It's a divisive topic. Studies show that men are more likely to opt for RT (radiation therapy) if they first go to an oncologist, whereas men are more likely to opt for RP (radical prostatectomy) if they first see a urologist. There are bias allegations against urologists (they make money from surgery), but oncology practices increasingly have a financial interest in radiation entities.
And then there is the bias that patients have - they tend to believe that they made the right choice, even when it was not a success.
The argument against study results such as from the new one is: "Yes, but radiation is superior today."
"We performed a retrospective cohort study by linking several administrative datasets to identify patients who were diagnosed with prostate cancer between 2004-2016 in Manitoba, Canada, and who were subsequently treated with either RP or RT."
"During the study period, 2,540 patients underwent RP and 1,895 underwent RT for prostate cancer.
"Unadjusted overall survival (OS) was higher for RP vs. RT (5-year OS 95.52% for RP compared with 84.55% for RT...)...
"... compared to patients in the RP groups, patients in the RT group had an increased rate of all-cause mortality (HR 1.93 ...), and PCSM {prostate cancer specific mortality} (HR 3.98 ...)..."
No mention of morbidities that might have steered patients away from surgery.
, 101097JU0000000000000805 2020 Feb 18[Online ahead of print]
The Comparative Outcomes of Radical Prostatectomy Versus Radiotherapy for Non-metastatic Prostate Cancer: A Longitudinal, Population-Based Analysis
Justin D Oake 1 , Benjamin Shiff 1 , Oksana Harasemiw 2 3 , Navdeep Tangri 2 3 4 , Thomas W Ferguson 2 3 , Bimal Bhindi 5 , Jeff W Saranchuk 1 , Rahul K Bansal 1 , Darrel E Drachenberg 1 , Jasmir G Nayak 1
Affiliations expand
PMID: 32068493 DOI: 10.1097/JU.0000000000000805
Abstract
Introduction: The comparative effectiveness of radical prostatectomy (RP) versus radiation therapy (RT) for prostate cancer remains a largely debated topic. Utilizing a provincial population-based linked dataset from an equal-access, universal health care system, we sought to compare outcomes among patients treated with either radiation or prostatectomy for non-metastatic prostate cancer.
Methods: We performed a retrospective cohort study by linking several administrative datasets to identify patients who were diagnosed with prostate cancer between 2004-2016 in Manitoba, Canada, and who were subsequently treated with either RP or RT. Cox proportional hazard models with inverse probability of treatment weighting (IPTW) were used to compare rates of all-cause mortality, as well as prostate cancer specific mortality (PCSM) between patients who underwent RP vs. RT.
Results: During the study period, 2,540 patients underwent RP and 1,895 underwent RT for prostate cancer. Unadjusted overall survival (OS) was higher for RP vs. RT (5-year OS 95.52% for RP compared with 84.55% for RT, p<0.0001). In IPTW-adjusted Cox regression analysis, compared to patients in the RP groups, patients in the RT group had an increased rate of all-cause mortality (HR 1.93, 95% CI 1.65-2.26, p<0.0001), and PCSM (HR 3.98, 95% CI 2.89-5.49; p<0.0001).
Conclusions: RT was associated with higher all-cause mortality and PCSM rates compared with RP. These findings highlight the importance of comparative effectiveness research to identify treatment disparities and warrant further investigation.
As always, thank you for your efforts in helping to increase our understanding of the knowns around PC.
Anytime cancer can be resected, Versus radiated I think resection is a good option. With regard to prostate cancer, the trouble is, once it has metastasized, it can’t be completely removed by surgery.
And I’ve noticed here, and I assume it holds true across the population, many people who have RP wind up doing salvage radiation due to persistent PSA.
One of our Drs, who’s advice I value. Knowing my husbands situation, said, “I’d do surgery and then you can do radiation afterwards.” My husband’s cancer is not confined to the prostate.
My husband did not want surgery and we are now in the process of doing radiation.
Either way— No Cure For Mortality—
PS: Radiation in good candidates, can kill most types of cancers. And, it can miss cancer cells (as can surgery) and unlike surgery, radiation can cause other cancers.
Good Point. If cancer is obviously localized RP is a great choice. If not, RP, will likely be followed by radiation and all it’s negative side effects. Compounding side effects of surgery.
Exactly what happened to me. They thought it was localized when they operated, but it wasn't. So radiation for me. Won't know what the damage is until the Lupron wears off.
I weighted both options very thoroughly and the final verdict was:
"If the RP can get me 2-3 years before salvage irradiation, WITHOUT having to pay the incontinence penalty, then my decision was right". For now, the former component is still proof-pending, while the latter seems successful. It will take some more time for me to be able telling whether I did right or not.
People who are offered RP technically would be considered “organ confined” unless they are receiving RP in a clinical trial. This skews data too between RP Versus RT. Clearly those selected for RP are way more likely to have longer PFS no matter what path they choose, compared with those who are presenting as metastatic.
We Dr shopped like mad for my husband’s treatment. And only 1 Dr suggested surgery was an option with PC in lymph nodes.
Right, this study is flawed unless adjusted for Stage. Obviously the majority of RP candidates are < Stage 2 and will have higher PFS just by that criteria alone.
I did not go to Radiation specialist...so NO radiation for me......I did not go to Urosurgeon...So NO surgery for me.... I just went to a plain ,vanilla,old fashioned Medical Oncologist...and she put me on Lupron,Zytiga and Prednisone...My PSA dropped from 830 to 0.4 and ALP from 191 to 59......in 9 months ...Thank God !
A MAJOR CONSIDERATION VERY IMPORTANT TO REMEMBER TROOPS:
There is still more that they do NOT know then what they know of our disease, thus, we are all guinia pigs here. Surgery does allow for surgical follow up-although rarely done, whereas with radiation, follow up surgery cannot be had, due to damage to adjacent cells so one cannot see the cancer contained areas.
Another very important factor is there is still much debate on when the spread of PC occurs, i.e. can a biopsy in and of itself start the tracking out of the prostate, or does the bleeding caused during the biopsy cause this leakage outside the prostate??
It is indeed a turkey shoot. No easy answer sad to say but to consider that getting rid of as much of the cancer during either procedure is the object of the exercise. This is thought to be because the more aggressive cancer is still in the prostate, so the less one has in one's body, the better.
I still recommend surgery if the cancer is confined to the prostate, in my view, the decision is not even close. That said, the skill of the surgeon and their team all play a role in outcome, as does radiation treatments.
PC is hell on wheels, no matter how one looks at it, there is no easy answer, no escape, and those of us who live a long time, have been beyond lucky, as compared to many who drew the bad card and died early.
Problem is, proof of this rarely exists. Mostly it is an assumption based on incomplete evidence.
I think its safer sticking with "getting rid of as much of the cancer during either procedure is the object of the exercise." One should assume there is a good chance that stragglers remain, and so be prepared for the potential of a future uprising.
I think regardless of what route each of us took, we have to move forward from there. We have to work with the results of each type of treatment. However, I believe it is very important that the information continues to be shared here and by our medical care teams, so newly diagnosed patients and those of us facing a new phase in our disease understand risks and benefits before making those critical decisions.
While it still seems not widely known, the evidence existed decades ago that many cancers began while men were in their 30s or 40s, and by the time those cancers were locally clinically significant, many years later, there was already the seeding of cancer cells OUTSIDE the prostate, most likely in the bone marrow.
So when asked if the RP or RT managed to "get it all" the correct answer in the (vast?) majority of cases should be "highly unlikely." That is not the answer given by most surgeons or radiation oncologists. It looks localized to them. But just because a cancer APPEARS localized, that does not mean it IS localized.
The scientific evidence points to concluding that a cancer that is aggressive enough to ultimately kill you is very likely also a cancer that has ALREADY metastasized microscopically by the time of "early" treatment, even if those cellular escapees remain dormant, undetectable and insignificant for decades (or forever).
The generally early systemic nature of this disease has been understated. And THAT is an understatement itself, as evidenced by the growth of a multi-billion-dollar industry of non-systemic treatment.
In the U.S., the 2019 estimate of the ratio of PCa deaths to new cases was ~18%. & yet 70% of men who get PCa mets are dead within 5 years. One can only conclude that the majority of men do not progress to metastatic disease. Presumably, RP & RT contribute to that.
In the U.K., where there is less screening, PCa mortality is closer to 25%. Even in countries where there is almost no screening, the PCa death rate is only ~35%.
"70% of men who get PCa mets are dead within 5 years"
Or... 70% of men who get diagnosed with clinically significant PCa mets are dead within 5 years. If one defines "mets" only as that which has been seen, and can be seen, that is a limited (and seemingly incomplete) definition.
"One can only conclude that the majority of men do not progress to metastatic disease. "
Or... one can conclude that some men do not progress to metastatic disease, some progress to highly visible (and lethal) metastatic disease, and some intermediately progress to a level of systemic disease with micro-metastases (maybe potentially lethal, maybe not) that is not visibly metastatic disease.
The point is, even if that latter scenario is not what one might want to call "metastatic" is is still systemic. Do local treatments definitively and permanently "cure" systemic diseases? Typically not.
We didnt know the extent of my disease until after RP. I was misdiagnosed as a 3+4=7 from the biopsy. My PSA was around 15 at the time. Scans showed no bone or tissue mets. During surgery it was discovered the cancer had escaped the prostate (ECE), and had traveled along the nerve bundle, and moved into pelvic lymph nodes. The pathology after surgery showed that about 25% of my tumor was grade 5 (not sure how the biopsy missed that). My PSA after RP was still around 11, so I was given the option of radiation or ADT. After reading many radiation horror stories, I opted for ADT. After 3 years of ADT with Firmagon, Eligard, and Xtandi, I am currently undetectable, and on a drug holliday !
My experience leads me to believe that everyone who diagnosed with Pca should have one of the more sophisticated PET scans before deciding on a treatment program. If not everyone, then at least those with 8,9, or 10 Gleason score. I had an RP without seriously considering Radiation. The biopsy said Gleason 9, while my PSA was 2.5. Emotionally, I couldn't get that thing out of me quick enough. My PSA nadir was .58 at 90 days and rose to 1.12 thirty days later. They did lots of scans and nothing was alarming, and they prepared to radiate my prostate bed and lymph nodes. I read about the Auximen scan and I convince the radiological oncologist to seek insurance coverage for an Auximen scan. United Healthcare said no and she fought for me, and it was ultimately approved. I had the scan 5 months after surgery, and it indicated 3 metastatic lesions on my skeleton.
I suspect the lesions were there before the surgery. The more precise knowledge of what is happening in our bodies before surgery would help us make better decisions. It would help surgeons and radiologists target hot spots and make adjustments as we begin treatment.
IMHO, Doctors are generally not trained to be proactive. They wait for something to show up and react. There are tools to help proactive treatment, and they are getting better all the time. Nevertheless, most doctors don’t seem too interested in using new tools and prefer to stay with what they have been comfortable with. In my case, we would have radiated the wrong area. We will never know but it is likely it saved me a long time in figuring out what to focus on.
It is unbelievable to me that more Doctors are not fighting for Auximen and/or PSMA 68 prior to RP or RT. My mind is trained differently and I intuitively try to cut down the odds of having problems. A friend diagnosed with Pca shortly after me with similar stats, asked for the Auximen before surgery after speaking with me. Dr. David Lee at Presbyterian got it done, and my friend believes it helped the surgeon to use tactics that were more precise, including resecting additional tissue on one side during the procedure.
These are anecdotal stories and not a scientific study, but intuitively it makes a lot of sense to me.
Likewise, when I had radiation, I developed shingles shortly after. As I told fellow warriors about my experience with shingles, a majority (more than 50%, not everyone) said the same thing happened to them. 3 weeks ago, my kid brother (60) had an emergency craniotomy and, tragically, has grade 4 glioblastoma PNET. Two weeks after the surgery we met with the radiologist and she told me my theory is nonsense. There is no statistical support. I think this is a stupid response, for several reasons. Most of all, if there is no danger with getting the vaccine, it is a prophylactic step to take that could prevent further discomfort for a guy who was just told he will be lucky to make it 2 years. My brother had one of the most violent cases of Chickenpox I ever heard of as a child. He has genetic similarity to me, and it happened to me. The likelihood is she never looked for this correlation. She will react if it comes. Not take a relatively free step to decrease the odds.
I don't have time to read more on the subject at the moment, but I wonder if the results of the studies are broken down for Gleason score, PSA at diagnosis, etc.
My urologist brushed off the newer scans mostly as overly pricy tools that exist mainly to make money for those who develop and deploy them. Only later did it occur to me that looking harder for mets, with better tools, would reduce the number of RPs he could perform (since many would move on to ADT if scans revealed mets).
Anthony Horan relates a story in his book about a urologist in the 1990s who routinely checked bone marrow for PAP, as a sign of systemic disease, but was finding so much systemic disease that he stopped looking for it, so he could actually make a living. Referring men to medical oncologists for ADT was obvious not cutting it for him (pun intended).
Horan claims over 50% of men getting RP would show signs of systemic disease... but ONLY IF we were actually looking hard enough to find it.
You offer a good insight: we all want to believe that the decision we made was the right one. I made my treatment decision before I read Scholz's book. By his algorithm I should have gone with RT because of my "stage of blue." I didn't. My MO and RO wanted me to do hormonal therapy + "salvage" RT after the surgery because the margins were/were not clear. I said no because my PSA was nil and I was busy dealing with the incontinence and the ED. The MO kept on hammering on ADT; I kept on saying no. By then, I was not convinced that a few months of additional "survival" was worth the side effects of ADT. I continued to say NO. Now 15 months post-op with an undetectable PSA my MO has said that my decision was the right one. Maybe. I could have thousands of PCa cells floating around in there. Right now, the incontinence is controlled and I am working on getting the erection back. Maybe. You make the decision you make and then you live with the roll of the dice you throw.
Here's a study with a median follow-up of 7.3 years:
"During the follow-up, for the low-risk patients, the adjusted PCSS {prostate cancer– specific survival} after metastasis was 86.2% and 79.3% in the RP and RT groups, respectively; for the intermediate–high-risk patients, the PCSS after metastasis was 76.3% and 63.3% in the RP and RT groups, respectively."
Patrick, do these results imply that the majority of intermediate to high risk metastatic PCa patients who had either RP or RT we’re still alive after the 7.3 year follow-up?
Exactly, in your words, “Certainly the majority did NOT die due to their PC.” So how does that square with Patrick’s statement above, “70% of men who get PCa mets are dead within 5 years”?
When I was trying to decide on treatment 16 years ago, I found an online calculator. It took all of my variables & gave 3 numbers - the probabilties of surviving 10 years after RT, RP & without PCa.
What surprised me was how great a chance a healthy 56 year old man has of dying within 10 years. It put the other numbers in perspective. RP survival was only 2 points less than for the healthy guy, but RT survival was 5 points less than RP. I found that quite shocking.
Of course, men with comorbidities might be drawn to RT, but are comorbidities much of an issue in men aged 56?
Anyway, to restate the numbers in the study, 13.8% of the men who chose RP & later develped mets were dead within that 7.3 years, whereas 20.7% of the RT men had died. 50% worse.
I read, quite recently, that 50% of men treated for local disease will developed mets, but that the median time for that is 8 years.
Well, obviously RT has improved, but so presumably has surgery. Certainly frustrating that after so much time this issue hasn't been settled. This study relates post-metastasis, but the treatment decision is first-line therapy. These studies show a clear advantage to RP; somehow I doubt all will agree.
Eureka!!!.... I spent my entire youth searching and digging for it....and sure enough it was there right under my nose all the time..
Thanks....
Good Luck, Good Health and Good Humor.
j-o-h-n Friday 02/21/2020 11:57 AM EST
As someone who had TURP surgery almost 10 years prior to PC diagnosis I was ruled out as a good candidate for RP and was steered toward RT. I chose HIFU instead. That was was 3 1/2 years ago. So far so good with slowly increasing PSA. Not high enough yet for an axumin scan.
The success rate of initial RP depends on initial Gleason score and nature of the tumor found. If about size of grain of wheat in middle of PG, and Psa is 5, then RP can achieve excellent result and man never has trouble with Pca again, especially if surgeon is skilled enough to not leave any prostate tissue behind, which has a later chance of developing Pca.
But man may have Ed, incontinence if nerves around PG have been severed to get inside PG capsule to cut away PG material. Its not such an easy op.
I had low Pas of 6 when diagnosed in 2009 at age 62, after regular yearly Psa testing. I expected to get Pca, and I sure did, and a Gleason 9 and there were 9 positive samples of nine taken in biopsy. Analysis was for aggressive + young man's Pca cells, so I thought I was doomed.
Docs tried to remove PG but found Pca all around outside of PG, so could not remove PG without making huge mess of what they were doing, and promoting spread that was 95% likely to have already happened.
So I had 70 Grey EBRT after 8months on ADT which reduced target area for RT. After 16 more months of ADT, it was paused, and testosterone returned after 3 months and Psa shot up from minimum after RT of 0.8 to 8 in 6 months, so I changed from urologist to oncologist to "see me out" and I expected another year of life and failing treatments.
in 2009, it was very common for our medical system to diagnose cancer when it was way too late for early surgery to beat the problem early enough. I should have had RP in 2004 when Psa was 3, and spread had not occurred.
Comparing RT to RP is a rather bullshit riddled process, because of what makes outcomes variable.
One man told me not to worry because he had had exactly same treatment as I had had, and 10 years later he was fine. I smiled, said little. He may have had a Gleason 5, and very sensitive to RT, so RT succeeded, and the many cells left behind after RT never developed PCA. He'd be still alive now. I wonder what he'd say now?
Maybe best RT is Brachytherapy with maybe 100 tiny gold pellets injected into PG using special applicator needle and guided by ultra sound or CT scan ( not sure which) and each pellet has tiny amount of radioactive isotope within that radiates alpha or beta particles which travel about 2mm max in flesh, and dose level for RT to PG tissue can be 160Grey which is about twice max able to be delivered my beam RT which travels through rectum / bowel and other things and cause side effects. So BT is maybe best RT, but depends on skill of doctor putting in the pellets. The PG is not removed, so great care must be taken to avoid RT damage to nerves surrounding PG and to prostatic urethra.
In Melbourne as I type there are trials of using Lu177 as initial RT because the Lu177 only goes where tumor cells are located, and its not dependent on surgeon skills. Radioactive Lutetium is parked alongside Pca cells, or within them, depending on tiny blood vessels delivering blood to tumor, and by using a special binding chemical to make Lu177 only gather in big numbers of molecules where Pca molecules are. The operation is being called a Lutectomy, and hopefully will be shown to be more effective initially than any RP or BT or EBRT regardless how locally advanced the Pca tumor is. Following types of known common treatment may still be used, and may need to be where Pca has spread widely at time of diagnosis. This spread may not be seen in scans until years later; it happened with me, it seemed Pca was only in PG, but when PsMa Ga68 scan arrived in Melbourne in 2015, it began to shock many men who thought they had no mets. Oh yes sir, you have mets!
So sir, you have a big long fight ahead. I'd had CT scans that were all clear in 2010 at time of EBRT, but in 2016, the first 2 mets showed up, and in years that followed, more and more mets were seen in PsMa scans.
I am still alive 10 years after Dx but with unknown amount of treatment to follow. Lu177 was used on me last year and it seemed to kill all soft tissue mets in lymph nodes. I have two active bone mets still. Psa wnr low to 0.32, but is rising again. But I feel well.
So how are the lymph nodes going? These tend to stop cancer cells entering organs from bloodstream and lymphatic system so if lymph glands are destroyed or weakened by Lu177, what then? I am in no position to insist docs tell me all because they just don't know all, and if I hadn't had Lu177, I'd might have been at end of palliative care, ready to begin un-living next week from now.
But yesterday I cycled 66km across by lovely city, I felt 27, not 72, and all seemed well.
I had to get used to sitting on my inner enemy, Puff My Magic Prostate Grenade and preside over it slowly exploding. LU177 therapy proves it is possible to target nuclide radiation. What is wanted is that chemo or immune therapy be targeted in a similar way. Meanwhile EBRT with powerful Xray beams seems very primitive to me. Its like knowing there is a criminal inside a house, then machine gunning the house until its badly damaged, and hoping the criminal is shot. Sometimes he is, and sometimes he ain't, and sometimes he's wounded, and he recovers while the house remains a mess. With targeted Lu177, they can send in the bullets without damaging the house or furniture, and spot the criminal, and "take this buster" But mets often breed to have a family so its not just one criminal cell you want to kill, and some family members are remarkably able to hide from guided nuclear bullets.
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