Can patients with low-risk PCa benefit from radical treatment?

[pjoshea13]

New (disturbing) meta-analysis below [1].

"Radical prostatectomy, radiotherapy and active surveillance are three widely used treatment options for patients with low-risk prostate cancer, but the relative effects are controversial."

"Twenty-two studies containing 185,363 participants were pooled for the comprehensive comparison."

"... the cancer-specific mortality of radical prostatectomy was significantly lower than active surveillance ... and external beam radiation therapy ... but not brachytherapy"

"Brachytherapy and radical prostatectomy were associated with a similar risk of cancer-specific mortality, and both of them were significantly superior to active surveillance and external beam radiation therapy"

-Patrick

[1] pubmed.ncbi.nlm.nih.gov/343...

Review Andrologia

. 2021 Jul 28;e14122. doi: 10.1111/and.14122. Online ahead of print.

Can patients with low-risk prostate cancer really benefit from radical treatment?: A systematic review and network meta-analysis

Liang Zhen 1 , Zhou Zhien 1 , Yang Shengmin 2 , Li Hanzhong 1 , Wu Xingcheng 1 , Zhou Yi 1 , Qiao Yi 1 , Ma Lin 1 , Chen Yuliang 1 , Feng Tianrui 1 , Yan Weigang 1

Affiliations collapse

Affiliations

1 Department of Urology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Dongcheng District, Beijing, China.

2 Key Laboratory of Endocrinology of National Health Commission, Department of Endocrinology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.

PMID: 34319588 DOI: 10.1111/and.14122

Abstract

Radical prostatectomy, radiotherapy and active surveillance are three widely used treatment options for patients with low-risk prostate cancer, but the relative effects are controversial. We searched PubMed, Embase and Web of Science until June 2020, focusing on the studies comparing the effect of radical prostatectomy, radiotherapy and active surveillance in patients with low-risk prostate cancer. Through the random-effects model, dichotomous data were extracted and summarised by odds ratio with a 95% confidence interval. Twenty-two studies containing 185,363 participants were pooled for the comprehensive comparison. The Bayesian mixed network estimate demonstrated the cancer-specific mortality of radical prostatectomy was significantly lower than active surveillance (OR, 0.46; 95% CI 0.34-0.64) and external beam radiation therapy (OR, 0.66; 95% CI 0.46-0.96), but not brachytherapy (OR, 0.63; 95% CI 0.41-1.03). The brachytherapy demonstrated the best treatment ranking probability results in terms of all-cause mortality, while no significant difference was observed when compared with other three treatment modalities. Brachytherapy and radical prostatectomy were associated with a similar risk of cancer-specific mortality, and both of them were significantly superior to active surveillance and external beam radiation therapy; nevertheless, there was no significant difference among the aforementioned treatment methods in all-cause mortality.

Keywords: active surveillance; brachytherapy; clinical outcomes; prostatectomy; prostatic neoplasms.

© 2021 Wiley-VCH GmbH.

References

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[treedown]

Would anybody with APC be considered low risk?

[cesces]

"Brachytherapy and radical prostatectomy were associated with a similar risk of cancer-specific mortality, and both of them were significantly superior to active surveillance and external beam radiation therapy"

This sounds like helpful information.

[Garp41]

PJ, So if we assume this study is correct, then AS is a joke.

It was done in China.....everything is political there.

Doug

[cesces in reply to Garp41]

"It was done in China.....everything is political there."

1. Either it's reproducible or not.

2. Historically, it would be hard to find something medical more political than PSA testing in the US, with the exception of Covid masking and vaccines.

[cesces in reply to Garp41]

Doug

You say the study was done in China.

But "We searched PubMed, Embase and Web of Science until June 2020, focusing on the studies comparing the effect of radical prostatectomy, radiotherapy and active surveillance in patients with low-risk prostate cancer."

Did you just make up your own facts because you saw some Asian names, am I overlooking something, or did you say that for some other reason?

Thank you

[pjoshea13 in reply to Garp41]

It's a meta-analysis - not limited to Chinese studies. One could look at the inclusion/exclusion criteria if one suspected bias or shoddy work or political pressure. lol

Let's face it, AS is a joke for the 30% who will progress. a PSA test every 6 months & a repeat biopsy every 12? Suddenly GS=4+3 or worse. And was the original GS=3+3 correct?

AS is perfect for the other 70%, but it's guesswork as to which group one is in. Unless one looks at other biomarkers (in addition to PSA.)

-Patrick

[MateoBeach in reply to Garp41]

Look at where the 22 studies were published. The most prestigious and respected peer reviewed journals in the world. And most from outside China. This cannot be discounted as political.

[Adam10]

Thanks Patrick. When it says RP and RT have significantly superior mortality (lower deaths), did the study give figures or percentages of improved longevity for RP and RT?

Is HIFU included in external beam radiation therapy (EBRT)? If so was HIFU the main type of EBRT considered in the study?

Did the study define Active Surveillance (AS)? Or is this a well known industry definition?

Ie does AS habitually include annual MRI snd six monthly PSA tests fir 3 years after op (HIFU) followed by 3-yearly MRI and annual PSA tests?

I could not see any details for the above but wondered if you spotted or you are aware of further details.

I had HIFU 3 years ago. My surgeon said when questioned that my latest PSA and MRI meant my lifespan should not be affected. I’m not laid-back about it but was hoping I could be less anxious.

Grateful for your thoughts and best guesses. Thanks again.

[pjoshea13 in reply to Adam10]

Hi Adam,

I can't get to the full text - will ask a member who can. Will get back to you when I have the text.

-Patrick

[MateoBeach in reply to Adam10]

Just for clarity, HIFU is not EBRT. RT means ionizing radiation such as photons (X rays and proton beams). Ultrasound does not ionize molecules such as DNA bonds. It is a thermal or heating effect on tissues. So not in this comparison.

[Hidden]

"there was no significant difference among the aforementioned treatment methods in all-cause mortality"

I don't have access to the full article. Do they discuss the causes for non-cancer deaths? I would think that ADT if estrogen is ignored would cause a lot of issues for us. Bone loss = fracture risk increase = immobility = leads to death in some cases (e.g. my grandmother; she was doing great, but slipped one day and broke a hip, and then died shortly thereafter). Cardiac risk also increases.

Surgery and radiation can make one inactive in the short term. If it becomes a habit.... Bad for life expectancy.

My thoughts are exercise, exercise, exercise. And then exercise some more. Weight-bearing, resistance, outdoors, social, just do it (don't overdo it but 99.9999% of us are nowhere close to overdoing it). If we don't exercise regularly, our QoL and our life expectancy both may suffer. This is conventional medical advice and makes sense. My NMD, my MO, and my PCP all preach the same thing. As do I. Exercise!!!

[questionanything]

If this study is based only on Chinese science or data, it is an issue of credibility.

[maley2711]

Hey folks...this is a meta-analysis, and you will need to read the full study to see how meaningful it would be. As has been pointed out repeatedly, when comparing studies, great care must be taken to assure that you are comparing apples to apples. It appears that the authors found that overall survival was similar for all options.....and generally overall survival is the most accepted endpoint for treatment success. ProtectT randomized study found little or no difference, except I believe slightly higher rate of distant metastasis for AS.

HIFU is not radiation!!!

No one says that AS has zero risk...but the risk is considered low enuf that AS should be considered (by the patient) as a good option for lowest/low risk PCa patients. BECAUSE of the risk of nasty side effects with treatment!

another thing that must be addressed is that older study results for radiation are mostly based on radiation techniques now mostly outmoded! And newer AS protocols may do a better job of catching progression than did older AS prptocols?

Why would Chinese in particular see some benefit in fudging studies.....and anyway, this meta-analsis not restricted to Chinese studies!!

All in all, some very uninformed responses to this post?

"there was no significant difference among the aforementioned treatment methods in all-cause mortality"

MSK's life expectancy nomogram for 100 men who are diagnosed with lowest risk 3+3 and PSA 8 shows that, of 100 men age 72 and excellent health, 2 will die of PCa in next 10 years and 32 will die of other causes. At 15 years, a total of 4 deaths from PCa and 54 from other causes. This is for men who did nothing when diagnosed...AS is NOT doing nothing.

for 3+4, considered intermediate risk, the 10 year number is 7 PCa deaths and 32 other causes. At 15 years, 10 PCa deaths and 54 other causes. The numbers for other causes will be higher if the diagnosed men are in less than excellent health at age 72!!

Finally, not certain why AS is considered political in USA?

[Cooolone in reply to maley2711]

maley2711

Nice post, I will debate one point. And that is this misconception that HIFU is NOT Radiation! By definition in Physics, it most certainly is Radiation! It's just a different source of radiation, but it is radiation... I've seen quite a few posts which have claimed that HIFU is not, or as being radiation free.

Here's a brief wiki copy:

In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium.

This includes: electromagnetic radiation, such as radio waves, microwaves, infrared, visible light, ultraviolet, x-rays, and gamma radiation (γ) particle radiation, such as alpha radiation (α), beta radiation (β), proton radiation and neutron radiation (particles of non-zero rest energy) acoustic radiation, such as ultrasound, sound, and seismic waves (dependent on a physical transmission medium) gravitational radiation, radiation that takes the form of gravitational waves, or ripples in the curvature of spacetime...

Biology does not escape physics, it is the fundamental laws that apply there.

As to the OP...

But yes, also misunderstood is that this was a comparative/retrospective study with data obtained from 22 other studies that encompassed +185k patients... The potential problem with these studies is that they can cherry pick data to support a position. The question is whether or not this is what has occured. I don't think so, but the data is always subjective of course

Thanks for posting pjoshea13

[maley2711 in reply to Cooolone]

yes, but what is COMMONLY understood as TOXIC radiation is not the type of radiation used for HIFU,laser, TULSA, etc. I would need to refer to other scientific sources to confirm agreement with what you found via wiki..not worth the effort really. It is all magical physics to most of us!!

[maley2711]

" While ultrasound is safe when performed by a trained medical professional, the sound waves used in sonography are powerful. Ultrasound can heat body tissues and has the potential to create small gas pockets in tissues or fluids. However, doctors have safely used ultrasound for decades with an impeccable safety record."

Don't believe scientists generally include sound waves as radiation....is sound radiation? not the general use of the word.