What do you think about this study?

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pipedream
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 8/6/2010 10:15 AM (GMT -6)   
After reading some the stories here, I was getting excited about the idea that my husband might avoid having a RP. Then I saw this just now - via my new Google News alert for Prostate Cancer

"Surgery better than radiation, hormone treatments for some prostate cancer, study shows"

news.ucsf.edu/releases/surgery-better-than-radiation-hormone-treatments-for-some-prostate-cancer-s/

Relevant snippet that caught my attention:

Researchers found that the risk for cancer-specific mortality was more than three times higher in patients who received hormone therapy versus radical prostatectomy (surgical removal of the prostate) and more than twice as high in patients who received external-beam radiation therapy versus prostatectomy.

For men at low levels of risk, prostate cancer mortality was very uncommon, and differences among the treatment options were small. The survival differences increased substantially for men at intermediate and high risk, according to the analysis, with the greatest relative benefit for surgery seen for men at higher levels of risk.


Based on what I have read I think my husband is at intermediate risk - though we are still pre-second opinion. His biopsy report didn't give percentages of cancer in the 6 of 10 positive, 5 of which had Gleason 7 score samples (2 were 4+3). So I'm guessing it is hard to evaluate his degree of risk without knowing if the percentage of cancer is 5% or 95% or somewhere in between.

I wondered if anyone here is familiar with this study referenced and has further input regarding the conclusion.

April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 8/6/2010 11:09 AM (GMT -6)   
Somebody said...
Researchers found that the risk for cancer-specific mortality was more than three times higher in patients who received hormone therapy versus radical prostatectomy (surgical removal of the prostate) and more than twice as high in patients who received external-beam radiation therapy versus prostatectomy.


If the study included all stages of PCa in their RP effectiveness treatment, then the conclusion is logical but misleading.

Normally, patients who get hormone treatments have more severe cases of PCa than patients who get the RP, so it is logical their mortality rates are higher. So unless all patients are at the same staging who are in the study, then this study is comparing apples to oranges.

Mild cases of PCa aren't normally even given Hormone Therapy as an option and advanced cases (PCa has moved to other parts of the body), RP is not common.

Dan
Here are some of my stats:
Age:54
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA 7/15/10 Zero Club membership card issued (trial membership with 90 day renewal)

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4225
   Posted 8/6/2010 11:47 AM (GMT -6)   
Usually the problem in these studies is that the studies compare the pathological staging from surgery to the clinical staging for radiation and HT. If surgery shows the PC is not confined or that the gleason grade is upgraded then those patients are removed from the study or risk upgraded. When only clinical data for staging is used the cure rates become very similar for surgery and radiation.
Clinical staging is the staging given before any treatment. Only surgery has pathological staging in which the entire prostate is looked at after it is removed and is much more accurrate, but since it is after the fact it is no use for a patient trying to make a decision on primary treatment.
If the study contains only those surgical patients whose disease is contained vs the total amount of patients given radiation you can expect these differences. This is the only study I have seen that gives surgery such a large difference over radiation.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 8/6/2010 12:37 PM (GMT -6)   
The entire article can be found at http://www3.interscience.wiley.com/journal/28741/home.

This seems to be a large,carefully conducted study. It uses compariable data, that is, the staging of the tumor before any treatment is given. As John T points out, if they didn't, it would be a lousy paper and not worth reading.

The trouble with almost all studies is that they are not randomized; meaning the patient and doctor decide what treatment is given. It may be that the patients who chose surgery and those who chose radiation are somewhat different patient groups with different disease, different ages, etc, and therefore have a different outcome, regardless of how they are treated. The only way to overcome this problem is to have patients agree to be randomized, that is, let the study decide what treatment they would get. This is a tough thing to do--many people don't want to hand this decision over to the study. There are only three studies that have done this, the most important being the Scandinavian study randomizing people between surgery and watchful waiting. There are no randomized studies comparing radiation to surgery. This paper discusses these problems honestly

It seems like a good study, though, the best that could be done without randomization. It's worth reading.

don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 8/6/2010 1:17 PM (GMT -6)   
Mayo published similar findings a few years back. The trouble with the Mayo study was it was biased and not a randomized study and included only Mayo patients. This was freely admitted in the article but they felt that their experience would hold true in general. The key here is that the PCa is "localized" or "locally advanced". In the Mayo study they claimed good results even with lymph node invlovement in the immediate area.

Even so, it does make logical sense that removing the tumor removes the primary engine for production of the PCa. Debulking I think is the term.

Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Two years on Lupron completed 01/2010.
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 were full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones
PSA 06/09 .36 or .30 depending on who did the test
PSA 09/09 .33 one year after IMRT and 16 months into hormone
PSA 03/10 .32 18 months after IMRT Still on hormones
PSA 05/10 .42 Rising a little as the lupron wears off. Last lupron shot 01/10.
PSA 06/10 .322 Maybe the .42 reported in May was in error?
PSA 07/14/2010 0.1

pipedream
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 8/6/2010 3:29 PM (GMT -6)   
When I try to access the full text of the study, all I get is a blank screen. Is there a secret to getting the text to show up?

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 8/6/2010 5:49 PM (GMT -6)   
don, i think that debulking can be a good thing, as the original source of the PC is from the prostate, and if you take it out of the equation with a good primary treatment, it greatly reduces the source. thats' why some men have surgery even though the cow is out of the barn so to speak. i think it can make good sense in a case like that.
Age: 58, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin

Incontinence: 1 Month ED: Non issue at any point post surgery, no problem post SRT
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16

Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 3
Latest: 7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped 9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4, Caths #11 and #12 ,Cath #11 - 21 days, Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 6:07 PM (GMT -6)   
This is a retrospective view from 40 centers. It is only a research article. Peter Carroll is one of the most respected in the business and I can concur these findings with the Stanford/Harvard radiological studies that are showing similar results. In the Stanford study (which is a real study) now at year 9, post RP men who were stage 3+ are showing remarkable results when a multi-modal approach is used. The addition of adjuvant therapies reduced relapses and mortality.

More time is still needed, but the results are similar to Dr. Carroll's findings.

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 8/6/2010 7:16 PM (GMT -6)   
Try this link for the html version of the article:

http://www3.interscience.wiley.com/cgi-bin/fulltext/123630095/HTMLSTART


In a nutshell, how they did this study:

It's prospective, not retrospective. Some years ago, they set up a registry where they collect this information from 40 centers. They then systematically collected information on diagnosis, treatment, and outcome over the years (prospectively= going forward in time, not retrospectively = look back in time at information that was not collected in a systematic way). Then they analyze the information by breaking it into groups by initial diagnosis (stages, gleason scores, etc at time of biopsy, before treatment) and treatment type, and seeing how outcome (for example, death from prostate cancer) differed among the different groups. They found that the surgery group did better.

What does this mean? Well, it could mean that surgery works better! Or, it could mean that the men who chose to have surgery weren't as bad off as the people who choose the other treatments and surgery doesn't work better! You can try to adjust for factors like Gleason score to see how different the treatment groups are, but the only way to prove that the difference in the results isn't because of patient selection is do a randomized trial, where men are randomly assigned to the different treatments, and cannot chose their own treatment. If the study is big enough, then you know the the different groups must be about the same, so any difference in the outcome is because one treatment actually is better. That study hasn't been done. Until it is, everyone is entitled to their own opinion about which is better, surgery or radiation. But if some says that surgery and radiation have been shown to be the same, that's not right, it's just that there isn't a study that conclusively PROVES that one is better than the other, beyond any doubt.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 8:31 PM (GMT -6)   
I guess I should state how I view the terms...

Retrospective ~ to take a look back at events that already have taken place. Such as this registry.

Prospective ~ expected or expecting to be something particular in the future or looking at cases moving forward such as a random study.

But I agree with your points... Some data can be ascertained with registries and clinical papers. But they can be subjected to biased research criteria...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4225
   Posted 8/6/2010 10:42 PM (GMT -6)   
When you read the actual study there is a 2.21% disease specific mortality for surgery and a 1.5% to 3.4% for radiation; hardly a large difference.
Also it cleary states that surgical patients were younger, Cacausian, and had lower risk features, but these were somehow adjusted for in the study.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/6/2010 10:48 PM (GMT -6)   
I forwarded this one to Mike Scott for his consideration on the InfoLink... He knows Peter Carroll. He should be able to add some sense to it...

A 125% difference in mortality probably matters to the families of those who did not die. If we could reduce any death rate by that number, it is a HUGE difference...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino
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