Evaluation of Cancer-Specific Mortality with Surgery Versus RT as Primary Therapy for Localized High-Grade PCa in younger Men

[George71]

Surgery was better:

urotoday.com/recent-abstrac...

[teamkv]

What is considered a young age? We have been recommended rediation at this point. 58 yr old Husband 7 months into treatment now. Gleason 7 no bone Mets, in a few lymph nodes and into the capsule on one side. Highest PSA before treatment 74. Jan 24 PSA at .34. Has steadily declined each month so far. MO says radiation within the year and then off ADT after total of 18 months. He does pretty consistent exercise with weights and elliptical, many supplements, a few preworkout aminos, and lots of organic veggie diet with fish. He personally would rather do radiation than surgery so there is that as well. Incontinence fears after surgery I think is his biggest fear, TBH.

[pjoshea13]

One of the problems with those who give advice for primary treatment, is that it is often the same treatment as the person giving advice received.

I was puzzled when my urologist gave me (& my wife) a lot of information on the various therapies, to be read before our next visit. I expected to get an up-front recommendation from him. Given by biopsy results, wasn't there a logical choice? When I later questioned him on this, he said that it was to make the patient feel empowered.

But it also stops patients coming back to the doctor later & accusing him of choosing the wrong treatment.

I soon learned that the guy next door, who was treated before your diagnosis, will invariably recommend his own treatment - even if it was unsuccessful.

When we make the decision, we are wedded to it. And didn't I always say that surgery was better? LOL.

-Patrick

[RCOG2000 in reply to pjoshea13]

Your urologist did the ethical thing. Not just self interest. I understand thst there is a law requiring breat cancer patients be given information on all megically recognized treatments at diagnosis in some states

All urologists should do this at initial diagnosis of PC

[George71]

The article said men under the age of 60 are considered young age. You can click on the link below and read about it. I may be better to do both --- in his case -- since the cancer is known to be in the lymph nodes already. Ask doctor if surgery to get the hornets nest out first and then radiate the prostate bed and surrounding lymph nodes. No one is a PC doctor on here, so don't rely on anything other than your doctors. You may want another doctors opinion before starting with radiation.

urotoday.com/recent-abstrac...

[Tall_Allen]

Very poor study. Most people who post studies on this site haven't a clue as to how to evaluate them. Here's how their peers responded (peer response is important in such journals). Patients should be wary of posts of research without commentary evaluating it and its context. Database analyses are often just a cheap and easy way for an academic to get published. They are notoriously plagued by selection bias. Here's a response to a similar database analysis:

"We read with interest the National Cancer Data Base (NCDB)

study by Berg et al. [1] comparing overall survival (OS)

between men aged 65 yr with high-risk prostate cancer

(PC) receiving radical prostatectomy (RP) and those receiving

external beam radiotherapy with a brachytherapy boost

(EBRT + BT). The authors conclude that EBRT + BT was

associated with significantly worse OS, with a hazard ratio

of 1.22 for all-cause mortality. When considering the validity

of this conclusion, three salient points must be considered.

First, cancer registries inherently cannot capture the

selection bias that affects treatment allocation to RP or

EBRT + BT, even among “healthy” patients. For example,

several different registry studies have shown implausible

OS differences among patients with low- and intermediate-

risk disease, with divergence of survival curves for RP and

EBRT—favoring RP—within 3 yr post-treatment, in stark

contrast to the level 1 evidence provided by the ProtecT

trial, which found no differences in all-cause mortality at

median follow-up of 10 yr [2,3].

Second, the dominant cause of death even in high-risk PC

is other-cause mortality [4]. The NCDB provides no

information on tumor control specifically, and one cannot

correct for unmeasured confounding variables that would

favor improved other-cause mortality in RP patients.

Therefore, any difference identified in OS is most likely

attributed simply to differences in other-cause mortality.

Third, the authors state that they did not account for the

use of androgen deprivation therapy (ADT) in the treatment

groups. Both the European Association of Urology/European

Society for Radiotherapy and Oncology/International Society

of Geriatric Oncology and National Comprehensive Cancer

Network guidelines recommend long-term ADT with EBRT

+ BT, reflecting the multiple randomized trials that have

demonstrated a robust OS benefit for use of long-term ADT

with EBRT. No high-level evidence exists to suggests that ADT

can be foregone with EBRT + BT, and hence all professional

societies consider it to be the standard of care to use ADT of

sufficient duration with EBRT + BT. Thus, the inclusion of

patients not receiving ADT (31% of EBRT + BT patients) and

the inability to account for ADT duration in this analysis are

troubling. This is evident if the results are contextualized

with two other studies with biopsy Gleason score 9–10

disease. The first found a PC-specific mortality benefit for

EBRT + BT (with median ADT duration of 12 mo) over RP

[5]. The second found an OS benefit for EBRT + BT (with

median ADT duration of 6 mo) overRP without postoperative

therapy, and equivalent OS between EBRT + BT and RP with

adjuvant EBRT [6]. Given the inherent differences between

patients who receive RP and those who receive EBRT + BT, we

acknowledge that all retrospective analyses are intrinsically

an “apples to oranges” comparison. However, in any such

comparison, it is even more imperative to enrich for explicitly

codified standard-of-care treatments.

Ultimately, the superiority or noninferiority of RP versus

EBRT + BT needs to be determined in a prospective,

randomized fashion. We would be highly supportive of a

clinical trial to help answer this question for the thousands

of patients diagnosed with high-risk disease annually.

References

[1] Berg S, Cole AP, Krimphove MJ, et al. Comparative effectiveness of

radical prostatectomy versus external beam radiation therapy plus

brachytherapy in patients with high-risk localized prostate cancer.

Eur Urol. In press. doi.org/10.1016/j.eururo.20....

[2] Pearlstein KA, Basak R, Chen RC. Comparative effectiveness of

prostate cancer treatment options: limitations of retrospective

analysis of cancer registry data. Int J Radiat Oncol Biol Phys. In

press. doi.org/10.1016/j.ijrobp.20....

[3] Hamdy FC, Donovan JL, Lane JA, et al. 10-Year outcomes after

monitoring, surgery, or radiotherapy for localized prostate cancer.

N Engl J Med 2016;375:1415–24.

[4] Johnston TJ, Shaw GL, Lamb AD, et al. Mortality among men with

advanced prostate cancer excluded from the ProtecT trial. Eur Urol

2017;71:381–8.

[5] Kishan AU, Cook RR, Ciezki JP, et al. Radical prostatectomy, external

beam radiotherapy, or external beam radiotherapy with brachy-

therapy boost and disease progression and mortality in patients

with Gleason score 9–10 prostate cancer. JAMA 2018;319:896–905.

[6] Tilki D, Chen M, Wu J, et al. Surgery vs radiotherapy in the manage-

ment of biopsy Gleason score 9–10 prostate cancer and the risk of

mortality. JAMA Oncol. In press. doi.org/10.1001/jamaoncol.

2018.4836.

Amar U. Kishan

William A. Hall

Daniel E. Spratt

europeanurology.com/article...

[George71]

I'm pretty sure the people who conducted the study would disagree. The facts are the facts.

[Don_1213 in reply to George71]

In this case - it appears the facts are somewhat selective, and some pertinent data is missing or not available.

[snoraste]

I agree with Allen that some of the statistical models dealing with cohort studies are misspecified. It's unfortunate that the researchers cannot do a better job to get rid of biases in their analysis - maybe limitations of the databases, and/or the publish or perish culture?

The real question is how to adjust for the biases, now that we now it's there. Can we create upper and lower limit "bands" around the impact of these biases on the results? I'm inclined to think that's plausible. There has been some studies that have attempted to take the state of "health" of the individual into accounts, using it as a proxy for the selection bias.

[ASAdvocate]

What was the time period that was studied? Did they use RT data from the 1990’s? I recall that the SEER database goes back decades.

Also, high risk PCa today is treated with the triple play of EBTR, BT, and ADT. As Allen stated, where does this study assess the RT combo?

While the authors do mention other studies with conflicting results, I’m not convinced that they made their case that “surgery is superior “.

[bobdc6]

then there's the Whack-a-Mole theory, it sometimes comes back no matter what treatment is chosen. No one knows why, so we just have to keep beating it back down.

Bob, G9, proton, adt (18 months)

[SUPERHEAT12]

Diagnosed at 58 with Gleason 9. Urologist wanted RP. Went to Johns Hopkins for second opinion. They said they would not operate over a 6 as chances were too great it was out of the capsule. Took their advice did 43 IMRT radiation and then ADT with Dr. Myers. That was in 2004. PSA currently undetectable after doubling in 2015 for a few months. Still on a Dr. Myers "cocktail". Think I have done pretty well and think the side effects of radiation and ADT are less than with RP. Never had incontinence although did have nausea.

[GeorgeGlass in reply to SUPERHEAT12]

Have you stayed on ADT since the radiation in 2003?

[RCOG2000]

One of the problems here is the rapid evolution of both radiotherapy, sytemic tehapies and surgical procedures. With all of us living so much longer a study that loikd at ten year survival, which was considered a cure 20 years ago is not comparing apples to apples

Very conplex dosease which varies dramaticslly from individusl to individual

Ten years from now there will be other treatments and what is done now will be considered primitive

[George71]

RCOG2000, Good point. It takes years to see if a treatment really works better than another -- over the long haul.

[j-o-h-n]

Hey wait a minute.....Young? Old? I say you're as old as the woman you feel.

Good Luck, Good Health and Good Humor.

j-o-h-n Thursday 02/14/2019 6:17 PM EST