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Why so many recurrences after surgery?

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halbert
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Joined : Dec 2014
Posts : 5814
Posted 10/9/2018 5:09 AM (GMT -8)
I'll answer the question of "why surgery when...RT is proven to be better" (which is really the question, isn't it?)

It had to do with location and ease of access. For me to have done radiation, it would have required (for IMRT for example), daily drives of 2 hours each way to get the treatments. SBRT was just coming online where it would have been accessible. Low Dose Brachy was available (again, a 2 hour trip each way), but didn't feel right. Which left me with the surgical option.

There is a real danger, IMO, with the emphasis on post-surgical side effects. And, no one actually has ever published RECENT data on this--and, as far as I know, no one has ever published comparative post surgery side effect data based on the various surgical profiles (clinical stage, nerve involvement, LN dissection, etc). On a personal level, it irritates me when men who chose radiation make blanket statements about how awful surgery and it's side effect always are. Pardon me, guys, you don't know. You didn't do it.

No everyone who chooses surgery does so out of ignorance. Sometimes it really is the only practical option.
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WeightLoss
Regular Member
Joined : Feb 2017
Posts : 189
Posted 10/9/2018 5:11 AM (GMT -8)

ASAdvocate said...
I am seeing studies with five year results showing BCR-free percentages of over 97 percent for low-risk men, and 94 percent for intermediate-risk men, who had either SBRT or Proton Therapy (PBT).

Those are amazing results, above (far, far above?) what has been reported for RP.

And, I hear of few, if any side effects from men who had SBRT or HDR-BT, and NONE from men who had PBT.

Yeah, sounds incredible to me also, but both studies and real people on forums are stating it.

The debate and the progress goes forward. All new patients can benefit.

The BCR-free percentages for SBRT are neither "amazing", "far far above" or "incredible". The D'Amico classification of low and intermediate risk are based on clinical stage i.e. biopsy, MRI, guess work etc. In surgery, roughly 30% of these clinical stage low and intermediate risk patients have adverse pathology i.e., ECE, Gleason > 7, surgical margins etc when the pathologist examines the dissected prostate. Patients with adverse pathology have a much higher risk of BCR and may need radiation anyway. The simple conclusion is that based on current technology we are misclassifying patients at the clinical stage. With future genomic testing, better MRI etc, the classification technology will get better and fewer misdiagnosed high risk patients will undergo surgery. But this doesn't answer the difference in 5-yr BCR rates because the studies of SBRT patients were also based on D'Amico classification.

Misdiagnosed surgery patients with adverse pathology have a high probability of BCR and the option of radiation, which theoretically gives them the same chance of not dying from Prostate Cancer as the SBRT patients, albeit with significantly more side effects. The definition of BCR for a surgery patient (e.g., PSA of > 0.2) is different from a SBRT patient, and most undergo radiation only on BCR, Pratoman not withstanding smile. Due to these differences, the 5-yr BCR stats for surgery patients are inflated relative to SBRT while their survival rates are not different since most surgery patients with adverse pathology will eventually have radiation after BCR. I hope I've made it clear that comparing 5-year BCR rates for SBRT vs surgery makes zero sense.

Why not do SBRT since survival rates are the same and side effects lower? Don't forget the lucky 80% of surgery patients who didn't have BCR for 5 years. They escaped radiation and almost all conquer bothersome incontinence, while there are no additional urinary or rectal side effects, that sometimes happen during radiation. Erectile Dysfunction rates for surgery are pretty high but the older patients all have rapidly declining potency anyway. Some studies show 25% of AS patients will have ED a few years after PC diagnosis because of naturally worsening potency.

When I say "escaped radiation", its not to say that SBRT is definitively bad for you, but many people don't want any form of radiation and SBRT hasn't been around long enough for us to be sure. The distaste by some from radiation come perhaps from the fact that Brachytherapy and IMRT do have their share of unpleasant side effects or perhaps worry (justified or not) about other cancers from radiation.

Perhaps SBRT will yet turn out to be a miracle in terms of effectiveness without side effects, but the jury is still out on that one and from what I have read, the definitive studies won't be out until 2022. But it should be made clear that the key advantage for SBRT is the minimal side effects vs current standards of radiation and surgery. It's definitely NOT that SBRT is better at preventing the low and intermediate risk PC patients from dying from Prostate Cancer. The reason for the lower 5-year BCR rates in surgery patients vs SBRT is simply the fact that the pool of D'Amico classified low and intermediate risk surgery patients includes those who will eventually be cured by radiation.
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tarhoosier
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Joined : Mar 2010
Posts : 520
Posted 10/9/2018 5:16 AM (GMT -8)
Radiation statistics for prostate treatment tend to be affected by adverse selection bias. Patients are diagnosed by urologists who are surgeons. If the patient is not suitable for surgery due to condition, advanced disease, age or other factors then the urologist refers the patient to radiation oncology. Thus the less promising patients are treated by radiation more than by surgeons. The reverse happens far less often. Thus long term results for radiation treatment will appear less successful over time unless there is a rigorous patient matching procedure and the treatment location is uniform and treatment technique and operator (or surgeon) is consistent with all patients. Thus few studies will offer this rigor. Also the studies would be retrospective by nature introducing another variance.

I have always wondered about the "second chance" theory of initial treatment choice. If X does not succeed I can still move to Y. I would want the treatment that gave the VERY BEST chance for success the FIRST time.
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WeightLoss
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Joined : Feb 2017
Posts : 189
Posted 10/9/2018 5:33 AM (GMT -8)

tarhoosier said...
I have always wondered about the "second chance" theory of initial treatment choice. If X does not succeed I can still move to Y. I would want the treatment that gave the VERY BEST chance for success the FIRST time.

Perhaps its about fear of radiation, where there are still some unknowns, hence there is general preference for X over Y. With a clinical stage diagnosis, chance of eventual cure is the same for X, X+Y and Y so if your definition of "success" is "cure", then there is no difference. So, if you have a distaste for Y, try X first since there is a 80% chance you won't need Y. Eventual success is the same.
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InTheShop
Elite Member
Joined : Jan 2012
Posts : 11468
Posted 10/9/2018 6:05 AM (GMT -8)
What WeightLoss said - don't discount the effects of fear/emotion/etc even after lots of research and objective thought.

At my DX I just knew that I didn't want surgery and oddly enough all my "research" lead me to the scientific conclusion that RT would be better for me.

Andrew
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halbert
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Joined : Dec 2014
Posts : 5814
Posted 10/9/2018 6:27 AM (GMT -8)
I'll keep saying it: not everyone has the luxury of time and/or money to travel distances to get the highest level treatments, and it's totally non-productive to criticize decisions made for those reasons. Add to it that we can get very US-Centric in our assumptions about what is available worldwide.
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fiddlecanoe
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Joined : Oct 2016
Posts : 730
Posted 10/9/2018 6:49 AM (GMT -8)
Returning to the original question, there are more failures of surgery than radiation for the simple reason that more surgeries are performed. I tried just now to find statistics on the number of people who opt for prostatectomy versus radiation, but couldn't find it. But I have read elsewhere that there are far more RPs than RTs as treatment for PCa. The key issue would be the rate of failure for RP and RT, controlled for risk and other factors.
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JayMot
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Joined : Feb 2016
Posts : 244
Posted 10/9/2018 6:51 AM (GMT -8)
halbert-----I've been saying the same thing since I've been on this board. I chose RP because of the ease of "secondary" treatments. That "ease" includes taking into consideration such things as location of treatment and cost of treatment, including available insurance coverage. I am not old enough for medicare. I hope I do not need secondary treatment. My SE's are extremely minimal. Drip here and there and NO ED. Of course, ED was very prominent for about 15 months post-op.

A couple members posted on this tread have implied that I am either not "knowledgeable" enough or did not do my "scientific" research prior to my treatment decision. These are the same people that preach, prior to selecting a treatment option of the many options available if BCR should occur post primary RT (salvage RP, Salvage brachy, salvage Cyro, etc.). But, when responding to RT BCR posts, their response is, oh, sorry buddy, you're on HT for life now, Good luck (just check the current 1st page post about post primary RT BCR for proof.).

Back on topic. There are over 90,000 RP's a year. How many HW prostate members? The members that hang around HW are ones that need advice, either prior to primary treatment, or post primary treatment failure. Most success stories, and there are way more successes than failures, move on with life and from this board.
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logoslidat
Veteran Member
Joined : Sep 2009
Posts : 7585
Posted 10/9/2018 7:17 AM (GMT -8)
IDK...I erase a lot of my posts and seriously at my age...Im not sure if its the mods or myself...lately I just look at any suspected mod erasure as a chance for me to write it in a different way...this is not to excuse what I consider lazy and sometime vindictive erasures imo...see I should be able to say that ...mods are not perfect beings any more than the rest of us and should not be immune to criticism...but this forum says mods can do no wrong ever... a silly premise for anyone to hold...again I can or will be held accountable for even saying that...It is absolutely nuts(oops there I go again) and a real sign of the times...but again...its China Town and the price of admission...I just wish more mods would admit it themselves...again a multitude of rule violations when and if any moderator wants to apply the silliness...there it is again...so ...well...so silly...I would not be surprised at all to have this post erased just be cause ' their (watch this one Sigmond} button is bigger than mine'...you fracking know I'm right...love that word provided...well...by a moderator and where the heck are the edit emogies...grumbling face
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jim nyc
Regular Member
Joined : May 2018
Posts : 41
Posted 10/9/2018 7:43 AM (GMT -8)
Thanks for bring the study /www.ncbi.nlm.nih.gov/pubmed/24510158 to my attention. It is quite amazing that surgery this good for G8-10 patients. I wonder why it was even used in these cases. Gleason scores aren't the only criteria; other measures of confinement must have given the doctors encouragement.

The Walsh book says that RP results are significantly different for high volume major cancer centers and other providers of RP. I wonder how much better the prospects for RP is at the better hospitals.
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halbert
Veteran Member
Joined : Dec 2014
Posts : 5814
Posted 10/9/2018 8:04 AM (GMT -8)
jim, it's commonly asserted in here that experience is a significant factor for surgical success--the RP surgery--whether it is open or robotic--is a complex and challenging surgery, and the skill of the surgeon is very, very important.

I've never seen--and I can understand good reasons for it--any kind of study that compares outcomes based on either the surgeon or the facility.
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ddyss
Veteran Member
Joined : Apr 2017
Posts : 500
Posted 10/9/2018 8:25 AM (GMT -8)
this is a tough discussion with no clear winner - decision depends on many factors. Outcomes depend as much on expertise as on luck.

The only winner when BCR happens are those nasty PCa cells.
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jim nyc
Regular Member
Joined : May 2018
Posts : 41
Posted 10/9/2018 9:58 AM (GMT -8)
Yes, it is a tough question but the debate is good for those of us thinking through the options. If nothing more it makes us better advocates when we question the surgeons and RO. So far my doctors are impressed with my tough questions. To their credit they respect a knowledgable self-advocate.
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alephnull
Veteran Member
Joined : Dec 2013
Posts : 2452
Posted 10/9/2018 10:12 AM (GMT -8)
Tudpock18,

I chose because my Uro thought there was a chance of cure.

It wasn't cured but looking back I'm still glad I had surgery.
Why?
It debulked my cancer.
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ddyss
Veteran Member
Joined : Apr 2017
Posts : 500
Posted 10/9/2018 11:27 AM (GMT -8)
Jim, please note my signature. I had ece in my mri report - but when they went in I was lucky enough to get negative ECE on the Post surgery path report. Just saying that MRI is not perfect. Also point from your signature is that your prostrate size is rather large (90 cc vs around a normal size of 30cc ) - so your higher PSA may not all be from PCa) and also size is a factor for Brachy and maybe for DaVinci ( some surgeons may want/try to reduce it before surgery if you deside to go that route).
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jim nyc
Regular Member
Joined : May 2018
Posts : 41
Posted 10/9/2018 11:54 AM (GMT -8)
Good points, ddyss. When my 1st oncological urologist suggested I needed a biopsy, last Dec, I was skeptical because my PSA is about normal for the size. I actually thought he was being somewhat fanatical. But I welcomed the more aggressive stance. When the MRI subsequently came back PIRAD-5, I was alarmed but the biopsy in Jan (2018) found no cancer. The second biopsy, in Sept 2018, did, 3 core with G8.

After talking to a RO and two surgeons (at two institutions) they all came to the same conclusion—that I’m a good candidate for surgery. The G8 is in the left base in the posterior in or near the MRI lesion. The tissue is greater there (as opposed to the apex) and both surgeons agree that by taking a large swarth, they can remove all the cancer leaving no margins. Bond scans, CAT scans, and the MRI itself indicate no signs of spreading.

I know the MRI and scans have finite resolution and biopsies sample a small part of the prostate. They are still convinced that even though it is G8, there’s an excellent chance that surgery will get it all. Even the RO came to this conclusion. I’m going for it! PS, I see your signature and appreciate your experience. Glad you weighed in!
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ASAdvocate
Veteran Member
Joined : Feb 2015
Posts : 1052
Posted 10/9/2018 12:27 PM (GMT -8)

fiddlecanoe said...
Returning to the original question, there are more failures of surgery than radiation for the simple reason that more surgeries are performed. I tried just now to find statistics on the number of people who opt for prostatectomy versus radiation, but couldn't find it. But I have read elsewhere that there are far more RPs than RTs as treatment for PCa. The key issue would be the rate of failure for RP and RT, controlled for risk and other factors.

The percentages of men having RP and RT were equal at 38 percent as of 2103. Analysts have projected that their shares today are less, but still equal, due to the rise of active surveillance.

So, now, newly-diagnosed men are choosing RP, RT, and AS about equally.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/pros.23496
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mattam
Veteran Member
Joined : Aug 2015
Posts : 3979
Posted 10/9/2018 12:40 PM (GMT -8)
Alephnul said:

“I chose because my Uro thought there was a chance of cure.

It wasn't cured but looking back I'm still glad I had surgery.
Why?
It debulked my cancer.”

My sentiments exactly. I’m sure hoping the debulking idea has merit. Even though my RP didn’t provide a cure, if getting rid of the primary tumor bought me some significant time it still will have been worthwhile.
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lifeguyd
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Joined : Jul 2006
Posts : 691
Posted 10/9/2018 2:53 PM (GMT -8)
I am of the opinion that prostatectomy is not a proper treatment for prostate cancer. Before high intensity radiation was available, surgery was about the only option. But we longer use leeches or blood letting either.

My surgery was 12 years ago and I have been forced to suffer the side effects of a procedure that should have been put on the shelf years ago. Now it is all about the money. Urologists and equipment sellers (DaVinci) refuse to give up the cash inflow. Check the failure statistics for mid to high Gleason cases. Most Gleason 6s don't need any treatment and higher numbers usually are not cured by surgery.

If I sound bitter, it is because I am.
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halbert
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Posts : 5814
Posted 10/9/2018 4:53 PM (GMT -8)
It may be that in the future surgery will become a niche treatment for unusual (not necessarily rare) cases--but we're not even close to that day.

I would like to comment on a couple of the early comments to this thread--and the OP itself--which comes close to suggesting that the logical, thinking, 'scientific' person would choose radiation over surgery every time. I, simply, don't think that is a fair statement--in that the corollary is the idea that those who choose surgery are functioning solely from an illogical, emotional, non-research based position. If I said that about someone who chose radiation, there would be plenty of frothing at the mouth.

Take care, guys, about generalizing your opinions and situations into globally true assumptions. THAT, IMO, is the biggest problem in our society today--unwillingness to consider that the person you disagree with might actually have something important to say. I'll stop there--I know I'm wandering into dangerous territory.
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AZ Guy
Regular Member
Joined : Feb 2017
Posts : 188
Posted 10/9/2018 5:28 PM (GMT -8)
I had a G6 and selected surgery. Why? Well, I'm relatively young and not particularly scared of surgery, liked the idea of having SRT as a back-up and wanted the full pathology of the prostate when removed. I had the surgery and the carefully selected surgeon told me it was a more difficult surgery based on the prostate's location (yeah I guess there are some nuances). I recovered well and wasn't incontinent and was able to get erections. The pathology did show it was worse- bumped up to 4+3 with positive margin. Then my first PSA was .40. Ugh. That was hard to hear. So within three months I was getting that SRT + ADT.

I can't say I'm disappointed with my selection of surgery given the information at the time. But if I knew then what I know now..I would have gone RT.
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JayMot
Regular Member
Joined : Feb 2016
Posts : 244
Posted 10/9/2018 5:38 PM (GMT -8)
halbert, I said the same thing earlier today. My statement was something to the effect that I chose surgery because I was not knowledgeable, according to InTheShop, and didn't do my "scientific research" according to tudpock18...or vice-versa (not sure who stated what). Then that post was promptly deleted. I assume by Tudpock (BTW, thanks for the email....NOT!)
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ASAdvocate
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Joined : Feb 2015
Posts : 1052
Posted 10/9/2018 7:18 PM (GMT -8)

halbert said...
It may be that in the future surgery will become a niche treatment for unusual (not necessarily rare) cases--but we're not even close to that day.

I would like to comment on a couple of the early comments to this thread--and the OP itself--which comes close to suggesting that the logical, thinking, 'scientific' person would choose radiation over surgery every time. I, simply, don't think that is a fair statement--in that the corollary is the idea that those who choose surgery are functioning solely from an illogical, emotional, non-research based position. If I said that about someone who chose radiation, there would be plenty of frothing at the mouth.

Take care, guys, about generalizing your opinions and situations into globally true assumptions. THAT, IMO, is the biggest problem in our society today--unwillingness to consider that the person you disagree with might actually have something important to say. I'll stop there--I know I'm wandering into dangerous territory.

Halbert, I have somehow managed to entangle myself with EIGHT different PCa forums. One of them is virulently anti-surgery. They ban people almost every day for for posts that mention surgery as a possible option.

Overall, I don't disagree with them, but I have great reservation about how they state their opinions. People who had surgery have had surgery....period. They should not be mocked as morons who deserve the side effects that they suffer. Well, I now am more sensitive to how hurtful those opinions can be.

Our support group attitudes are almost as nasty as our politics, and we really must try to rise above that.
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WeightLoss
Regular Member
Joined : Feb 2017
Posts : 189
Posted 10/9/2018 11:38 PM (GMT -8)

ASAdvocate said...

Overall, I don't disagree with them, but I have great reservation about how they state their opinions. People who had surgery have had surgery....period. They should not be mocked as morons who deserve the side effects that they suffer. Well, I now am more sensitive to how hurtful those opinions can be.

Our support group attitudes are almost as nasty as our politics, and we really must try to rise above that.

Thats great! However, do note that the negative reaction to the RT advocates is not due to regret and therefore hurt. It is outrage because most surgery patients had great success in definitive cure and find the mocking to be outrageous misstatements.

The few surgery patients who had bad side effects from surgery or had adverse pathology are those who are likely to feel regret and be hurt. It's a terrible thing to rub it in for this minority, under the guise of saving the majority.
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Jaybee&GG
Regular Member
Joined : Jul 2016
Posts : 395
Posted 10/10/2018 1:45 AM (GMT -8)
The spectre of BCR looms large with high risk surgery guys 'tis true. And GG fits that description to a tee. I'd be lying if I said that every PSA test wasn't also a test of another kind. But he dodged a major bullet in the SE's department, so I guess he's in the minority there (by the sounds of things).

We also fall into the morons category, as we never knew there was more than one type of treatment for his disease when we were sent off to a uro by his GP. We were told "it must come out", and believed it. The only thing I DID do, was research the best surgeon in the land, and I'm pleased to say I'm pretty sure I found him! The word radiation was never uttered by a single soul - not his GP, not the first uro, or the second and third. Of course I was so busy freaking out and googling urologists all day and night, I had absolutely no idea I should have been searching for radiologists as well.

So yeah... we went from never having gone to the docs for anything more than a cold or some travel immunisations, to a full-blown cancer diagnosis. It's been a steep learning curve, but thanks to the good folk here, we are armed and dangerous if and when it comes to the first sign of a return! (but hoping and praying it never comes to that of course).

And yep - I've beaten myself up more than enough over that, so negative feedback regarding surgery only serves to make us feel a bit queasy, and really won't help all the other newbies who stumble in here, having already made the same choice. Encouragement and support is what we all need, and some of Andrew's beautiful poetry along the way doesn't hurt either!

At this point in time, we are just grateful GG is in remission, and we have his surgeon to thank for that. It may not last, but there's no point in thinking negatively about something that may never happen.
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