Surgery + Radiation for Advanced PCa ... - Advanced Prostate...

Advanced Prostate Cancer

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Surgery + Radiation for Advanced PCa Offers Better Survival than RT + xRT

George71 profile image
George71

Primary treatment of locally or regionally advanced prostate cancer (PCa) with radical prostatectomy and adjuvant radiotherapy is associated with a lower risk of cancer-specific death and improved overall survival compared with primary treatment consisting of radiotherapy plus androgen deprivation therapy (ADT), new study findings suggest.

renalandurologynews.com/pro...

62 Replies

Yes Sir:

Nalakrats

Take out the mothership....LOL... makes me think of George Clinton... tear the roof off the mother...

j-o-h-n profile image
j-o-h-n in reply to NPfisherman

youtube.com/watch?v=2DdCQ0J...

Geez I can't stop the grove... Hard to type and move....

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/15/2019 4:20 PM EST

NPfisherman profile image
NPfisherman in reply to j-o-h-n

Almost as good as listening to Rick James...brings back memories...Thanks Brother J

NPfisherman profile image
NPfisherman in reply to j-o-h-n

For you, Brother J--just skip the ad....

youtube.com/watch?v=dWZkxYa...

Always the best to you, Mr. Stand Up Comic Relief...

Fish

j-o-h-n profile image
j-o-h-n in reply to NPfisherman

Love it.... thanks...

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/15/2019 5:09 PM EST

Hidden profile image
Hidden in reply to NPfisherman

Best version that I’ve ever heard.. nice job. Mary Jane is a classic. This version the band sounded better than ever. Rick wasn’t disco. A god given gift fueled by Peruvian flake and sex produced some songs I loved then and even more now . I was 20 . If our hand could turn back time. I should have learned how to moon walk. I’m Rick James Bitch!

Hidden profile image
Hidden in reply to j-o-h-n

This was around the last time that I saw live the P - funk all stars.. thanks for taking me back. GeorgeC Tears the roof off the sucker every live performance. An original . Thank you

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 profile image
George71 in reply to Tall_Allen

I welcome what others post that they find in their research that they think may be of interest to the community -- All here are grown men with the ability to read and decide for themselves -- I value the opinion of the persons who do these studies over yours TA.

If someone finds an article written by clinicians or doctors I hope they will post it for all to evaluate for themselves and not wait for you to approve or let you censor this forum.

George71 profile image
George71 in reply to George71

The people that conducted the study and published their findings are much more qualified anyone on this forum -- I would trust their judgment over yours since you are not a doctor or qualified to treat anyone.

as opposed to the authors of the study :

Thomas L. Jang MD, MPH

Neal Patel MD

Izak Faiena MD

Kushan D. Radadia MD

Dirk F. Moore PhD

Sammy E. Elsamra MD

Eric A. Singer MD, MA

Mark N. Stein MD

James A. Eastham MD

Peter T. Scardino MD

Yong Lin PhD

Isaac Y. Kim MD, PhD

Grace L. Lu‐Yao PhD, MPH

.

Tall_Allen profile image
Tall_Allen in reply to George71

There are reasons why one kind of evidence is better than another. Some people post mouse studies and claim they are as good as large randomized clinical trials. People can decide for themselves if this understanding is provided. Those who neglect to do so may be misleading others. I have spent 20 years in research and understand how to evaluate studies. I hope you will take the time to learn.

The authors of that article also wrote "The investigators stated that their findings should be interpreted within the limitations of an observational study design. “Because our patients were not randomized, the 2 treatment groups may have differed in measured and unmeasured ways that are associated with differences in survival despite our best efforts to rigorously adjust for confounders,” they noted."

They understood the limitations of the study and the conclusions to be drawn from it in a way you apparently do not. Since you trust the authors, you should trust them on this too.

George71 profile image
George71 in reply to Tall_Allen

Most of us here are simply sharing our treatment plans, results, doctor recommendations and latest research, studies, trials etc. etc. solely for the benefit of the community and for each of us to read (or not) and decide for our self.

On the other hand - some appear to have a broader agenda – to use the forum to represent their self as an authority and to enhance their own stature. The process is to (1) find any reason to criticize virtually every post making him look like the authority over (in this case) 13 doctors (2)and then reference an article he wrote on his website to get everyone go over there instead.

If I wanted to go to his website I would .. his website will never be an open forum like this is intended to be-- because obviously, there is no room for any views other than his. He is high jacking Healthunlocked as if it is his website.

People here are looking for more than TA's opinion – otherwise they would go to TA’s website where you won’t be able to speak openly since TA won’t allow it here either.

If TA is allowed to censure everyone here – and talk down to them -- soon people will find other alternative sources to share ideas and communicate at. Healthunlocked is being used by TA to enhance himself – TA is not a doctor or qualified to treat anyone.

The 13 doctors should have checked with TA prior to doing the study so he could tell them they are wasting their time.

Tall_Allen profile image
Tall_Allen in reply to George71

Some people who post hide the important parts. I can't say if the intention is to mislead or it is out of ignorance. I assume the latter, and have tried to educate you - which you seem to resent.

George71 profile image
George71 in reply to Tall_Allen

As I said-- (1)You post links to your own site to articles you wrote that are shaped to fit your opinion. (2) You are not a doctor or able to treat anyone (3) while criticizing articles written by 13 people who actually ARE doctors -- and (4) direct others from here to your website regularly.

And, as I said -- The 13 doctors should have checked with TA prior to doing the study so he could tell them they are wasting their time.

Unlike you -- I didn't rewrite the article - I posted the link to the actual article for everyone to read for themselves rather than have you interpret it for them.

Hidden profile image
Hidden in reply to George71

Let’s ask T_A if he’s a paid advocate . By Hu or big pharma..

Tall_Allen profile image
Tall_Allen in reply to Hidden

No, I get no pay for this.

Hidden profile image
Hidden in reply to Tall_Allen

Then I commend you for helping others..

Hidden profile image
Hidden in reply to Tall_Allen

Although we differ on many things, I hope that I can call on you if I need your help.. Surley no is here to create bad blood or enemies. Peace you T_ A .

Hidden profile image
Hidden in reply to Tall_Allen

As much time as you put in . You should be paid...

Break60 profile image
Break60 in reply to Tall_Allen

TA

What are the “inherent differences” between men receiving RP and SRT vs. RT , BT and ADT?

I didn’t realize there was a clear cut difference in N0M0 patients and I thought that either tx was a viable option.

Bob

Tall_Allen profile image
Tall_Allen in reply to Break60

Men suitable for surgery tend to be younger (10 years on the average), healthier, and have fewer known comorbidities. Because of this, there is an inherent bias in favor of surgery on survival. For example, expected 10-year survival for a healthy 60 year-old man is much better than for a 70-year-old man with, say, COPA. Multivariate statistics can only partially correct when the variables (like age) are given - they can't correct for unmeasured variables or when there is not significant overlap. Database analyses have inherent data limitations (they collect only certain data about patients), so they cannot be used to decide between the effectiveness of therapies.

Break60 profile image
Break60 in reply to Tall_Allen

I agree re: younger men and healthier men are more amenable to RP . The study did at least say all men were 65 or older.

Hidden profile image
Hidden

Like so many . Surgery wasn’t an option for me... Adt & RT have worked so far.. if you are a candidate for RP , by all means go for it...

Hidden profile image
Hidden in reply to Hidden

In my case qualifying for surgery was fairly stringent: under 60, BMI under 25, fit, and good odds of success. With all that and a perfect pathology report, except bumping from G8 to G9, my PSAnever went undetectable, and I was bcr I three months. That said was it worth it? I dunno. I figure I had to give it a shot, since a “cure” was at least possible, though not likely. Owed my family that, I guess.i’d do Anything for them.

Break60 profile image
Break60 in reply to Hidden

Interesting. I guess the prerequisites for RP at Johns Hopkins weren’t as stringent: age 69, BMI around 30, otherwise healthy but Gleason 9. I have total ED and very minor incontinence but thankfully low volume bone mets.

Hidden profile image
Hidden in reply to Hidden

No guessing. You will .

Let’s not demean ta. He is extremely resourceful and analytical. Rutgers??

Hidden profile image
Hidden in reply to Hirsch

True , unless you differ of opinion . Then expect to be put down..

Tall_Allen profile image
Tall_Allen in reply to Hirsch

U of Rochester undergrad - Columbia U grad school

Hidden profile image
Hidden in reply to Tall_Allen

Fantastic !

Hidden profile image
Hidden in reply to Tall_Allen

Nice to meet you . I’m an eighth grade drop out . But at least I Was taught how to be kind and respect others opinions and viewpoints.. and if I don’t , I try my best to hold my tongue. Thanks for doing all of your research into Pc. But talking about APC , especially #4 , is different then living with it. Nobody with APC need s to be put down or belittled , especially , harshly by someone that doesn’t. If you had it you would know this.

Tall_Allen profile image
Tall_Allen in reply to Hidden

I suppose you would say the same about Darryl or the hundreds of researchers, caregivers and patient advocates who devote themselves to helping people with prostate cancer. if you don't want to further your reputation as a troll, you should share comments like that only privately or keep them to yourself, because I'm not interested, nor, I assure you, are the many caregivers who you are insulting.

Hidden profile image
Hidden in reply to Tall_Allen

You suppose much ..that’s not scientific . I see no one except you doing the insulting . Whom have I insulted? I apologize. Not my intent . Can you say that you don’t know that you insult not just a few but many? Troll , voodoo , is that all you’ve got. Talk about insults.. “ when the debate is over , slander becomes the tool to the loser” slander is your forte..

Break60 profile image
Break60 in reply to Hirsch

Yes Rutgers:

cancer.gov/research/nci-rol...

Hidden profile image
Hidden

Hahahaha

Darryl is doing just fine. I hope that such postings do not go unchallenged. Many might be misled by misleading posts.

Hidden profile image
Hidden in reply to Tall_Allen

All I know is that I know nothing...I’ll leave it to the more superior minds than my own , to understand the convoluted life with APC.. Everyone is fighting a hard battle so a little kindness to those that are uninformed or to those that offer different viewpoints than yours would create peace on HU. No one deserves to be put down. Things like “ Vegan smeagan “ belittle others beliefs. I believe that you yourself said “” Alternative medicine is more of a religion than science. “ Then why insult another’s religion. “.? You’re better than that T_A.....

Tall_Allen profile image
Tall_Allen in reply to Hidden

Religion is no way to treat prostate cancer. You may advocate voodoo or naturopathy or whatever, but that may get in the way of the survival of others. What you do to yourself is your business, but when you publicly advocate it, you are inviting response. "Vegan Shmegan" was my humorous title for a post about a randomized clinical trial that found no benefit to increasing vegetable intake.

Hidden profile image
Hidden in reply to Tall_Allen

Humorus to you..

Hidden profile image
Hidden in reply to Tall_Allen

I don’t profess to be an advocate. I tell people what I’ve done... no benefit to veggies is pure .. idiocy

Tall_Allen profile image
Tall_Allen in reply to Hidden

"I don’t profess to be an advocate. I tell people what I’ve done... no benefit to veggies is pure .. idiocy" You do see the irony in that post?

Hidden profile image
Hidden in reply to Tall_Allen

No , but you do , and that’s all that matters . Your bio starts off first thing “ Advocate” To me it seems like HU is a place for you to establish your dominance in intellectual prowess .. But when insults start you lose that battle. Kindness and compassion are also treatments for APC. No double blind clinical proof of that either. But 99 % of us living with APC understand that.. a kind approach helps the medicine go down . Not to just those that agree with you on everything.

Tall_Allen profile image
Tall_Allen in reply to Hidden

It's ironic because you contradict yourself by first claiming not to be an advocate for your position, and then calling anyone's proof that your advocated position is invalid "idiocy." if you want to believe whatever you believe in spite of all evidence to the contrary, that is certainly your right. I hope you understand that I would still try to help you in any way I can in spite of your trollish behavior.

Hidden profile image
Hidden in reply to Tall_Allen

Thanks for that T_A ..Trolls can’t help being trolls. But thanks for the compliment.. You know so much. I grew up with a Mensa society know it all. Nobody knows it all. I’m stating what I do or have done thats it. Many of us are not here just for scientific explanations .. and not many are here to argue or to prove a point . Certainly not me. when the debate lowers to argument we should all walk away. Peace ..thanks for keeping it interesting.. take care..

Hidden profile image
Hidden in reply to Tall_Allen

My evidence is that I’m living in clear status. Not to say I’ve beaten the beast . We all know the stats, but if I believed in stats I’d be dead already .

cujoe profile image
cujoe in reply to Tall_Allen

And, I suppose, You have appointed yourself to make that determination for all the rest of us. You are just Too Much! Be Well & Stand Tall - cujoe

Tall_Allen profile image
Tall_Allen in reply to cujoe

You are free to state your opinion as well. It's an open forum. If someone finds my arguments more convincing, that is up to them. The fact that you find it necessary to attack me rather than the content of what I post, shows everyone the bankruptcy of your argument.

Good to hear!🤕

Hidden profile image
Hidden

They are good buddies.. so what.. we all need friends..

Tall_Allen profile image
Tall_Allen in reply to Hidden

We have met twice, briefly. I'm sure we would be good buddies if we didn't live 3000 miles apart. I would say we have mutual respect.

The doctors don't need a non doctor or anyone else to rephrase what they said -- they said what they meant, Here is what the Doctors said in THEIR words:

"Results:

From 1992 to 2009, 13,856 men (≥65 years old) were diagnosed with LAPCa or RAPCa: 6.1% received RP plus XRT, and 23.6% received XRT plus ADT. At a median follow‐up of 14.6 years, there were 2189 deaths in the cohort, of which 702 were secondary to prostate cancer. Regardless of the tumor stage or the Gleason score, the adjusted 10‐year prostate cancer–specific survival and 10‐year overall survival favored men who underwent RP plus XRT over men who underwent XRT plus ADT. However, RP plus XRT versus XRT plus ADT was associated with higher rates of erectile dysfunction (28% vs 20%; P = .0212) and urinary incontinence (49% vs 19%; P < .001).

Conclusions:

Men with LAPCa or RAPCa treated initially with RP plus XRT had a lower risk of prostate cancer–specific death and improved overall survival in comparison with those men treated with XRT plus ADT, but they experienced higher rates of erectile dysfunction and urinary incontinence."

As I said earlier:

"Unlike you -- I didn't rewrite the article - I posted the link to the actual article for everyone to read for themselves rather than have you interpret it for them."

Maybe true, maybe not, who cares anyway? My guess is that primary treatment choices are made very subjectively by each of us based on our own outlook on life and the QOL vs longevity concerns. Debate this to your heart's content, it matters hardly at all.

All the best

My doctors, who have seemingly done right by me so far, would strongly disagree. They would also say that the bulk of the credible studies on the subject would contradict that statement. I guess my point would be that such a strong assertion seems contentious at best.

On a lighter note, I just finished 35 of 35 EBRT treatments today so I'm feeling good. I'm not an expert on the studies, but I ALSO had RP just 6 months ago too, SO I'm hoping to get benefit of the big triple play....RP + RT + ADT.

Now, I just need to endure the months of ADT still ahead...

Hidden profile image
Hidden in reply to PGDuan

Knock it out of the park.

Hidden profile image
Hidden in reply to PGDuan

Great job escaping the easy -bake.. oven . That glow stays with us for some time. It can work .. good luck..

I was too far gone for RP or RT. Never the less, this was a very entertaining post. Monte: school of hard knocks.

Appreciate your post....as I say...take out the mothership when you can...using data from over 10,000 patients adds validity to this ....as they said, we attempted to remove any confounders with this study....I am a believe in stereotactic radiation for treatment--someone else here is not---the studies so far indicate that it works and well on OS but until double blind Phase 3, someone will not endorse it...My question is....

If his followers don't get stereotactic radiation and it proves to be of significant value, will that poster feel regret ...I doubt it...

Ok guys you want pedigree? Well here it is: Undergraduate degree from King Farouk University in Cairo, Egypt. Graduate degree from Sam Houston Institute of Technology, and doctorate from Columbia University Northern Texas. So got me a BSMSPHD = Bull Shit, More Shit, Piled High and Deep. Diplomas up the gizzou hanging in my 1985 Yugo rag top.

Just in case you missed the King Farouk University's nickname it's Farouk U.

Good Luck, Good Health and Good Humor.

j-o-h-n Friday 02/15/2019 4:35 PM EST

Hidden profile image
Hidden in reply to j-o-h-n

What do ya call a Yugo When it breaks down? You don’t go...diplomas or not that thing is a classic now.. if it goes..?

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Hidden

Hail to king Farouk , aka , j-o-h-n for keeping our sinking ships afloat with intergrity and humor .

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