Randomized controlled trial of radical prostatectomy vs. watchful waiting

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Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 3/25/2011 8:21 PM (GMT -6)   
The Scandinavian trial that compared surgery to no surgery is one of the very few randomized clinical trial of treatment of prostate cancer. It is level 1 evidence that show that surgery can work, but it's not as effective as you might think. I saw that the article and the graphs from the most recent report of this study, with 12 years of followup, is now posted for free on the pubmed website. It's worth looking at these.

There is a recent thread here about longevity with prostate cancer. This is the best article I've seen to answer that, because if you ask the question, "will surgery help me to live longer", the next question is "compared to what?". The answer that you want to this second question is, "compared to those who didn't have surgery". This study gives some of the answers to these questions. It was helpful to me when I was deciding on whether to get treated:

The link to the charts:

www.ncbi.nlm.nih.gov/images?term=18695132[PMID]

The article:

www.ncbi.nlm.nih.gov/pmc/articles/PMC2518167


Especially look at Figure 3. In this patient group, surgery increased survival if it was done on men younger than 65. When it was done on older men, there was no difference in survival between surgery and watchful waiting.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/25/2011 8:23 PM (GMT -6)   
Some interesting and useful data there, thanks.
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 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

biker90
Veteran Member


Date Joined Nov 2006
Total Posts : 1464
   Posted 3/25/2011 10:34 PM (GMT -6)   
Numbers don't mean anything to me. I'm only interested in my own survival and have chosen to get rid of the cancer as soon and as completely as possible. As a result, I have piece of mind that I have done everything possible to stay in remission.

I did this for prostate cancer for my own peace of mind. I watched my dad die from stage IV PCa. It took 18 months and was a heartbreaking ordeal that I wanted to avoid at all costs.

By having surgery for lung cancer followed by chemo I raised my chances of living 5 years from 0% to 65%. Once again I am at peace with my decisions.

Early detection followed by aggressive treatment are the best ways to battle cancer, in my humble opinion.

Jim
Age 76. Diagnosed 11/03/06. PSA 7.05. Stage T2C Gleason 3+3.
RRP 12/7/06. Nerves and nodes okay.
Catheter out on 12/13/06. Dry on 12/14/06.
Pathological stage: T2C N0 MX. Gleason 3+4.
50 mg Viagra + .05 cc Trimix = Excellent Results
PSAs from 1/3/07 - 8/02/2010 zero.
Next PSA - July/2011
Lung cancer dxed 6/08. Surgery followed by chemo. In remission since.

Worried Guy
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Date Joined Jul 2009
Total Posts : 3742
   Posted 3/26/2011 9:25 AM (GMT -6)   
Wow. I looked at those plots comparing Watchful Waiting vs Radical and the differences seem very significant to me.

Scandinavian Prostate Cancer Group

It's a bit like Pascal's Wager: Do you ignore the surgery and risk the 3x higher rate of progression, the 50% increase chance of Metastices, and the 25% increased chance of overall mortality for the price of months or recovery, 11% chance of incontinence, 50% chance of ED?

The numbers are far more dramatic if you are under 65.

Studies like this are valuable tools.

Jeff

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 3/26/2011 10:08 AM (GMT -6)   
Yeah, that figure (#2) shows that surgery greatly cuts down your chances of having local progression or needing hormonal therapy. If you compare the chances of dying from prostate cancer, the differences aren't so great. If you have growing prostate cancer, it causes all kinds of problems, even if you don't end up dying from it. That's an argument for getting treated.

Also, this study has limitations, especially that most of these patients had their cancer found by rectal exam and symptoms, not by PSA. Also treatment has hopefully gotten better over the years, although that could help both the surgery and the watchful waiting groups to live longer.

Post Edited (Postop) : 3/26/2011 9:51:56 AM (GMT-6)


John T
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Date Joined Nov 2008
Total Posts : 4269
   Posted 3/26/2011 11:06 AM (GMT -6)   
Without classifying patients to low, intermediate and high risk according to the D'Amico classifications this study is limited. We know that surgery is highly cureable in low risk disease and much less effective in high risk disiease. The same holds true for wachful waiting.
JohnT
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.

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 3/26/2011 11:45 AM (GMT -6)   
I wouldn't say that! This is a randomized study, where patients are randomized between surgery and no surgery. This is level 1 evidence, which is the gold standard for proving that a treatment works! There are thousands and thousand of prostate cancer studies done without a control group. If you ask the question of whether the treatment you are getting is actually making a difference for you, you need to know what will happen if you don't get the treatment. That means a control group. Also, how the control group is picked is important. If the doctor decides to operate on the worse cases, and watch the mild ones, that kind of control group is meaningless. The only way to have a meaningful control group is to randomize the men between treatment and no treatment. You can image how hard it must be for someone to agree to be randomized between surgery and no surgery. That's why this is the only level 1 study of surgery for prostate cancer. It is a unique piece of information.

Studies of prostate cancer studies without a control group may claim that a particular treatment works, but can't answer the question, "does it work better than not treating?" Since prostate cancer is so slow growing, that's an important question. Treating prostate cancer with surgery or radiation does nothing to increase lifespan in an 80 year old person with severe heart disease, for example. When I was deciding whether to get treated, my question was, "how much better off would I be getting treated than if I didn't do it?" Everyone deciding on treatment for prostate cancer needs to ask that question.

Also, you are incorrect to say that these patients are not classified according to the severity of their disease. There are exhaustive data in this paper on this, as well as other papers on this study (some which can be accessed from the article in the link) on this, including PSA and stage at the time of diagnosis.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 3/26/2011 11:58 AM (GMT -6)   
Starting to think we need a resident attorney present during some of these exchanges. You realize that it gets too nit-picky for a lot of the average readers, and at best, its the opinion, and opinions only of fellow sufferers of PC, none whom are medical professonals or researchers. Let's keep it in simpler terms, its not a college debate team going on here.

david in sc
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 2/11 1.24
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10,

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3892
   Posted 3/26/2011 12:35 PM (GMT -6)   
The younger you are, the more benefit surgery offers..This is no revelation. I was 68 when I had surgery. My surgeon seldom operated on men over 70. I asked why? He responded "The surgical risk gets to high and the benefit becomes less..When you are older than 70, other forms of treatment do just as well if not better"..

Something about your projected lifespan and your cancer mortality coming together at the same point...
Age 68.
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5, DRE "Abnormal"
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA 0.0

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 3/26/2011 12:38 PM (GMT -6)   
There used to be a program called "College Bowl". Maybe we could have "Prostate Bowl". Hit the buzzer, come up with the right answer, and win a free copy of Walsh's book.

Herophilus
Veteran Member


Date Joined Sep 2009
Total Posts : 664
   Posted 3/26/2011 12:55 PM (GMT -6)   

I have spent most of the morning looking at this study and following various links. John T, Worried Guy and Postop all make real good points. I’d like to see what kind of take Casey has on it. I have several questions that I’ll get answered Monday. Those darn Scandinavians..


Age 51 PSA 6.8
Bxy 10 of 12 Cores positive for Gleason 6. up to 75%
Robotic surg 11-02-09
Post op path. 20% neoplasm;4+3=7 Gleason
All nodes (14) and other related tissue negative for cancer
No EPE
Post op PSA x 3, all <0.01
walkbobwithjack.blogspot.com

davidg
Veteran Member


Date Joined Feb 2011
Total Posts : 4093
   Posted 3/26/2011 1:27 PM (GMT -6)   
i'm 40.

Everyone told me that at my age watchful waiting wasn't a good option. It certainly didn't feel like a good option to me.

I read much of Walsh's book in the store and I recall him saying something along those same lines for people in my age group.
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