I know some of you are in serious trouble with your prostate cancer, and, sadly, this note may not apply to you. But I suspect it will apply to LOTS MORE of you than you would expect. On Sept. 10, 2009, the JOURNAL OF CLINICAL ONCOLOGY published this article:
"Prostate Cancer-Specific Mortality After Radical Prostatectomy for Patients Treated in the Prostate-Specific Antigen Era." JOURNAL OF CLINICAL ONCOLOGY, Vol 27, No 26, Sept 10, 2009, pp. 4300-4305. Authors: Andrew J. Stephenson, Michael W. Kattan, James A. Eastham, Fernando J. Bianco Jr., Ofer Yossepowitch, Andrew J. Vickers, Eric A. Klein, David P. Wood, and Peter T. Scardino.
This explores "the long-term risk of prostate cancer-specific mortality (PCSM) after radical prostatectomy is poorly defined for patients in the era of widespread prostate-specific antigen (PSA) screening." As most of you likely recognize, the authors are well-known researchers in the PCa community, and their "multi-institutional" study comes from the Cleveland Clinic, Memorial Sloan-Kettering Cancer Center in NYC, and the Dept. of Urology at the University of Michigan.
(The first two places there are among the so-called "centers of excellence" in the study & treatment of PCa.)
So, I have faith in the researchers here, and the institutions they work for. Morever, this study was based on a multi-institutional cohort of 12,677 patients treated with RPP between 1987-2005, and the researchers thus tracked these patients for some 18 years or so. (It's good, of course, that the "cohort" was so large, and that more than one institution was involved in the treatment & follow-up research.)
Here are some random quotes from the abstract and the article:
"Fifteen-year PCSM and all-cause mortality were 12% and 38%, respectively. The estimated PCSM ranged from 5% to 38% for patients in the lowest and highest quartiles of predicted risk of PSA-defined recurrence, based on a popular nomogram [I'd guess that was supplied by Kattan!]. Biopsy Gleason grade, PSA, and year of surgery were associated with PCSM." [I.e., for patients in the lowest quarter of predicted risk of "persistence"--maybe a better word than "recurrence"--only 12% of the 12,677 men had died, by the 15th year after surgery. And even 62% of those with the most serious Gleason scores and other threatening PCa clinical features were still alive at 15 years, and apparently the same number of men in the study (38% also) died of other causes than PCa.]
"Only 4% of contemporary patients had a predicted 15-year PCSM of greater than 5%." [They based this on a "nomogram predicting the 15-year risk of PCSM" that they developed while working on this project. As best I can interpret, the quote here indicates that "contemporary patients"--i.e., those receiving surgery most recently, apparently had even greater chances for long-term survival. Later, in the body of the article, the authors reiterate: "Among the patients treated after 1998, only 4% had a 15-year PCSM probability of greater than 5% and less than 1% had a risk of greater than 30%. God, I hate math, but I do love THOSE particular numbers.]
Their "Conclusion": "Few patients will die from prostate cancer within 15 years of radical prostatectomy, despite the presence of adverse clinical features. This favorable prognosis may be related to the effectiveness of radical prostatectomy (with or without secondary therapy) or the low lethality of screen-detected cancers." [Geez, don'tcha just love THAT---and don't we ALL hope these guys are right! I plan to build a SIGN for my study quoting Stephenson et al., and it will say: "Few patients will die from prostate cancer within 15 years of radical prostatectomy, despite the presence of adverse clinical features."And, again, I apologize to any of you who have advanced PCa. I'm not so Happy here that I forget that 30,000+ men a year are dying of this cancer. Maybe some of them lived 15 years.....or at least a long time....between cancer and mortality. And maybe many of those years were good-quality ones. How would we know?]
The authors offer all sorts of tables & figures and numbers [God, I hate math] to support their conclusions, and I encourage you to get hands on this article if you can, to wade through their "evidence." They're pretty good about breaking things down, so that you can find yourself, your own numbers, in the charts, and can get a sense for what these researchers think the future may hold for you.
Here are a few quotes from the body of the article:
"PSA recurrence has a highly variable natural history and POSES LIMITED THREAT TO THE LONGEVITY OF MANY PATIENTS." [I.e., if your PSA bumps up 0.1 in your next lab report, you do not have to have your will finished by 5 p.m. the same day, and the fact that you have a PSA "recurrence" indicating that the PCa is still floating around somewhere in your body is not, according to these fellows, a death sentence. Good to hear.
"Hitherto poorly defined, the risk of death as a result of prostate cancer in a screened population is low, even for patients with adverse clinical features.
. . . The discrepancy between the risk of PSA recurrence and PCSM may be explained by the variable natural history of PSA recurrence; only patients with a short PSA doubling time have a higher risk of PCSM relative to mortality from competing causes." ["Screened population" of course refers to PSA testing before diagnosis.]
This article is not all happiness, for us. The authors declare: "Our study has several limitations worth noting. The nomogram predicts the probability of PCSM within 15 years, but patients seem to be at risk of PCSM for up to 20 years after treatment." [The "good" news there, of course, is that a PCa patient *may* live that long. My beloved wife Jeannie died in 2005 of thymic cancer; she lasted just 14 months after diagnosis, and we knew the prognosis almost from day 1. So, I guess I'm "lucky" to have a cancer that is generally slow-growing. I wish Jeannie had had one of those, too.]
My surgeons at Hopkins tend to dismiss "nomograms," so maybe THIS ONE crafted by Stephenson, Kattan, et al., should be taken lightly as well. But I like the numbers these guys produced, and I shall cherish them and hope their findings will hold up, over time, in other studies.
I just joined HW. To make a long story short, I had a Gleason 9 (4+5) after biopsy, & the slides were confirmed by pathologists at Hopkins. I had RPP at Hopkins in April '08, and the post-op Gleason was downgraded to a 7 (4+3). So far, 20 months out, my PSA stays below 0.1. I had an "implant" implanted three months ago, and so far, it's certainly better than.....nothing, which is what I had going, since the PCa surgery at Hopkins in '08. Prostate cancer is, despite the sanguine (and comforting) statements I have quoted from the JOURNAL OF CLINICAL ONCOLOGY article, a *****, and I sympathize with all of you who are reading by words here. I heard a quote recently, that struck me: "When you're walking through hell, keep walking." (And may we all WALK a long time, yet.)
P.S. Forgive all my misspellings etc. here. In another blog on another website I just joined, I referred to "prostate-specific morality." Well, if you have prostate cancer, it WILL likely affect your "morality" (if not your "mortality"), so maybe that wasn't the worst of errors!