Medicare and IMRT therapy

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Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 744
   Posted 12/10/2010 11:29 AM (GMT -6)   
I'm an avid WSJ reader, thought I would share this article with the group.
 

BuiDoi
Regular Member


Date Joined Aug 2010
Total Posts : 234
   Posted 12/10/2010 7:16 PM (GMT -6)   
.
IMRT = Radiation - and Radiation COOKS things !
Once cooked - surgery is out.
Thus Radiation should be the LAST option.
How sad that it might be used as a first option, just because it is there.

It's like a surgery having a CT scanner in-house.
Everyone will be asked to have a CT Scan to help Dx.

Whilst I know that here in Oz. we enter the sausage factory with a raised PSA and get shunted to ALL the different "Specialists" on the production line, it's up to the individual to know what is best.
Each specialist charges their 'specialist fee' and then WE decide which is the preferred treatment.
.
.
I simply said "No Thanks" to all the rest.
Nov 2009 = First-PSA 5.3 @ 60yo - Asymptomatic - DRE-Non-Palpable
Jan-'10 = TRUS Bx DX - AdenoCar T1c - GS(3+3)=6 , 5 & 45% max., L-MidZone
May-'10 = RRP-Nrv-Spare
Post Op. GS(3+4)=7, 1.1cm3, Pos Margins, EPE (focal) Lateral Left
Margin-Involvement (extensive) Posterior , Grade3 x 8mm
+8week PSA<0.01, ED-85%, Incont-30%
+16W PSA<0.01, ED -85%, Cont -5%
+17W First 'DRY' day. ED -90%

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 12/10/2010 8:42 PM (GMT -6)   
Buidoi,
If radiation is so bad why does it have better cure rates and less side affects than surgery? If it can kill cancer left behind by surgery, why would you think it cannot kill it if used first?
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

fulltlt
Regular Member


Date Joined Nov 2010
Total Posts : 264
   Posted 12/10/2010 11:19 PM (GMT -6)   
There  are many miscceptions about radiation.  Radiation treatment is not the same as cooking food in a microwave.  Radiation disrupts the DNA in the cancer cells so they can't reproduce.  Normal cells that are not cancerous can recover from the DNA changes whereas the cancerous cells can't.  That's how it was explained to me by my radiation oncologist.
age 57 2/2010
PSA 8.2 2/2010
biopsy 2/2010 - 2 of 8 left & 2 of 8 right positive, Gleason 3+4=7
attended support group - advised to get a second opinion
second opinion on pathology from Johns Hopkins 4+4=8
PSA 15 4/2010
5 weeks IMRT 4/2010-6/2010 at Copley Hospital in Aurora, IL
91 implants of palladium 103 7/2010 at Chicago Prostate Center, Westmont, IL
PSA 3.97 10/2010
no ED or incontinence

Post Edited (fulltlt) : 12/10/2010 10:33:46 PM (GMT-7)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/10/2010 11:57 PM (GMT -6)   
Fulltlt,
Radiation cause DNA mutation in ALL cells it comes in contact with regardless of whether they are healthy or cancerous. Morbitities are felt early on and simmer down. They can become more prevalent later in life.

John T,
I missed that study that compares the efficacy of differing treatment modalities and proves that radiation has better cure rates. Perhaps you can show us that study.

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

Post Edited (TC-LasVegas) : 12/11/2010 12:00:57 PM (GMT-7)


fulltlt
Regular Member


Date Joined Nov 2010
Total Posts : 264
   Posted 12/11/2010 5:33 AM (GMT -6)   
TC-LasVegas said...
Fulltit,
Radiation cause DNA mutation in ALL cells it comes in contact with regardless of whether they are healthy or cancerous. Morbitities are felt early on and simmer down. They can become more prevalent later in life.

John T,
I missed that study that compares the efficacy of differing treatment modalities and proves that radiation has better cure rates. Perhaps you can show us that study.

Tony


Please guys - the second to last letter in my handle is the letter "L" not "I".

Yes, you are right radiation causes DNA disruption in all cells. The cancer cells die as a result. Noncancerous cells can recover. Some of the non cancerous cells may die as a result too. This is how my radiation oncologist explained it to me. I apologize if I wasn't accurate enough. I'm not a doctor. I'm the patient. My point was that radiation is not the same as "cooking" as BuiDoi stated.

This is an exceprt from wikipedia:
[URL]http://en.wikipedia.org/wiki/Radiation_therapy/URL]
...
"Radiation therapy works by damaging the DNA of cancerous cells. This DNA damage is caused by one of two types of energy, photon or charged particle. This damage is either direct or indirect ionizing the atoms which make up the DNA chain. Indirect ionization happens as a result of the ionization of water, forming free radicals, notably hydroxyl radicals, which then damage the DNA. In the older, most common form of radiation therapy, Intensity-modulated radiotherapy (IMRT) (photons), most of the radiation effect is through free radicals. Because cells have mechanisms for repairing single-strand DNA damage, double-stranded DNA breaks prove to be the most significant technique to cause cell apoptosis (cell death). Cancer cells generally are undifferentiated and stem cell-like, they reproduce more, and have a diminished ability to repair sub-lethal damage compared to most healthy differentiated cells. This single-strand DNA damage is then passed on through cell division, accumulating damage to the cancer cell's DNA, causing them to die or reproduce more slowly."

As Michael Scott said on The Office - "Wikipedia is the best thing ever. Anyone in the world can write anything they want about any subject. So you know you are getting the best possible information." wink
age 57 2/2010
PSA 8.2 2/2010
biopsy 2/2010 - 2 of 8 left & 2 of 8 right positive, Gleason 3+4=7
attended support group - advised to get a second opinion
second opinion on pathology from Johns Hopkins 4+4=8
PSA 15 4/2010
5 weeks IMRT 4/2010-6/2010 at Copley Hospital in Aurora, IL
91 palladium 103 seeds 7/2010 at Chicago Prostate Center, Westmont, IL
PSA 3.97 10/2010
no ED or incontinence

Post Edited (fulltlt) : 12/11/2010 8:29:44 AM (GMT-7)


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4156
   Posted 12/11/2010 6:13 AM (GMT -6)   

Buidoi, you said, "Thus Radiation should be the LAST option. How sad that it might be used as a first option, just because it is there."

I realize that is your opinion and you are relatively new here.  I invite you to read back over some of the older threads on this forum wherein surgery vs. radiation was discussed.  I think that will give you another perspective.  There are many of us here that believe radiation is a perfectly acceptable FIRST option for many good reasons.  Anyway, please check out some other perspectives before being so adamant.

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 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 12/11/2010 8:13 AM (GMT -6)   
TC-LasVegas said...
evalent later in life.

John T,
I missed that study that compares the efficacy of differing treatment modalities and proves that radiation has better cure rates. Perhaps you can show us that study.

Tony


Have a look at this study.

www.prostatecancertreatmentcenter.com/Resources/Reports/15YrBiochemicalRelapseFreeSurvivalI125ProstateBrachytherapy.aspx

The fifteen year fifteen-year BRFS figures reported are, I believe, higher than for any studies reported with surgery. Similar results can be found in studies by the Datoli Institute and the RC Cancer Centers of Georgia.]

Sancarlos

edited to add coding for clickable link

Post Edited By Moderator (James C.) : 12/11/2010 7:27:26 AM (GMT-7)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 9:03 AM (GMT -6)   
Sancarlos,
I am keenly aware of results reported by radiation oncology centers. I am not aware of any results that are reported by multifaceted centers that agree with them. When you use the MSK predictive nomograms you get much different results and a surgical approach has better results. MSK is not trying to push one treatment modality.

We are also comparing BFRS results using two different criterial. The surgical method of determining is absolute, any rise in PSA will be deemed a recurrence. The radiation methods use a different criteria, and it can be the ASTRO or Phoenix criteria and it could take years to call anything BFRS.

Thus, the only criteria that matters is prostate specific mortality. There is no study that directly compares this data. There is a new study that has been started somewhere, but the results will be many years ahead.

One piece I find to be interesting discussion is John's point. EBRT Radiation is useful when BRFS occurs after prostatectomy. So EBRT must be superior? Can I ask why it was ever necessary then to use "combination" therapy to achieve superior results to surgery alone? Obviously, if brachytherapy is better, then EBRT should scarcely be needed. But seeds plus EBRT is essentially the same as surgery plus adjuvant EBRT. And those results are excellent as well but these centers choose to not make that comparison.

I guess we choose to get the study results we want and put them together ourselves and call them facts...

I choose to support anyone here regardless of therir decisions and call them brothers in this fight...

PS: fulltlt, I am very sorry for the spelling error. It is somewhat of an optical illusion I guess. I got it now...

Tony

Post Edited (TC-LasVegas) : 12/11/2010 11:51:48 AM (GMT-7)


Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 12/11/2010 2:19 PM (GMT -6)   
TC-LasVegas said...
Sancarlos,
I am keenly aware of results reported by radiation oncology centers. I am not aware of any results that are reported by multifaceted centers that agree with them. When you use the MSK predictive nomograms you get much different results and a surgical approach has better results. MSK is not trying to push one treatment modality.

Tony


Tony,

I believe it is inaccurate to claim that the MSK predictive nomograms give different results and better results from surgery. In fact, the MSK nomograms don't even allow one to calculate results for any combination of brachytherapy + IMRT so in what way do they show better results than the study I cited? Unfortunately there are no reliable reports of any kind that are worth squat (at least IMHO) by any multifaceted center so we are all forced to use the center studies, be they radiology or surgery. And every center out there is pushing an agenda.

What I find is that people tend to believe what they want to believe and use whatever study happens to support their point of view. But it is absurd to think that any of these results are truly reliable. PCa is just much too complicated and all of the studies are by necessity limited in both scope and time.0.

Sancarlos
Age 66, PC diagnosed 7/2009 at age 65
Stage: T2c, Gleason: 9 (4 + 5), 6 of 6 cores positive
Bone, CAT and MIR scans negative

Treatment: brachytherapy (103 palladium), 100 gy, 11/2009 + ADT3 (Lupron + Casodex+Avodart) + IMRT on Novalis, 45 gy, 3/2010.

PSA: 7/2009, At time of diagnosis -- 11.9
10/2009 -- 5.0
12/2009 -- 0.56
5/2010 -- 0.15
8/9/2010 -- 0.06
11/2010 -- 0.013

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 3:23 PM (GMT -6)   
Sancarlos,
It is not a claim. You can do it yourself and see what I see, and you will see the favorable predictive numbers for surgery when compared to brachytherapy in the MSK nomograms. But first, I agree with the other points you make. I am a staunch believer that studies are virtually useless in prostate cancer for long term results when they have only say 11.2 years as a median like the one you linked. Even the study you show from Grimm whom I have have the privilege of discussing directly with via email. It's deceptively, in my opinion, called a 15 years results study ~ then I would expect that all in it are 15+ years. But what it really is ~ is actually data compiled over 15 years which includes men with 3.2 years and also 18.4 year follow ups. Adding men with 3.2 years after treatment to show "15 year" results is a poor criteria. It makes it sound like at 15 years you can expect these results. In truth the median is 11 years. I would like to see their study of even 10+ years only patients. They have the data, but they do not show it (probably not very many of the 215 patient in the inclusion).

Back to checking these results yourself. Go to the nomograms and you can use my data:

1st select the Pre-Treatment nomogram. You can select either the pre-treament prostatectomy or the brachytherapy and then compare against the other after.

My pretreatment PSA was 19.8
My age was 44
Primary Gleason was 3
Secondary Gleason was 4
The sum was obviously 3+4=7
My clinical stage was T1C
I had 4 positive cores.
I had 4 negative cores.

You can click the calculate...The results:

Brachytherapy 5 year probability of progression free disease is 51%
Surgery 5 year probability of progression free is 86%
Surgery 10 year probability of progression free is 79%

This is derived from a cohort of over 20,000+ patients.

Do I trust these numbers? Not anymore. Even though I am near my 4th year with an undetectable PSA, I am much better educated patient. I do not trust any studies when I know that all centers have their biases. I only trust multi center blind inclusions when discussing prostate specific mortality.

Your point about no method to compare combination therapies is well noted. However the study you linked is only showing mono-therapy results and the MSK nomogram does make that comparison. The criteria used in the study you posted uses the Phoenix criteria to define BFRS. It would be interesting to apply that same standard to surgery. I bet it would make it nearly impossible to get usable results in a 3.2 post prostatectomy with a PSA of 1.7 at three years. He would still be considered disease free using that criteria. This makes these comparisons very difficult and it certainly skews data results.

Please note that I believe that you have chosen well for your course. You should have faith in it and stay true to your decisions. There is no looking back, and no need to do it. However John T makes a claim that I do not believe can be substantiated in any study available today.

Tony

Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 12/11/2010 3:53 PM (GMT -6)   
TC-LasVegas said...
Sancarlos,
It is not a claim. You can do it yourself and see what I see, and you will see the favorable predictive numbers for surgery when compared to brachytherapy in the MSK nomograms.
Tony


Either you missed my point, or perhaps I made a mistake in looking at the MSK nomograms. But I did not find any information in the MSK nomograms that involved a comparison of results with surgery versus brachytherapy + IMRT. If I missed it please direct me to the link.

I am absolutely at peace with my choice of treatment and am convinced that surgery would have been pointless, and would have almost certainly had more side effects, since in fact I have none with seeds +IMRT. On the other hand, I have stated several times on this forum that no one should regret their choice of treatment. The issues are simply much too complex to allow anyone to be certain that in the long term the treatment chosen was the best, and in the end what probably determines whether or not the PCa will come back at some point in the future is whether we already had micro mets at the time of treatment.

Sancarlos
Age 66, PC diagnosed 7/2009 at age 65
Stage: T2c, Gleason: 9 (4 + 5), 6 of 6 cores positive
Bone, CAT and MIR scans negative

Treatment: brachytherapy (103 palladium), 100 gy, 11/2009 + ADT3 (Lupron + Casodex+Avodart) + IMRT on Novalis, 45 gy, 3/2010.

PSA: 7/2009, At time of diagnosis -- 11.9
10/2009 -- 5.0
12/2009 -- 0.56
5/2010 -- 0.15
8/9/2010 -- 0.06
11/2010 -- 0.013

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 4:43 PM (GMT -6)   
Sancarlos
You missed what I stated. I made it clear that MSK compares mono-therapies in their nomograms. I stated only to use the results of the study you provided with the predictive tools at MSK for brachytherapy. The study you provided says that they have a 80.4% success rate for all risk groups using brachytherapy. The MSK nomogram says 51% in my risk group (79.3 in the BT study). Do you believe the study you provided over the comparative information for brachytherapy at MSK? If so, on what premise would you say the MSK information is invalid?

Furthermore, here is a study representation that shows various combinations of radiation therapies by Drs. Sylvester and Grimm:

www.prostateseedinstitute.com/PCRSG_0409_Results.aspx

Pay close attention to the each risk graphs. Virtually all comparisons in the intermediate and high risk groups are combinations therapies with EBRT/seeds versus mono-therapies of all other treatment modalities. And interestingly the surgical results represented in all risk groups do not match the MSK nomograms, in fact they are not even close.

Recent studies by Harvard, Stanford, and MSK substantiate that these results should be compared with other combinations using other primary therapies. Both these centers are currently running studies that utilize RP + adjuvant radiation, and RP + adjuvant radiation + ADT. they are at year 8 for the hight risk group with BFRS at 90% at year eight of the study (still ongoing). This would be a huge discrepancy with the charts shown here.

As I said, I do not trust these methods of comparison. I believe that the truths are somewhere in the middle. And I also believe that the criteria to make determinations as what a failure is flawed. That is why I would only like to see disease specific mortality since in truth that is what matters. I do not believe that we will see those results and therefore any statements about which has a better cure rate is only opinion and cannot be substantiated.

Tony

Post Edited (TC-LasVegas) : 12/11/2010 3:58:48 PM (GMT-7)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 12/11/2010 5:32 PM (GMT -6)   
Tony,
"The prostate Cancer Study Group" was the one study that showed results from multi center, All other studies are single center studies. You have already stated that you found this study biased as you have said about every study on radiation that has been posted. You believe all the surgery studies and always find something wrong with the radiation studies.
Combination seeds/IMRT in most every study has better results than surgery alone and the reason is pretty obvious. There is a 21% to 31% positive margin rate with surgery depending on what institution you look at. Any IMRT treatment added to either surgery or Brachytherapy will result in a more effective cure rate because of the wider margin of the radiation.
"Long Term PC Control using PD 103 and external Radiation in patients with a high likeihood of Extra Capsular Extension" Dattoli and Sorace. 282 consecutive patients with at least 1 high risk factor, mean psa 19, median, 15. 81% Biochemical freedom using psa of 0.2. risk of failure was only 1% after 5 years with a 14 year follow up. Yes this is a single center peer reviewed study, but you cannot find a single center surgery study for high risk PC with an 81% cure rate and a 1% reoccurrance after 5 years.
Seeds/IMRT is a common primary treatment option; Surgery and adjuvant radiation is not at all common when based on clinical staging. and the side affects of Seeds/IMRT are far better than combination surgery/radiation.
JT
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 7:42 PM (GMT -6)   
John,
I admit that in the past I was not fair to the radiation community (even though I am among them). It was wrong and it does not promote a positive environment to the survivors who went that rout. I am doing my very best to work on it and have repositioned my thoughts and biases more towards the center. Perhaps this is because of education, perhaps it is because I have learned to be more objective because I now run a large live group.

Here is an example of how I look at things now:

On studies I have stated the following:
1> I have said that EVERY study has some bias regardless of modality it is studying.
2> I do not trust studies in general because they lack the maturity necessary to give us true results on survival. BFRS is not a good marker alone especially in any study under ten years median. For example: Any study that has 18 year patients mixed with 3 year patients in an attempt to show "excellent long term results" are useless and deceiving.
3> Studies that have differing criteria in defining failure are useless to use in comparison.
4> It is pointless to look at studies when what really matters for anyone who has made their decisions that we try to give equal support to. This is in the spirit of providing support moving forward.
5> I still find it important to point out the imperfections of unsubstantiated claims as it indirectly degrades the support group...

I still am in the learning process and don't think I will never not be. This is in contrast to anyone who would try to take studies that truly are not designed to make fair comparisons and do so anyway. As I pointed out to sancarlos, I have to believe that MSK and the Grimm report information differs because both are done with some bias. My personal surgical results are more consistent with the MSK nomograms at this point. but I know many here whose results are less favorable. I have used top of the line doctors to date and perhaps that has something to do with it?

We have discussed the positive surgical margins thing before and it seems that some look at every positive margin as failure or that AHA! moment, yet only look at BFRS when referring to radiation failure. Positive margins is not a failure in itself and many men with them never have a PSA increase after surgery. We can find dozens here at HW with those results. John, I agree with your point that adding IMRT helps improve the overall results but that it is not exclusively used in combination with seeds. Surgery/adjuvant IMRT is very common and a growing protocol, but it is only used when it might be helpful after surgical results have that indication. There is growing criticism when using combination therapies except only when necessary. Combination radiation therapies for high risk cases seems to be used regardless of if it's necessary but rather a play of the odds. The argument to adjuvant radiation after post prostatectomy is only suggested when there are more definitive information available and is being studied by virtually ALL major cancer centers. But the results are there and it is going to continue to grow in application.

On the Dattoli study you mentioned, I am wondering why the percentages you mention don't match the study here:
www.goldjournal.net/article/S0090-4295(06)02249-7/abstract

This study with the same author and title of your example shows far less desirable results than you posted. Help me out here...please...

On the subject of morbidities, your best argument, there are increasing cases of them with combination therapies regardless of the primary treatment modality. Simply put adding IMRT regardless of whether its with seeds or done as adjuvant therapy post prostatectomy, is going to increase morbidity. Typically seeds/IMRT tend to do very well early on but when things eventually do go wrong they tend to be worse than "surgical alone" morbidity. Probably still the case with the surgery/IMRT, however, as I stated, with a surgical approach it is only presented as an option when there are positive seminal vesicles or other determinate factors as opposed to a "best guess". (I know that it is maybe only a "better guess" but the decision is made with more information post prostatectomy.

I think Bui Doi's comments above are too strong, but they are not entirely inaccurate. If anyone wants to have both radiation and surgery in their pocket, they should start with surgery. The benefit is that they may never need to add radiation.

My hope is to get to a point that we work together to provide better support to anyone here. Less bias and more balance. My experience with my disease is a good reference for anyone whom has similar numbers to mine that wants to do surgery. John's experience with his disease is a good reference for anyone wanting to go his rout. All you have to do is look and see it is possible to do either path with no incontinence or ED. And most importantly with desirable results aginst prostate cancer.

Tony

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 8:23 PM (GMT -6)   
Squirm,
This article has touched on various points of view and was discussed earlier in the forum. i apologize for being one who "hijacked" the thread but again, we have discussed this with varying interpretations as to the meaning of it. The Wall Street Journal looks at the business aspect of urological centers purchasing radiation equipment and performing radiation as a new form of revenue. In reality this has been a concept for many years. With Medicare paying on average $ 40K for radiation therapy, and just 15K for surgery, it makes business sense for doctors originally trained as urological surgeons to cross train or contract out to have their offices perform that aspect of treatment as well. There is a serious conflict of interest here.

Truth be told, there is really no reason why a doctor cannot train and be affective at both methods of treating patients. To become a "specialist" is only the tail end of a doctor's training and education. To see this happening is something I do not like but will have to get used to. Thank you for posting it, and again...

Sorry for the hijack...

Tony

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4226
   Posted 12/11/2010 8:45 PM (GMT -6)   
Tony,
Thanks for your response; I think we are in general agreement. I admit that I'm more biased towards radiation and it comes out stronger on this forum because of the strong surgical bias on the forum that I feel needs some balance.
The Dattoli/Sorace study is the same. You read the abstract and I read the study results in the appendix of Dattoli's book which goes into greater detail, especially when PAP is used as a preditor of failure. The 81% freedom from progression is 13 years in the abstract and 14 years in the book; this was for patients with 1 high risk factor. 1% reoccurrance after 5 years in the book and 1% reoccurrance after 6 years in the abstract. This is for the entire patient cohort of 282, of which 243 had at least 1 high risk factor. The abstract futher breaks down the high risk patients into futher risk classifications based on multiple high risk factors and this may be where the confusion arises. Those with two or more high risk factors, gleason >7 AND psa over 10 AND or an elevated PAP had higher biochemical reoccurrance rates than 81%, as would be expected, but the average for all patients was 81% at 13 or 14 years, which means that those who had only one high risk factor had a cure rate of much better than 81%. I hope this clears up the confusion.
Of interesting note: PAP was the strongest predictor of failure followed by Gleason Grade then PSA.
JT

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/11/2010 9:16 PM (GMT -6)   
I have had the PAP tests because Dr. Vogelzang wanted them done. He does not have any deep faith in them either as they have been around longer than PSA and have a large margin of error as well. He prefers to use all the information versus any one marker. I think that is a best approach and it should be interpreted by a medical oncologist versus a radiation or surgical center. Especially in studies that start out talking about a PSA definition of BFRS but change course to PAP failure which is NOT defined in the study.

I did notice the Dattoli study used PAP when mentioning that 1% failure rate after 4 years. The Dattoli study does not mention in the abstract whether cases of PSA increase were disregarded in favor of PAP staying low. There are a lot of us laymen out here that will read that and miss the change in definition. I noticed it but I bet almost a hundred percent of those deciding what to do with their cancer won't recognize that concept. Can you forward that write up to me?

Let's work together, John. Let's help others understand that what we learn when we set out on our journeys, can and likely will be a changing position as time goes on. This forum will be a better place for it.

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 : 4226
   Posted 12/11/2010 11:07 PM (GMT -6)   
Tony,
I don't have an electronic copy, only the copy in Dattoli's book. Selection criteria was PSA>10; Gleason < or= 7, clinical stage>=T2B; and elevated PAP. My take that the study was primarily done to loook at PAP, Gleason Grade and PSA as predictors of biochemical failure. Predictors of failure were PAP (p=0.001), Gleason (p+0.03) and psa (p=0.41).
Strum also believes that PAP is a very strong predictor of micomets. PAP was used before psa to indicate PC. I can see how it may may be used along with other staging indicators to identify those that may need more agressive treatment. My low PAP and PCA3 were two indicators I used along with imaging to decide not to include 2 years of HT to my treatments. I don't believe you can use just one or two indicators to come to a decision, but many things taken in total can give you a pretty good picture of your PC. Most good Oncologists like Vogelzang and Strum will use a number of markers in order to make a recommendation.
Dattoli used a strict defination of psa>0.2 to arrive at biochemical failure. He mentions elsewhere that many patients have stable psa's above 0.2 and as high as 5 with no sign of reoccurrance and no indication of PC from follow up biopsies and considers them cured(or in remission), but for this study he used 0.2 as an indication of failure, which is a very strict criteria. for any radiation treatment. All failures had follow up biopsies and there were no documented local failures.
JT
JT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.
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