Active surveillance and upgrading

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An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1148
   Posted 9/13/2010 3:29 AM (GMT -6)   

April 28, 2010 ( Barcelona, Spain) — Men with seemingly low-risk prostate cancer who are considered candidates for an active surveillance strategy might want to consider robotic-assisted laparoscopic prostatectomy (RALP) instead, a team from Mount Sinai Medical Center in New York City reported here at the European Association of Urology 25th Annual Congress.

Active surveillance, otherwise known as watchful waiting, has been enjoying a surge in popularity as a management option for men with low-risk localized prostate cancer.

The new results are drawn from a trial that evaluated the final histopathologic and functional outcomes of a large cohort of men who qualified for active surveillance under conventional active surveillance criteria, but who opted instead for RALP.

The researchers found a 44% rate of upgrading of cancers. However, there was a low rate of upstaging, and a nerve-sparing procedure was performed in most patients with excellent potency and continence outcomes.

"The findings are extremely important," David Samadi, MD, chief of the Division of Robotics and Minimally Invasive Surgery, told Medscape Urology. "First, the 44% upgrading rate in men whom we thought had slow growing disease represents men who never should have been placed on active surveillance in the first place," he said. "Second, we demonstrated that we can eliminate the risk of missing an aggressive cancer by successfully treating these men with minimal compromise to their quality of life."

Recent studies have questioned the use of radical therapy for all patients with prostate cancer, especially those with low-risk disease, in favor of active surveillance, Dr. Samadi observed. At the same time, improvements in surgical and radiotherapy techniques and perioperative management have decreased the morbidity of prostate cancer treatments.

Although active surveillance has been shown to be a valid treatment option for patients with low-risk disease, clinically low-risk prostate cancer does not necessarily translate into indolent or insignificant disease on final pathology, he added. Given the difficulties of accurate preoperative staging and grading of prostate cancer, upgrading and upstaging are extremely common at the time of prostatectomy.

When discussing treatment options for men who are candidates for active surveillance, it is important to be able to provide solid data on outcomes, both histopathologic and functional, following prostatectomy. This study was designed to provide such data to patients deciding between RALP and active surveillance.

Dr. Samadi presented data on 368 men deemed candidates for active surveillance who were drawn from a "prospectively maintained" database of 1249 RALPs.

Men who were categorized as eligible for active surveillance had a prostate-specific antigen (PSA) below 10 ng/mL, a clinical stage of T2A or below, and a biopsy Gleason score of 6 or less in 1 or 2 cores, with less than 50% tumor volume in a single core.

The study found that, on final histopathology, 147 active surveillance candidates (40%) were upgraded from a Gleason 6 biopsy score to 3 + 4 = 7. Fifteen (4.1%) patients were upgraded to 4 + 3 = 7, and 1 patient was upgraded to Gleason 8 or higher.

Seventeen patients (4.6%) were upstaged to pT3 or pT4 disease, and 12 of these were also upgraded.

Bilateral nerve-sparing was performed in 97% of patients.

Follow-up of 221 patients at 12 months showed that 88% of men had recovered potency (meaning they were potent preoperatively and had a Sexual Health Inventory for Men score of 16), and 95% were continent (meaning they needed 0 or 1 security pad per day).

Biochemical recurrence, defined as a PSA of 0.2 ng/mL at least 6 weeks after prostatectomy, occurred in 1.6% of patients at a median follow-up of 13.9 months.

As for which men with prostate cancer should choose active surveillance over RALP, Dr. Samadi said: "I think that active surveillance is ideal for older men and those whose PSA doubling time and velocity are slow."

"This study is interesting and somewhat surprising," Carl A. Olsson, MD, John K. Lattimer Professor of Urology (emeritus) at Columbia University College of Physicians and Surgeons in New York City, told Medscape Urology. "What surprised me is the 44% rate of upgrading, which is substantially higher than the 10% to 20% rate reported in the studies I am familiar with."

Dr. Olsson, who is also chief medical officer at Integrated Medical Professionals, PLLC, in Melville, New York, noted that "it would be interesting to know who did the actual pathology reporting."

He added that if the data are true, "they would put a damper on any policy of active surveillance in patients presumed to be at low risk preoperatively."

Dr. Samadi and Dr. Olsson have disclosed no relevant financial relationships.

European Association of Urology (EAU) 25th Annual Congress: Abstract 578. Presented April 18, 2010.


An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1148
   Posted 9/13/2010 3:48 AM (GMT -6)   
My comments on the article above.
The rate of upgrading in this study makes much more sense.

If we take the 4 Gleason 6 cases in the August surgeries thread whose Gleason scores pre and post surgery were known then 3 out of 4 cases had their Gleason score upgraded. It would be quite freaky for this to happen if the chance of upstaging in the general population was say 15%. I pulled out my advanced statistics textbooks from university and I calculated that if you picked 4 people with Gleason score 6 randomly from a population where only 15% of the Gleason score biopsies were upgraded post surgery then the chance these would contain 3 cases with upgraded Gleason scores post surgery would be a very low at 1%.

Either the August thread people have hit some sort of unlucky lottery or the 15% is not right and the article above is much more realistic.

There is no doubt that the idea of not treating people who are genuinely low risk is a noble one - this issue is that pre-surgery we do not know in an unacceptably large number of cases whether a case presenting as low risk is actually intermediate risk.

Also the rates of side effects post surgery tie in with almost everything I have read.

An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)

Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4. Neg margins, seminal vesicles, extraprostatic extension. Multifocal, with involvement in the peripheral, apex, fibro-muscular and transitional zones.

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 9/13/2010 7:08 AM (GMT -6)   
When everybody piled on the "Prostate Snatchers" bandwagon, I KNEW they were buying into a very risky treatment protocol..

Stay tuned for the next chapter, "Surgeons Fight Back!"
Age 68.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA age 66 9.0 DRE "normal", 2ed biopsy, negative, BPH, Proscar
PSA at age 67 4.5 DRE "normal"
PSA at age 68 7.0 third biopsy positive, 4 out of 12, G6,7, 9
RRP performed Sept 3 2010

rhb47
Regular Member


Date Joined Mar 2010
Total Posts : 208
   Posted 9/13/2010 7:13 AM (GMT -6)   
Great article, An-thanks for posting it. It confirmed what we already knew-a pre-op gleason 6 isn't always a gleason 6. Geoff had 5 of 10 cores positive so he wouln't have fit into the AS guidelines but your husband would have-without surgery he wouldn't have known he was a 3+4 and that could have been dangerous. I admire anyone brave enough to try AS and obviously there is over treatment of the disease for some men, but for my husband I am very grateful that his prostate is gone! Hopefully in the future there will be better methods of determining which cancer is indolent but for now better safe than sorry.

Renee
Husband diagnosed 3/10
Age 56, PSA 4.7, free 7.6%

Biopsy 5 of 10 cores positve-all right side-25% to 57%
Gleason 6
DaVinci surgery with Dr. Vip Patel scheduled 8/9/10

Post Op: Gleason 3+4=7
Negative surgical margins and lymph nodes
No seminal vesicle and angiolymphaic invasion
perineural invasion present
Both nerve bundles spared

ejn
Regular Member


Date Joined Jun 2010
Total Posts : 87
   Posted 9/13/2010 8:16 AM (GMT -6)   
An,  I am the 1 out of 4 that stayed a 6 in the August club.  I can tell you that AS was not even an option I considered after after PCa was found in the biopsy for the exact reason that the pre surgery staging was nothing more than an educated guess and I was not comfortable with that.  I will never regret making the decision to have surgery as I believe I made the right choice. 
 
Ed
53

Pre OP PSA: 1/2008=5.9, 2/2010=6.0 (free=9%)

Biopsy, 4/10/2010 This was my 2nd Biopsy. The Uro put me out and took 36 samples. 3 samples positive 1%, 2%, 2% no evidence of perineural invasion. T1c

April 2010


CT Scan: Negative


DaVinci: Coming up 8/11/10, Dr David Bryan, SSM DePaul-St Louis
Post Op Path:
Gleason 3+3=6
Tumor involves left lobe only
Tumor constitutes less than 5% of gland volumne
No vascular or neural invasion detected
No capsular invasion detected
Distal urethral margin of resection free of tumor
Proximinal urethral margin of resection free of tumor
Radial margin of resection free of tumor
Seminal vesicles uninvolved by carcinoma
TM stage T2a (unilateral less than 1/2 of one side), NX, MX
ALL Margins uninvolved
Extra Porsaatic extension: Absent

el perro
Regular Member


Date Joined Mar 2010
Total Posts : 46
   Posted 9/13/2010 8:25 AM (GMT -6)   
By the same logic, one would expect recently reported AS studies (or any AS study) to have a similar percentage of understaged men among their participants. Yet there seems to be no greater risk (in the studies I've seen) for adverse outcomes in these men. My point is that some higher-risk men are unknowingly included in AS programs due to imperfect screening, but they still fare ok overall. Maybe they are the ones that show progression and end up getting treated after a year or two, but they don't seem to be experiencing recurrence at any increased rate over the folks receiving immediate treatment, at least in the short term. So then the argument is that they may experience more recurrence 10 years from now... Maybe that will be the case (who knows?), but personally I would take my chances that there are better treatments available in 10 years.
Dx 11/2008, Gleason 3+3
Active surveillance for now

Ziggy9
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Date Joined Jul 2008
Total Posts : 981
   Posted 9/13/2010 9:48 AM (GMT -6)   
el perro said...
By the same logic, one would expect recently reported AS studies (or any AS study) to have a similar percentage of understaged men among their participants. Yet there seems to be no greater risk (in the studies I've seen) for adverse outcomes in these men. My point is that some higher-risk men are unknowingly included in AS programs due to imperfect screening, but they still fare ok overall. Maybe they are the ones that show progression and end up getting treated after a year or two, but they don't seem to be experiencing recurrence at any increased rate over the folks receiving immediate treatment, at least in the short term. So then the argument is that they may experience more recurrence 10 years from now... Maybe that will be the case (who knows?), but personally I would take my chances that there are better treatments available in 10 years.


It's back to another panic thread here on AS. Just think if it wasn't for PSA testing the last few years the amount of men dying from PCa wouldn't have dropped so drastically like it DIDN'T. Meanwhile over treatment and men living with lower quality of life effects has sky rocketed. It's still true for most that more men will die with PCa than of it. As far as waiting for new treatments many are not 10 years away but here now or will be soon. Look at my sig for one.
Diagnosed 11/08/07 - Age: 58 - 3 of 12 @5%
Psa: 2.3 - 3+3=6 - Size: 34g -T-2-A

2/22/08 - 3D Mapping Saturation Biopsy - 1 of 45 @2% - Psa:2.1 - 3+3=6 - 28g after taking Avodart - Catheter for 1 day -Good Candidate for TFT(Targeted Focal Therapy) Cryosurgery(Ice Balls) - Clinical Research Study

4/22/08 - TFT performed at University of Colorado Medical Center - Catheter for 4 days - Slight soreness for 2 weeks but afterward life returns as normal

7/30/08 - Psa: .32
11/10/08 - Psa.62 -
April 2009 12 of 12 Negative Biopsy

2/16/10 12 of 12 Negative Biopsy

Post Edited (Ziggy9) : 9/13/2010 1:33:14 PM (GMT-6)


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4149
   Posted 9/13/2010 10:19 AM (GMT -6)   
An, I have the following comments re your postings on this thread:
 
1. I cannot explain why this study is an outlier but most studies (many of which have been posted on this forum) have indeed shown that the rate of upgrading is in the 10% - 20% range.  We need to be careful not to draw too many conclusions from a study presented by reseachers who have a vested interest in the outcome.
 
2.  I don't question your statistical expertise but any statistician worth his or her salt would caution you not to try to make a point with a small sample size.  That's why the pollsters don't call the results of elections by only talking to a handful of voters.  Besides that, if I recall correctly, most of the men in your small sample would not have qualified for AS anyway if you use the Epstein criteria.
 
3.  Bc careful when assuming that his figure of 88% potency at one year post surgery is correct.  The devil is in the details of the definition.  If it wasn't sad that surgical patients would believe that 9 out of 10 of them would be "potent" after a year, it would be laughable.  Reference the 2008 study on quality of life and satisfaction with outcome amoung prostate cancer survivors that was published in the New England Journal of Medicine.  In that study 64% of men two years post surgery reported "erections not firm" and 43% reported "overal sexuality problem".  That is in line with what most reputable sources report when looking at the REAL consequences of an invasisve procedure.  Perhaps your husband's situation will be better...I hope so...but please don't lead others to believe what is generally not true.
 
4.  The point that el perro makes is a good one, i.e. even if your data was true it does not necessarily mean that their long term results are any worse than if they were treated immediately.
 
And, Fairwind, the support of Scholz' conclusions and AS as a treatment option is not as a result of the recent book.  My support and that of others pre-dates the book publication and stems from a reading of collective data that indicates that...for some (not all) cases, AS is a suitable option.  You may not choose to believe that and that is your prerogative.  I will once again point out however that you are personally now engaging in a form of active surveillance for which I do not criticize you and which I would also probably choose if I had your stats.
 
Tudpock (Jim)
Age 62, Gleason 3 + 4 = 7, T1C, PSA 4.2, 2 of 16 cores cancerous, 27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 4/10/10.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 9/13/2010 11:41 AM (GMT -6)   
This is another "glass half empty arguement". The purpose of AS is to identify the 30% that have been understaged or who have progressed so the 70% can remain untreated for as long as possible. Also all data consistantly shows that the outcome is the same for deferred treatments, which the study doesn't mention.
As others have mentioned all of the other studies at Toronto, Hopkins and UCSF have an understaging or progression rate in the 30% range.
As Tud mentioned, if Scardino, considered by many to be the best surgeon in the US, can get a trifecta, (potency, continance and cure,) only 64% of the time then the incontinance and potency numbers are indeed laughable. Numbers like these contribute to the over expectations of those recieving treatment.
Some patients that would never consider AS would gladly wait for a progression in the face of bad pathological results instead of considering any adjuvant treatments. I don't see how this differs from AS except that it entails much more risk.
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 9/13/2010 12:36 PM (GMT -6)   
We are continuing to see large variations in studies. I don't think anyone has a solid position to stand on using imperfect retrospective studies.

I am an engineer by trade. I used to keep a message in my office on the wall. Optimists may feel a glass is half-full. Pessimists may feel that same glass is half-empty. Engineers feel there is too large a glass in use...

It will be interesting to see in 15 years who the engineers were...

Just my thought...

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 9/13/2010 12:42 PM (GMT -6)   
We are hearing the same arguments over an over, like a broken record. Clearly a controversial area. The last word on AS has yet to be written.

This is an important topic. I think many lurkers are struggling with this decision--"To AS or not to AS?", as well as secondary questions, like "How to AS? How much should AS cost? How long to AS? Who should AS?" etc., etc. Should there be a permanent thread that collects the best posts on this issue?

Question for John T: Winning the trifecta depends more on the horses than the bettors. If the "horses" are men with low grade, organ confined PCa, what percentages win the trifecta in the hands of your favorite surgeon?

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 9/13/2010 1:45 PM (GMT -6)   
Postop,
Scardino doesn't break it down by risk grade. The surgery for different risk cases is basically the same except where there is nerve involvement, then the nerves are taken. I know that Scardino published positive margin numbers for MSK. The best surgeon was 11% and the worst was 45% and the median was 24%. Again this was across all risk grades. Again it points out that the doctor you choose is probably more important to outcome than the treatment option. I would imagine the same goes for both impotance and incontinance. Obviously the lower the risk grade and the smaller the tumor the less chance for a positive margin, but this also holds true for AS. These positive margin rates should be a concern as surgery is by no means close to a 100% cure, and many argue that AS has too high of a risk factor compared to surgery. Looks to me the risks are about equal.
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 9/13/2010 2:03 PM (GMT -6)   
To continue with my somewhat labored horse racing metaphor, when Secretariat won the triple crown, who deserves greater credit? The horse, or the jockey, Ron Turcotte? Obviously both have some role.

I don't believe that the state of the PCa wouldn't make a difference in surgical outcomes. If you've got a small tumor, the margins are likely to be negative. If the PCa is small and organ confined, the surgeon can feel more comfortable leaving the autonomic plexus that surround the prostate alone. So, if you are discussing the risks of surgery in AS candidates, you really should look at stats for this subgroup, not all comers.

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1148
   Posted 9/13/2010 7:56 PM (GMT -6)   
It's interesting how we all see what we want to see. John and a few other quote Dr. Scardino as the best but many would argue that Dr Samadi who presented these numbers is in his league. These are his findings and he has as much vested interest in this as Dr Scholz has in AS.

The pro-AS lobby says that AS is for low risk patients. When the underlying assumptions in this statement are questioned (i.e how do you know the low risk patients are low risk) then the answer seems to be it that it doesn't matter after even if they are intermediate or high risk, if the PC progresses you will know.

Make up your mind I think. If you believe strongly that waiting till a cancer is proved to have progressed is the solution then don't limit it to low risk patients - tell the intermediate/high risk patients that thats what they should do too. After all the name of the game in AS is finding the small proportion of cases that are indolent. If you do not recommend AS for intemediate/high risk patients then you should be very concerned that you are telling a large group of intermediate/high risk people (44%) who are unlucky enough to have a biopsy not pick up the aggressive parts of their cancer to continue with an approach thats wrong for them. This study should be raising a red flag.

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4149
   Posted 9/13/2010 8:30 PM (GMT -6)   

An, at this point I guess it's clear that you don't feel AS is appropriate.  And, if you want to stick your head in the sand and believe that 9 out of 10 men have a satisfactory sex life one year after surgery feel free.  But please don't expect such out-of-the-mainstream statistics to go without a challenge as there are literally hundreds of reputable studies that show this is not true. Some of us place a very high value on quality of life, hence we choose AS when we meet those criteria or less-invasive-than-surgery treatments when we don't meet the criteria for AS.

As postop said, these are the same arguments over and over...I guess we all just have to pick our experts, do our own research and examine our own psychological makeup when making our decisions. 

Tudpock (Jim)


Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 9/13/2010 8:49 PM (GMT -6)   
Postop makes an important point.. Many of these cancers studies begin something like this.." In a study of 526 prostate cancer patients, it was found that all but 6 of them lived to be 92 years old or more..."

In a different magazine, you read "In a study of 442 prostate cancer patients, it was found that less than 200 of them were still alive at their eightieth birthdays.."

Since we don't know who was in the study and how they were selected to be in the study, the results of these studies must be taken with a grain of salt....They become part of the sales pitch...With statistics, you can get any result you want as long as you are paying for that result...
Age 68.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA age 66 9.0 DRE "normal", 2ed biopsy, negative, BPH, Proscar
PSA at age 67 4.5 DRE "normal"
PSA at age 68 7.0 third biopsy positive, 4 out of 12, G6,7, 9
RRP performed Sept 3 2010

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/13/2010 8:53 PM (GMT -6)   
sad, but true, fairwind
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1148
   Posted 9/13/2010 10:25 PM (GMT -6)   
I guess I am just objecting to the reams of posts about AS and the fact that there is just widespread acceptance of the “facts” that AS are based on. The competing “facts” that are presented to show that AS may not be as safe as it’s presented to be and that surgery is better than the horror it is presented to be are pulled apart and brought under question.

At least Dr Samadi has facts to present and these are facts based on his hospital’s patient database which is auditable by a third party. For AS we are expected to believe that CDUs are worth trusting with your life to the extent that you don’t need biopsies, without supporting research.

You are right Tudpock. I am not convinced. But I can see other people are and I wish them all the best.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4223
   Posted 9/13/2010 10:34 PM (GMT -6)   
An,
Intermediate and high grade cancers have a very high probability of progressing so waiting for them to progress is not a good stratagy. Low risk cancers have a high probability of not progressing; that's the major difference.
As soon a patients understand that there are three different distinct types of cancer and they all act differently then progress will be made. Treatment should be fited to the individual cancer you have. One size does not fit all. If you don't buy into this basic issue then you should get the most agressive treatment you can for all PC, and that is a combination of surgery, radiation and HT, as this gives the best probability of eradicating the cancer whatever the risk level. I don't see many patients taking this route.
You don't believe that progresson in low risk pc can be easily identified before it is too late. I am convinced that it can with a probability in the high 90% level which is the same cure level for any treatment of low risk PC.
The patients in the study you cited were only selected based on psa and gleason on biopsy. I have always said that a color doppler and a PCA3 test should be a part of the criteria along with psa density. I would never go on AS without this. I'm sure that the majority of intermediate risk patients in this study screened in this fashion would have been eliminated as low risk. Any tumor identified with CDU would have been biopsied and all tumors above G6 would have been identified. This is how you initially separate the low risk from the higher risk cancers. This greatlly increases the probability that you indeed have a low risk cancer and not a higher grade that was missed. I personally think that everyone should get a CDU and PCA3 before deciding on any treatment regardless of the initial risk catagory just because it gives you so much more information on which to make a more informed decision.

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


Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3741
   Posted 9/13/2010 11:07 PM (GMT -6)   
"In the vast majority of patients blah blah blah........"
"In most of our patients blah blah blah....."
"Many of our patients have done well by blah blah blah..."
"A large number of prostate cancer victims will need blah blah blah...."
" A recent study shows that 737 men who chose blah blah blah...."
"Statistics can prove it doesn't make any difference if you blah blah blah.."
"At our clinic, 97% of the patients who received XXX and XXX had no
detectable XXX for x years or more, with many men going X years without...."

What?? You want exact percentages? You want to know WHO did the study? Where? You want to know how the subjects were chosen? Who paid for it? Why would anyone want to know that?

Gleason 6 (and under) ...All the good things about PC apply to you..
Gleason 7 ..................... You are in the Twlight Zone...Stay on your toes..
Gleason 8 and up ......... Your life will never be the same and it may be somewhat
shorter than you had planned..Little of what you read about
PC applies to you....

PSA .5 to 2.0 .................Congratulations! You are "normal"! Now bend over...
PSA 2.0 to 5.0 .............. See "Twilight Zone"..(and bend over)
PSA 5.0 to 10.0 ............ Call your urologist tomorrow and inquire about a biopsy..

Please forgive me, I'm in a weird mood tonight...

kbota
Regular Member


Date Joined Aug 2010
Total Posts : 486
   Posted 9/14/2010 7:50 AM (GMT -6)   
Gleason 6 (and under) ...All the good things about PC apply to you..
Gleason 7 ..................... You are in the Twlight Zone...Stay on your toes..
Gleason 8 and up ......... Your life will never be the same and it may be somewhat
shorter than you had planned..Little of what you read about
PC applies to you....

PSA .5 to 2.0 .................Congratulations! You are "normal"! Now bend over...
PSA 2.0 to 5.0 .............. See "Twilight Zone"..(and bend over)
PSA 5.0 to 10.0 ............ Call your urologist tomorrow and inquire about a biopsy..

Please forgive me, I'm in a weird mood tonight...
=========================================================

You may have been in a weird mood, but you were right on target. You have a way of boiling complicated topics down to the bare essentials.

From many different perspectives, a high gleason is difficult to overcome isn't it?
Age 57 at Diagnosis
May, 09 PSA 2.26
June, 10 PSA 3.07 Free PSA 18%
Met with Uro, DRE +
June, 10 Biopsy, 7 of 12 cores, up to 60%, 4+5=9
July 21, 2010 - RRP
Nodes negative
Vesicles negative
tumor contained in capsule, still 4+5=9
perineural invasion extensive
Aug 5, 10 catheter out
Sept 3, 10 PSA - 0.00 (great big whew)
As of 9/3/2010, I'm 99% continent - only occasional stress incontinence !

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 9/14/2010 9:55 AM (GMT -6)   

In support of your posting, An, about the incidence of upgraded Gleason grades, here is yet another study confirming this outcome.  However, it also reveals important information on more critical outcomes.  What do I mean by "more critical outcomes?  By way of example, after my surgery I was less concerned about what my final Gleason outcome was, and more concerned about positive surgical margins and extraprostatic extension.  My Gleason score was upgraded, but I had negative SM and EPE; I was thrilled!  Read on…

 

In a study published yesterday in the Journal of Urology, comparative outcomes of radical prostatectomy were assessed for two groups:

·         men who underwent RP as their primary treatment

·         men who underwent AS as their primary treatment, and then had a deferred RP

 

There was a statistically significant difference in the Gleason grade (“upgrading”; the original topic of this thread) for the two groups; specifically, upgrading in surgical specimens vs. core biopsies was less frequent after primary (25%) vs. deferred RP (38%).

 

However, perhaps more notably, the other important factors (perhaps more important factors) involved in the study were not statistically different.  Specifically, there was no significant difference in the percentage of men who underwent primary vs. deferred RP for positive surgical margins or extraprostatic extension. 

 

Link   URL:  http://www.ncbi.nlm.nih.gov/pubmed/20723940?s_cid=pubmed

 

Draw your own conclusions.

 

edit:  added URL in case Link doesn't work

Post Edited (Casey59) : 9/14/2010 6:18:02 PM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 9/14/2010 11:22 AM (GMT -6)   
kbota

you and fairwind  have a point. it's dreary sometimes watching people having these endless mind battles here, trying to prove and disprove details about the subject that in the end, will have no practical bearing to the average patient that is dx or already battling with PC. For most of us, we trust our doctors and specialists, they are the experts, not the patient, no matter how "informed" the patient is, or however clever the patient thinks they are by "googling" endless hours about things PC. (not at all saying knowledge or learning is bad). for some of us, learning about this cancer and how it effects us and our treatment choices is why we are here. for others, it seems at time that is some kind of mental game or challenge to see who gets the "I am the smartest" award.

almost reminds me of the" my weiner is bigger than your weiner" silly game that some play.

if the experts can't even agree on these fine points in these studies, leaves little room for a mere patient to do better.

david in sc

Post Edited (Purgatory) : 9/14/2010 11:27:19 AM (GMT-6)


TryingToStayCalm
Regular Member


Date Joined Aug 2010
Total Posts : 53
   Posted 9/16/2010 11:02 AM (GMT -6)   
I appreciate all the commentary here and I can see both sides of the equation. Fair, I appreciated your grid and also felt you were spot on but I do believe that younger men need to be concerned SOONER.
 
The only thing that worries me about AS is that as you are "watching" things can take a turn quickly.

When M's PSA was 1.7, 1.8, 2.2 no one said a thing. It's WAY under 4. Then we watched it go to 2.5. Well, he had no symptoms and no enlargement upon DRE so why do anything? Then we saw it go to 3.2. Now that is quite a jump! Doc says lets WATCH it for 4 months. Come back then. Still no symptoms or enlargement upon DRE but NOW we are at 5.8 and NOW we are enlarged, and the biopsy showed considerably aggressive PC. We schedule the surgery and 1 month later we are at 7.9, the gland is out and we are looking at G7 (4+3) with some scattering 8 and 9, tissue and seminal vesicle invasion and 70% of the darn prostate is malignant.

We obviously were NOT candidates for AS but what IF we had the PSA taken 4 months later? What IF we had waited the full year as most do under 4? Would it now be T4 instead of T3b? God knows. And, what IF we had done something at 3.2 after the big jump - even though there were no symptoms and no enlargement upon DRE - would it have spread as much? Or might it have been contained?

No, I am not a fan of AS except for very low risk PCa. PCa is an insidious form of C and it blindsided M and I. M's PCa turned aggressive quickly and I agree with Tony who I have seen write that men under 60 should take more active steps if their PSA goes over 2 not 4.
Judy
Husband DX on 6/30. Age 56. PSA b/fore surg. 7.9. Biopsy 6/12 positive 5=50%/90%, 1/10%. PNI present. Gleason 7 (3+4). Robotic RP Mt Sinai. NYC. 8/26. POST SURGERY PATH: Extensive bilateral involvement. Gleason 7 (4+3) w/ some 5 patterns. 70% of slides contain tumor. 42g. Extends beyond capsule into tissue and left seminole vesicle. Extensive Intra & Extra prostatic PNI w/tumor. Lymphs neg. pT3b

Rolerbe
Regular Member


Date Joined Dec 2008
Total Posts : 235
   Posted 9/17/2010 1:26 PM (GMT -6)   
It is sad to see that we continue, collectively, to be in the state of projecting questionable results on data with high variance onto outcomes for single individuals.  But that's the nature of statistical analysis, and its the best we can do.
 
In my case, overtreated?  Probably.  Quality of life impacted by treatment?  Definitely.  If we were talking 1 in 10,000, or even 1 in 1,000 statistics for negative outcomes, OK, there's an argument to be made.  Although many of those I consulted in the medical establishment told me my negative outcome chances were " really low", for me, 1 in 10 type chances simply don't cut it.
 
It seems certainly true, and I think most here would agree, that the majority of PCa's are slow growing and we are overtreating.  But, without good differential tests to segment the populations early enough to not place the fast growing sufferer's at significantly increased risk of negative outcome, we will continue to have to take potshots in what is, at best, a dim twighlight.
 
 
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