I figured that if I didn't post this new study [1], it might get lost. What with the prevalent bias towards radiation hereabouts.
Soundbite: ""Our data suggest that radical prostatectomy holds a cancer-specific mortality advantage over external beam radiotherapy in Johns Hopkins very high risk patients.""
"Within the Surveillance, Epidemiology, and End Results database (2010–2016), we identified 24,407 NCCN HR patients, of whom 10,300 (42%) vs 14,107 (58%) patients qualified for JH HR vs VHR, respectively. Overall, 9,823 (40%) underwent RP vs 14,584 (60%) EBRT. Cumulative incidence plots and competing-risks regression addressed CSM after 1:1 propensity score matching (according to age, prostate specific antigen, clinical T and N stages, and biopsy Gleason score) between RP and EBRT patients. All analyses addressed the combined NCCN HR cohort, as well as in JH HR and JH VHR subgroups.
Results:
"In the combined NCCN HR cohort 5-year CSM rates were 2.3% for RP vs 4.1% for EBRT and yielded a multivariate hazard ratio of 0.68 (95% CI 0.54–0.86, p <0.001) favoring RP. In VHR patients 5-year CSM rates were 3.5% for RP vs 6.0% for EBRT, yielding a multivariate hazard ratio of 0.58 (95% CI 0.44–0.77, p <0.001) favoring RP. Conversely, in HR patients no significant difference was recorded between RP vs EBRT (HR 0.7, 95% CI 0.39–1.25, p=0.2).
Conclusions:
"Our data suggest that RP holds a CSM advantage over EBRT in the combined NCCN HR cohort, and in its subgroup of JH VHR patients."
Francesco Chierigo , Mike Wenzel , Christoph Würnschimmel , Rocco Simone Flammia , Benedikt Horlemann , Zhe Tian , Fred Saad , Felix K. H. Chun , Markus Graefen , Michele Gallucci , Shahrokh F. Shariat , Guglielmo Mantica , Marco Borghesi , Nazareno Suardi , Carlo Terrone , and Pierre I. Karakiewicz
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pjoshea13
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.... 1:1 propensity score matching (according to age, prostate specific antigen, clinical T and N stages, and biopsy Gleason score)...
Hope that they took the biopsy data for BOTH RP and EBRT cohorts otherwise RP gets an additional and significant advantage over EBRT. Pathology staging is usually higher than that of biopsy. I was T2b, 4+4 as per biopsy and T3b, 4+5 per pathology
This was from a national datbase....so a mix of treatment skills...for both surgeons and ROs....so not a big factor I'd guess. This was NOT a study of SBRT vs RP...it was various methods of EBRT +/-ADT vs RP +/- ADT. Of course, other retrospective studies have shown an advantage of combo RT over both EBRT and surgery....with EBRT results same as RP. .....especially in metastasis- free duration.
Thanks for posting this, Patrick. I must point out that there is a high risk for selection bias, specifically that comorbidities and things like frailty could have caused less healthy men, who may be more at risk, to be steared towards EBRT and away from surgery. Just a question mark. Does not invalidate the results.Personally I favor RP for primary treatment when no mets are evident at diagnosis. Because 1) You have tissue for testing. 2) Gleason grading may be higher or lower than on biopsy. 3) You can know if the capsule has been violated or if margins positive. 4) Know if spread to seminal vesicles or to the sampled lymph nodes. And 5) it is much easier to follow surgery, if not curative locally, with SRT than it is to follow EBRT with prostatectomy. More information and more options.
Don't they mention propensity matching for co-morbidities.....anyway, aren't co-morbidities more importand re overall survival, not cancer specific survival?
Get a Decipher test using biopsy tissue as well as the 3T MRI. If test results are unfavorable (MRI Stage, Decipher score, PSA, Gleason stage), then get surgery. I don't understand why everyone diagnosed with prostate cancer does not do this. The indicators are not just the Gleason score or PSA. The Decipher test is the most accurate gauge of future metastasis odds.
One of the reasons is that physicians do not educate their patients about the test and it's meaning, and insurance doesn't want to cover it! I had to file 2 insurance appeals for the Decipher test with a GL 9 biopsy and T2N1M0 stage 4 APC.
After prior TURP surgery I was told that I wasn't a suitable candidate for RP. I was steered toward EBRT but chose HIFU instead. The jury is still out on my choice with PSA having slowly risen, after 5 1/2 years, to 1.7 from a nadir of undetectable.
Not an attractive option -- I paid a lot out of pocket the first time. I had sufficient income then to get a tax write-off that I wouldn't get much of this time. Interestingly, a big score in a poker tournament paid for that surgery. Maybe lightning can strike twice? WSOP = World Series of Poker. Here I come again, with my 72 year old brain attempting to reclaim glory. That big final table was intoxicating. That was almost 9 years ago.
Impressive back-story. I can imagine the intoxication. Your 72 year-old brain is probaly still in good shape & will help you navigate your way through this pesky illness.
{You & Nalakrats might make a formidable bridge partnership.}
This will settle any "this against that argument". I say men should take back that one rib from women and give them our prostate gland in return........ Problem and argument solved.....
Patrick, another well researched topic, perfect for this site. Thank you…again.Remember, many of us, like me have been told upfront after CT, MRI, and Bone Scan that after our high PSA and a week of scanning, we are Stage 4 Metastatic (forget about possibility of metastisis with Decipher), and INOPERABLE! UNRESECTABLE !
Still I tried for RP because I am persitent and wanted to throw the kitchen sink at it. Cut it out, stomp it, ablate it, freeze it, burn it, radiate it, kill it! 7 surgeons said NO.
Then if you look at the STAMPEDE TRIAL w 10,000 men from Canada, UK, and Switzerland down to Arm L ( I believe), you find that men with lighter metastisis who had Radiation Therapy (SBRT/SABR) have the best outcome with 83% alive at year 3. Think it is ages 49 to 79 +/-. These are some of the best results in the Stampede Trial for Stage 4 guys.
Just my penny in the hat. Some/many of us have no choice.
No discomfort during the procedure However I did experience bowel issues which settled down shortly after and the exercises Definitely help I had an excellent response
Retrospective studies like this have huge problems with selection bias. There is no way of knowing, for example, that fitter men are chosen for surgery and frailer men for EBRT. The data aren’t really very helpful.
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