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

JohnK11 said:

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).</p>

JohnK11 said:

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).</p>

bdhilton said:

I totally agree that
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

MCinNC said:

30-35% with rising PSAs...
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

JohnK11 said:

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.</p>

Kongo said:

Interesting Perspective
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 said:

Interesting Perspective
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