PCa is perhaps a unique disease, in that treatment largely depends on whether the patient first sees a urologist or oncologist. As recent as 2014 (U.S.):
"Radiation oncologists and urologists both prefer the treatment modalities they offer, perceive them to be more effective and to lead to a better QOL. Patients may be receiving biased information, and a truly informed consent process with shared decision-making may be possible only if they are evaluated by both specialties before deciding upon a treatment course." [2]
& August (Australia):
"Radiation oncologists were more likely to recommend adjuvant RT and consider it to be underutilized, and more likely to recommend salvage RT at lower prostate-specific antigen thresholds ... Urologists were more likely to recommend salvage radical prostatectomy or cryoablation for local salvage after RT, whereas radiation oncologists were more likely to recommend RT-based modalities and more likely to report that local salvage was underutilized after RT ... Urologists were more likely to report that upfront radical prostatectomy was a better definitive treatment .., whereas radiation oncologists were more likely to report the opposite ..." [3]
"A plague o' both your houses" Shakespeare
Every now & then, an oncologist will publicly insist that RP is not the gold standard. Only to be followed by a study that shows that it remains so.
In the new study:
"Population-based data indicated that patients with prostate cancer who received treatment with either surgery or radiotherapy had improved overall survival compared with a cohort of matched noncancer controls."
"Surgery produce longer survival compared with radiation therapy."
So far, so good. But then comes the interpretation bias:
"These results suggest an inherent selection-bias because of unmeasured confounding variables."
In other words, if it wasn't for selection bias, RP would not have won.
Since we know that there is selection bias, based on the specialist one sees, the selection is essentially random for many men. An ideal basis for a comparative study.
Cancer. 2017 Jan 18. doi: 10.1002/cncr.30506. [Epub ahead of print]
Discerning the survival advantage among patients with prostate cancer who undergo radical prostatectomy or radiotherapy: The limitations of cancer registry data.
Williams SB1, Huo J2, Chamie K3, Smaldone MC4, Kosarek CD1, Fang JE1, Ynalvez LM1, Kim SP5, Hoffman KE6, Giordano SH2,7, Chapin BF8.
Author information
1Division of Urology, The University of Texas Medical Branch, Galveston, Texas.
2Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas.
3Department of Urology, University of California-Los Angeles, Los Angeles, California.
4Department of Urology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, Pennsylvania.
5Department of Urology, Case Western Reserve University, Cleveland, Ohio.
6Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
7Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
8Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
Abstract
BACKGROUND:
The objective of this study was to compare the overall survival of patients who undergo radical prostatectomy or radiotherapy versus noncancer controls to discern whether there is a survival advantage according to prostate cancer treatment and the impact of selection bias on these results.
METHODS:
A matched cohort study was performed using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. In total, 34,473 patients ages 66 to 75 years were identified who were without significant comorbidity, were diagnosed with localized prostate cancer, and received treatment treated with surgery or radiotherapy between 2004 and 2011. These patients were matched to a noncancer control cohort. The rates of all-cause mortality that occurred within the study period were compared. Cox proportional hazards regression analysis was used to identify determinants associated with overall survival.
RESULTS:
Of 34,473 patients who were included in the analysis, 21,740 (63%) received radiation therapy, and 12,733 (37%) underwent surgery. There was improved survival in patients who underwent surgery (hazard ratio, 0.35; 95% confidence interval, 0.32-0.38) and in those who received radiotherapy (hazard ratio, 0.72; 95% confidence interval, 0.68-0.75) compared with noncancer controls. Overall survival improved significantly in both treatment groups, with the greatest benefit observed among patients who underwent surgery (log rank P < .001).
I'm not sure what was meant by the conclusion. One way to read it is that the authors thought that the evidence was that surgery was better than radiation and that by "selection-bias" the authors meant to say that patients were selecting radiation because of factors having nothing to do with better treatment outcomes but instead had to do with the type of specialist they happened to consult.
The full article probably explains the term, but I didn't want to pay the money to rent or buy the article.
It's fascinating to me that, after decades of experience, there is still tremendous argument over whether surgery or radiation is best. This is not the first study I've seen arguing that surgery is far better than radiation. I saw one some years ago by a Mayo Clinic surgeon that actually argued that radiation patients have worse outcomes than patients who get no treatment at all. I've also seen studies arguing that radiation is better than surgery and studies arguing that outcomes are about the same.
Bias in doctors seems to be matched or exceeded by bias in patients. Patients are often adamant that the treatment they chose was the very best one. The idea that they may have received a treatment that was inferior to some other treatment that was available at the time is psychologically intolerable to them. I have seen patients whose treatment failed but still insist that they made the right choice and that, if it failed, then any other treatment would also have failed.
I think that some of the worst bias I've seen is in favor of new treatments. When a new treatment appears - HIFU, cryotherapy, laparoscopic surgery, Cyberknife, proton beam therapy, etc. - there are patients who will mortgage their house to pay for it, convinced that it's the only thing that will save their lives and leave them side-effect free. I think that actual history shows that new treatments are typically worse than standard ones, at least until some years of experience are gained to learn the best ways to use them and the most promising conditions under which to apply them. But like new computers or new cars, the customer is dazzled by the prospect of advancing technology.
I once read a study of bias in medical publishing. The author claimed that, for articles published in the United States and Europe, there is an average built-in bias of 1.4 times. He said that if a study showed that one treatment was 1.4 or more times as good as another treatment, then the effect was likely to be real. But if the benefit was not at least 1.4 times better, the observed effect was more likely to be due to bias. Bad as that is, the author claimed that the bias effect was far worse in other countries, reaching 3:1 (rather than 1.4:1) in Chinese medical publishing.
Oh well. At least we've gotten beyond spells and incantations as treatment for disease.
I think the biggest argument over which treatment is best, throwing out all other factors, age, stage, etc. that may dictate a certain treatment, is caused by advancement. As Each treatment is improved upon, I had IMPT last year. In 1977 the dosage that was used for Proton was, for the most part, sub therapeutic. As imaging, technique and experience occurred, the dosage went up. The beam was more accurate and the Dosimetry plans became more sophisticated to address movement and such. The results were better than the previous "generation". The same for the other treatments. I believe that what I received is as good as RP, at least to me. I quess we are biased.
I saw a urologist and a radiation oncologist. The radiation doctor thought too that surgery was the way to go. Since the Partin table only gave me a 56% capsule contaimement, I chose radiation. Salvage was done by a cryosurgeon who had an 89% salvage cure rate.
I pushed for a regional block, he took the ice ball 28 degress beyond the manufactuer's recommendation. He didn't punch a hole in my rectum. He was an artist. Probably one of the best in the country. I failed cryosurgery, thru no fault of his. In fact, I recommended two patients to him that are now cured.
Big Rich said, "Salvage was done by a cryosurgeon who had an 89% salvage cure rate."
Three highly-recommended radiation oncologists told me my likelihood of cure with SRT were 75% and my likelihood of significant SEs were 3%. I knew otherwise and asked for citations, then read the published references they cited. As I thought and as their own mentor, another nationally renowned Mayo Clinic oncologist, and the foremost Mayo Clinic radiologist confirmed later face to face:
• My odds of cure were zero. Not low; ZERO.
• My odds of a scant 48 months before relapse were < 10% (the same as doing NOTHING).
• My odds of life-altering SEs, including but not even CLOSE to limited to, being tethered to a toilet for the rest of my life, were 100%.
• Other SEs, including severe permanent bowel and bladder damage due to not-uncommon internal configuration which all these docs knew about, were 100% certain IN MY CASE.
I can cite at least 25 similar instances of irrefutable BS out of the mouths of countless physicians, including oncologists, 2 cardiologists, 2 orthopedics, 5 neurosurgeons, and much more just in my own personal experience. I no longer believe one damned important word out of any doctor's mouth until I have verified it with a preponderance of peer-reviewed evidence from at LEAST a meta-analysis, better yet the Cochrane Collaboration if it's really important. That has saved my butt ... literally ... and my bladder, my knee, my back, even my life on at LEAST one occasion ... many times.
Our doctors have at least hundreds of patients to spread their time among. Most of us have only one.
Our oncologists lose many patients ... heck, MOST of them, ultimately. Our wives don't have that luxury.
Why do I keep harping on this? Because I can't interest the guys in my flesh and blood PC forums to read even the single best of the dozens of PC books I've studied. They're actually willing to place their very lives in the hands of a few dudes yakking about their personal experiences.
You are smart to be a skeptic The most dangerous words in the English language are: "Whatever you say doc;" In my case, I did the research, and I knew the dangers going in to the operation. That said, I did not get cured, it was not my destiny. SE's an operation to fix harm done by the radiation and two other SE's I don't care to discuss in a public forum.
I think staging is important. I was stage IV at diagnosis. Of three urologists I saw, two said they didn't recommend an RP, while one said he thought it was worthwhile as there is a survival benefit (but didn't show me any evidence). I also saw a Radiation Oncologist who (surprising to me) said there was no role for radiation to the prostate for me. I ended up getting cryoablation, which has stabilised my condition (no progression in 9 months). I am currently getting a second opinion regarding radiation to the prostate.
Stage IV => your cancer has escaped your prostate into nearby organs, maybe even to distant organs. How would salvage radiation (i.e., radiation to the prostate bed) help?
I see that there was no mention of HIFU as a treatment choice. It has been in use, with very good results and at low cost, in Europe, Canada, and elsewhere for over 10 years. The FDA has finally gotten around to approving it for 'prostate ablation' but not prostate cancer (hence no Medicare coverage). Seems like a turf issue. Entrenched surgical practitioners (and equipment manufacturers) and radiation practitioners (and equipment manufacturers) have a vested interest in keeping the new (old) technology out of the US. There are definitely biases at work.
Well I for one certainly hope the expert I choose to to treat me has a strong bias in favor and strong belief in what they are doing. I think it is absurd to think otherwise. Can you imagine a surgeon getting ready to cut you open while thinking maybe this guy should have had radiation therapy instead, oh well here goes...
In my opinion it is very important to understand our options do the research and then understand possible bias and to recognize that we as patients also have a bias.
Since science can not determine an absolute set of criteria for treatment of prostate cancer and since in fact it cannot explain many aspects of prostate cancer, then my opinion, it cannot provide a guaranteed solution or even an unbiased option. My understanding is that there are many different subtypes of prostate cancer and as such response rates can differ.
There are also so many variables to the process of being diagnosed that in my opinion it is as much of an art as a science. Just take for example reading of a prostate cancer sample, a sample can get different Gleason scores when read by experts of similar experience and training. As we all know Gleason scoring has been associated as a prognosticator of disease outcome. Why would there be a difference? Is it based on some professional or institutional bias? Or just the fact that science does not have the answers at this time.
Maybe I feel different because I recognize my bias and it is built into my own personal decision making process (I have a clear personal bias towards surgery). That does mean I do not recognize other valid treatment options only that at the end of the day, absent proof that there is a better option, I will lean towards surgery.
I think it is completely unfair for someone to go back and second guess someone else's choice of treatment. Many of us here understand that first line treatment does not always work and when I read postings that attempt to generalize and disparage first line treatment decisions it makes me angry. I believe it is unfair and unproductive. Many of us who failed first line treatment did our research and took our best shot. It is not surprising we still believe our choice was the best course of action regardless of the outcome (even though we may have known the odds were not in our favor).
Keep in mind that the bias treatment continues after first line treatment failure. For example, if you chose an oncologist who believes in chemotherapy he or she is likely to suggest chemotherapy options conversely if you chose one involved in immunotherapy then ...,
Anyway as always I am not an expert and this is just my personal opinion based on my personal experiences. My cancer and treatment history is outlined in my profile on this site.
"Many of us who failed first line treatment did our research and took our best shot."
My feeling is that in the days following diagnosis, with pressure to make a decision, there is only so much due diligence a man can do. It is highly probable that he will be unaware that urologists & oncologists exist in alternative universes. It is irresponsible for the medical profession to act as though it doesn't matter which specialist he sees.
The gloves came off when oncologist Mark Scholz co-wrote “Invasion of the Prostate Snatchers". The message being that one would be crazy to go to a urologist. It's a scurrilous book & I think the AMA should step in to make sure that newly diagnosed American men are given the same info, regarless of specialist.
Ideally, there would be an approved site where age, stage & all the other data could be entered & a man would learn what his 5- & 10- year probabilities were of biochemical recurrence & survival were for each of the treatment options.
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