prostate begone said...
If you are going to cite your own blog post as authority for your own opinion, you should at least disclose that fact.
In fact, I do, and pretty much everyone here knows it. My full name is on the blogs, there is a link in my signature that says "my PC blog", and an email link with my full name. I write for two blogs, the New Prostate Cancer Infolink and Prostate Cancer News, Review & Views. They are pretty much the same, except once in a while I write on other topics beyond my assignments on the InfoLink. I take great care in examining high quality peer-reviewed studies and discuss their shortcomings. None of it is anecdotal.
prostate begone said...
The average urologist at a major medical center is far more informed than any of the posters here.
I don't think you would say that if you had met with as many doctors as I have. We regularly hear myths circulated by doctors that have no basis in fact. Some doctors are incredibly well informed, some are still spouting yesterday's news. A lot of doctors are very busy and just can't keep up with it all. Several doctors have told me they regularly refer their patients to my blogs because I'm pretty good at translating medicalese and difficult statistics into clear comprehensible language. I pay strict attention to sources.
And it's not just me. There are several posters on here who have been motivated by their personal experience with this disease to become expert in it in ways that specialists usually have little time for. This doesn't mean that any of us are better than specialists; it just means that we encourage a collaborative relationship with specialists, who have great practical experience. Letting patients know what questions to ask goes a long way towards patient empowerment. Most of us have learned that a specialist in one area has little reliable info to provide on disciplines outside of his specialty. That's why we advocate meeting with experts in each therapeutic option and making up one's own mind. One of the questions I advise patients never to ask is "what is the best option and which would you choose if you were me?"
prostate begone said...
Retrospective studies are common, but their value not especially reliable.
I believe that the general consensus in the medical and scientific community is that there are no meaningful differences in cure rate or side effects between radiation and surgery. Tall Allen, I think it is irresponsible to say that brachy boost is the most curative option "by far" as if this were an accepted fact in the scientific community.
There is no such consensus. I agree that retrospective studies are a lower level of evidence than randomized clinical trials (RCTs). In fact, what I wrote was "Brachy boost therapy is by far the most curative option, according to the statistics:" and I provided those statistics. The authors compiled data from many of the top tertiary cancer care facilities in the country (btw - they have expanded it since then - I'll write it up next week). The fact that it is retrospective doesn't mean we can ignore it. It does mean that selection biases can influence outcomes. That's why I include an analysis of the selection biases. The bias is in favor of surgery
-- examination of patient characteristics shows that those who chose surgery were younger with less progressed disease, and yet they did worse after their chosen treatment.
Another hazard of database studies is that patients treatments may have differed in quality. That, and the lack of detailed treatment data and standardized ways in which diagnostics, treatments and outcomes are reported make SEER database analyses like the one you showed suspect. Hypothesis generating only. It was also only 5 years, whereas survival differences in high risk patients are not likely to emerge for at least 10 years (most would survive 5 years even without any treatment).
Here is how I addressed the selection bias in the single institution UAB trial:
The results in favor of initial radiation therapy are particularly impressive because radiation patients in this study had more progressed disease at the time of treatment. They had higher Gleason scores, higher stage, and higher risk of lymph node involvement. They were also considerably older. The results are all the more impressive because the amount of radiation given was low by today’s best practice standards, and because combination therapies of external beam radiation with a brachytherapy boost to the prostate have been proven superior to external beam monotherapy in randomized clinical trials. If anything, the selection bias and treatments in this study should have favored those who were initially surgically treated.
So we see that the bias is, in anything, towards surgery, yet the outcomes of brachy boost therapy far exceeded treatments that began with surgery and often included salvage radiation as well.
All of the participants in the Kisan consortium study are top-notch institutions that are known to provide excellent quality of care. It currently includes over 1400 patients treated at UCLA, Cleveland Clinic, Johns Hopkins, Fox Case, Mt. Sinai, Wheeling Hospital, U of Michigan, Oslo U Hospital and the LA VA. Ten year prostate cancer mortality was 12% with brachy boost, 20% with EBRT only, and 19% with RP - evidence of a meaningful prostate cancer survival difference when brachy boost therapy was used.
Because we will never have an RCT randomized to surgery vs brachy boost, we will never have information better than this. We do have an excellent RCT (ASCENDE-RT) done in Canada that proved a clear oncological advantage to brachy boost therapy, and the numbers are very much in line with this retrospective analysis. This is the best info we have at the moment on which to base a decision.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
•SBRT 9 yr onc. results
•SBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEsmy PC blog