the best approach for patients with aggressive prostate cancer."

If you're going to post studies, please include all the so called "facts." BTW, is this some sort of marathon posting binge of any & all "studies" that seems to hint at supporting RP surgery as best tx for any & all stages of PCa...give me a break...the CSN site was down this am from overload...might it be from obsessive lengthy postings from one very determined poster?

Huh?
I posted the URL what is your point? I am now responsible for overloading the CSN site? :-)

mrspjd

Kongo said:

Good Points
mrspjd:

Good points. In addition to the advances in radiation treatment after the timeframe of this study, surgery has also seen technological improvements in the form of robotic assist in the removal of the prostate. Given the time frame, the study obviously does not address the difference between robotic and open, but if I were to chose surgery for an advanced prostate cancer diagnosis I think I would go the open route because there is probably a good chance that the surgeon would also need to remove the nerves and perhaps the seminal vesicles as well.

My personal opinion is that a T3 or later diagnosis is strongly indicative that there are tumors outside the prostate, at least in the margins, and perhaps elsewhere as well. In such a situation I don't understand the reasoning behind removing the prostate. Sure, you will get the source but the strong possibility is that the surgeon is going to be cutting across margins and may well end up taking your nerves and who knows how much around the bladder connections...so the risk of adverse side effects goes up. Since prostate cancer grows much faster outside the prostate than within the prostate, it seems to me that the area of concern would be addressing the cancer that has moved out, not what may still be inside the prostate.

Even the surgeons I consulted with were all in agreement that if there was evidence that the cancer had moved outside the prostate, surgery was not a good option.

Early in my research when I was considering surgery I read about a procedure where nerves from the ankle are removed and grafted to replace those damaged or removed during RP. I haven't seen any posts by anyone who had that done. Since the nerve sparing procedures we all hear about involve trying to save nerves that are about the size of a human hair, I can easily understand how easily they could be damaged in the surgical process and perhaps if they were transplanted from another source it would be easier since the "nerve sparing" techniques that Dr. Walsh pioneered is difficult to perform and has varying degrees of success.

accurate pre tx staging is critical
While the study in question didn't look at RRP since it was not available at the time, open RP was the standard, and while RRP is evolving, open RP then is pretty much open RP today, given a skilled and experienced surgeon, and with better pre RP imaging today (the same used for both pre RP and RT in many cases).

There was an interesting discussion a few months ago about comparing apples to oranges and like fruit, in regard to PCa staging and tx choices & outcomes. Studies can get confusing when grouping various stages of PCa and txs together to determine outcomes:
http://csn.cancer.org/node/191255
The importance of proper/accurate staging, agreement on definitions of low, intermediate, and high risk PCa T1-T4, ("locally advanced," "localized," "advanced contained," and advanced T4 w/metastasis--pretty confusing even for the drs) is critical and related to potential tx choices and risk assessment. Tx choice with high % of success is dependent on the accuracy of pre tx staging (as best as current testing can determine). A 2nd opinion biopsy slide read at a respected well-known pathology lab specializing in PCa path is critical and is the one thing everyone can obtain right from the start. This can help to determine whether further testing is appropriate (such as bone scan, CT, endo MRI w/Spectroscopy, etc) and lead to considering tx choice options.

Q and A, as well as sharing critical thinking pathways for PCa decisions is essential on this site. There is little room for championing one PCa tx modality over another, as obviously, what works for one, may not be right for another. Be an educated consumer/patient and do your own homework.