Long-term overall survival of radical... - Advanced Prostate...

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Long-term overall survival of radical prostatectomy patients is often superior to the general population

pjoshea13 profile image
pjoshea13

New German study below [1].

An odd observation. Perhaps the lifestyle changes that men make after diagnosis really do make a difference?

It is not surprising that the benefit would diminish with the seriousness of the cancer, but even the high-risk guys did slightly better than the life table.

"A total of 6483 patients were treated with RP between 1992 and 2007 at the Martini-Klinik Prostate Cancer Center."

"For ... low risk and intermediate risk, 10-year OS was 12.0% and 9.2% above predicted {life-expectancy} in the simulated cohort, respectively.

"... high risk, OS was virtually the same as predicted {life-expectancy}"

-Patrick

[1] pubmed.ncbi.nlm.nih.gov/341...

Prostate

. 2021 Jun 8. doi: 10.1002/pros.24176. Online ahead of print.

Long-term overall survival of radical prostatectomy patients is often superior to the general population: A comparison using life-table data

Christoph Würnschimmel 1 2 , Mike Wenzel 3 , Nuowei Wang 1 , Zhe Tian 2 , Pierre I Karakiewicz 2 , Markus Graefen 1 , Hartwig Huland 1 , Derya Tilki 1 4

Affiliations collapse

Affiliations

1 Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

2 Cancer Prognostics and Health Outcomes Unit, Division of Urology, University of Montréal Health Center, Montréal, Québec, Canada.

3 Department of Urology, University Hospital Frankfurt, Frankfurt, Germany.

4 Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany.

PMID: 34101879 DOI: 10.1002/pros.24176

Abstract

Background: To examine overall survival rates within a large cohort of German prostate cancer (PCa) patients and to compare these with life-expectancy (LE) predictions derived from German life tables. We hypothesized that the advantage of good general health in radical prostatectomy (RP) patients combined with favorable cancer outcomes might lead to even higher overall survival rates over 10 years compared to the LE of a general population.

Methods: A total of 6483 patients were treated with RP between 1992 and 2007 at the Martini-Klinik Prostate Cancer Center. Preoperative risk classification was performed according to D'Amico. Postoperative risk classification was performed according to the Cancer of the Prostate Risk Assessment score (CAPRA-S). A simulated cohort was created that resembled the exact age distribution of the RP population using Monte Carlo simulation which was based on data derived from official male German life tables (1992-2017). Markov chain was used to represent natural age progression of the simulated cohort. Kaplan-Meier plots were created to display the differences between 10-year observed overall survival (OS) and the simulated, predicted LE.

Results: For D'Amico low risk and intermediate risk, 10-year OS was 12.0% and 9.2% above predicted LE in the simulated cohort, respectively. For D'Amico high risk, OS was virtually the same as predicted LE (0.8% difference in favor of RP treated patients). For CAPRA-S low and intermediate risk, OS was 11.8% and 9.7% above predicted LE. For CAPRA-S high risk, OS was virtually the same as predicted LE (0.3% difference in favor of the simulated cohort).

Conclusions: Low- and intermediate risk PCa patients treated with RP can expect a very favorable overall survival, that even exceeds LE predictions. High risk patients' overall survival perfectly aligns with LE predictions.

Keywords: life table; life-expectancy; prostate cancer; radical prostatectomy; survival.

© 2021 The Authors. The Prostate published by Wiley Periodicals LLC.

References

REFERENCES

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23 Replies

Very interesting as this is I think your 3rd Post that is putting nails in the coffin of having as your initial Treatment--->Radiation after your DX

Nal

I will remind my doctors of this :)

This data is a minimum of 14 years old. RT and other treatments have improved geometrically in the last five years. Current thinking is that there is little or no OS difference between RP and RT plus associated treatments after DX.

pjoshea13 profile image
pjoshea13 in reply to dexy1234

The study doesn't compare RP to RT.

What it is saying is that men who had RPs beat the life expectancy table.

This has very little to do with PCa itself but with behaviour changes, IMO. RP in itself will not reduce fatal heart attacks, etc.

Did men on RT do as well? Who knows?

-Patrick

Cooolone profile image
Cooolone in reply to dexy1234

There are studies in regard to OS that show not much difference between the twonas an aside to this thread. RT/BT/ADT being slightly better statistically up to 10yrs and RP edging it post 10yrs ever so slightly. Long term advanced patients benefit from debulking via RP early on... I don't have the links but remember this well. I'm sure if you search you'll find the actual data if you like.

The Martini clinic does more prostate surgeries per year than any other clinic in the world. So they just have data about patients with RP in their database. As Patrick wrote, this study had no intention to compare surgery and radiation against prostate cancer.

Women live longer than men. One reason that was suggested is that women see their doctor more often than men. As a PCa patient you see your doctor often too so this may be a factor here.

Cooolone profile image
Cooolone in reply to GP24

Quote: "The Martini clinic does more prostate surgeries per year than any other clinic in the world."

Can you post data that supports this? Data that shows location and numbers of procedures performed, etc. Those metrics may be recorded, but I'm not sure that it is accessible to the general public. At least not here in the U.S. Even finding statistically data on surgeons is impossible if they don't willingly share it as far as I'm aware.

I'm interested because finding data in this regard is next to impossible.

Thank you

GP24 profile image
GP24 in reply to Cooolone

They do 2.500 prostate surgeries per year. It is mentioned in the German Wikipedia article:

de.wikipedia.org/wiki/Marti...

pjoshea13 profile image
pjoshea13 in reply to GP24

Almost double the Mayo:

"Mayo Clinic urologists have been performing radical prostatectomy procedures for several decades. In fact, on average Mayo surgeons perform more than 1,300 of these procedures each year."

... which was about the same as Hopkins reported in 2006

***

If the Martini clinic were twice as big, would it be twice as good? It would probably only mean that they would have twice as many surgeons.

GP24 profile image
GP24 in reply to pjoshea13

I did not want to say they are twice as good. Although they have excellent results and achieve a high patient satisfaction. Otherwise they would not have that many patients.

I wanted to explain why they only have surgeries in their database and why this database contains so many patient records.

I changed many things after dx including diet (more diverse, predominantly vegetable), exercise (increased frequency and duration), going to the doctor for all available screening I can think of and trying very hard to reduce stress.

I'm afraid there is another way to phrase results of this study that gives potential clues to why it might be so: "Long-term overall survival of Martini-Klinik patients is often superior to the general population."

Because this is a highly specialized PC-only clinic (with patients coming from all over the world) and not just "the local hospital" I would strongly suspect that the clientele would lean towards being composed of men who are more likely to be better-educated and more financially secure and more prone to healthier and less-risky lifestyles (not to mention fair-skinned). Would such men tend to have lifespans "often superior to the general population?" I would think so, as is the case elsewhere in the world.

pjoshea13 profile image
pjoshea13 in reply to noahware

I doubt that many Americans would have found it necessary to go abroad for a prostatectomy, but who knows? The same would be true for other countries with plenty of experienced surgeons to choose from - particularly in those countries with a national health insurance system.

Incidentally, a rough & ready way to divide PCa patients into health-conscious & otherwise, is whether or not the cancer was detected via screening. & the US Preventive Services Task Force (USPSTF) notwithstanding, I doubt that I would still be alive if I hadn't been screened - regardless of my lifestyle. {Time for a sip of a fine cabernet before I click on 'Reply'.}

-Patrick

noahware profile image
noahware in reply to pjoshea13

Here is one description of the patients and facility:

"Martini patients are now international. Along with Germany, they hail from countries such as Greece, Cyprus, Sweden, Austria, Poland, the Ukraine and, increasingly, from Arabic countries. For all of them the facility not only provides high performance medicine and amenities similar to those of a luxury hotel (meals are à la carte), but it is also conveniently within easy reach of Hamburg airport, and offers a special accommodation package for family and friends. Private rooms have en suite bathrooms, refrigerators and multimedia terminals with internet access."

Probably some pretty good cabs on the wine list, too!

So to some degree, this sounds like a facility that caters to the well-off. We know in the US that it is estimated being rich adds about a decade to lifespan when compared to being poor, and in Germany the differential is estimated by some to be about half that, but still significant.

Should we expect rich men without prostates to live longer than poor men with prostates? I think maybe we should!

Justfor_ profile image
Justfor_ in reply to noahware

I am neither German not rich yet opted for them mainly for their large numbers on RPs. They have 4 surgery rooms, three of which are for robotic, the fourth for open, doing 3 RPs each per day. The usual waiting period for RALP is two months. With 12 surgeons and 12 operations per day they have gathered a unique expertise.

noahware profile image
noahware in reply to Justfor_

Well, you have provided another element for consideration: you had the ability and willingness to learn enough to know the best place to get an RP is a place that specializes in them and does tons of them using the best surgeons, and then traveled to another country to pursue that. That doesn't mean you are highly educated in the formal sense, but I would say you had an understanding and proceeded in a manner that is not consistent with what "the general population" typically knows and/or does.

The few aspects I mentioned -- wealth, education, lifestyle -- are just part of an array of characteristics that might make "Martini men" a bit different from average guys. At the very least, the men of the general population that have the absolutely LOWEST levels of education, wealth, IQ, social stability, job satisfaction, healthy relationships, etc. are probably entirely absent from the RP group in this study. It seems possible, since these men DO have shorter lifespans, they are bringing the average down for the non-RP group relative to the RP group and that this is the "cause" of the perceived benefit of RP.

Justfor_ profile image
Justfor_ in reply to noahware

Agreed. My very-very-very limited/unscientific analysis on patients' behavioral classification show that the absolute majority (>50%) follow the dogma: "I will find a "good" doctor and do as he/she says". There are two major flaws underlying this rule:

1) Lack of objectiveness regarding the definition of what makes a doctor "good", plus total absence of any compliance testing methodology for attributing and maintain such a rating.

2) A substantial number of doctors posses better social and marketing skills compared to their medical ones. Layman "buyers" aren't beware of the distinction.

pjoshea13 profile image
pjoshea13 in reply to Justfor_

Too late to keep the thread alive, but I'll just add:

i) "long-term survival" after RP implies keeping in touch with paitients for many years. Is that likely with RP tourists?

ii) patients do not notify interested parties of death. Countries that maintain a central database for its citizens are ideal in this regard. Gaining access to foreign databases might be problematic.

iii) to beat the mortality table, implies that they only looked at patients in the population covered by the table. i.e. presumably Germans.

-Patrick

Justfor_ profile image
Justfor_ in reply to pjoshea13

Correct, yet they have a vast archive (12RPs X 220 work days per annum) to select fully documented cases.

Hey pjoshea13!

Another thought provoking post. Thank you.

Currumpaw

I would also assume some medical conditions (which cold shorten a person's life) would rule out someone as a candidate for RP in the first place--a different kind of pre-selection.

Several websites state a founding year of 2005, and a very high volume of over 2000 annual surgeries... both facts at odds with the study saying, "A total of 6483 patients were treated with RP between 1992 and 2007 at the Martini-Klinik Prostate Cancer Center."

Given that total, do you suppose the actual years might be 2005-2007, or?

Justfor_ profile image
Justfor_ in reply to noahware

It is more complex than that. Martini Klinik was an initiative of University Klinik Ependorf (UKE) and its surgeons. I may be wrong, but believe that UKE is among, if not THE, principal shareholder. They only do prostatectomies. Nothing less, nothing more. Everything else is undertaken by UKE. Due to my mild sleep apnea, I had to pass my first night after surgery monitored at UKE's intermediate care. Imaging and pathology is also UKE. Patents medical data go to another institution where UKE also has a stake. I signed a document granting them permission to use my personal data for research purposes. Consequently, they have access to data predating their founding year.

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