RP/Chemo vs RT/ADT - 43% difference in recurrence for high-risk PCa patients.

[Don_1213]

The video is short enough:

medpagetoday.com/meetingcov...

It's entitled: Is Radiation Better Than Surgery for High-Risk Prostate Cancer?

Hopefully, you can view it. If not - let me know.

This is a huge hole blown in the urologist's claim of better long-term control of PCa with the surgery standard of care vs radiation standard of care. It's not even close.

Worth a listen for anyone debating that choice. It doesn't cover less-serious cases, so they may be different (but I'm betting they aren't...)

[MrProstate]

A real comparison of surgery to radiation should be just that.

This business of adding chemo or ADT or grandma’s favourite potion may be interesting for those that want to go all out from the start.

So as far as blowing holes out of urologists claims I doubt it very much.

The other thing to be mindful of is that BCR versus metastatic spread in the context of clinical trials are seperate measures.

In my humble opinion chemo and radio both offer some control but both select for more aggressive clones.

At least with surgery if the cancer is truly contained in the prostate no matter it’s definition you would very likely be cured.

[Don_1213 in reply to MrProstate]

You said: "This business of adding chemo or ADT or grandma’s favourite potion may be interesting for those that want to go all out from the start" - and I said "standard of care" for HIGH RISK PCa patients.

I don't think you'll find any oncologist (medical, urologic, radiation) who would suggest a man with G9 or G10 PCa is going to do well without the additional treatment.

Both surgery/chemo and radiation/ADT are standards of care for G9-G10.

Even with cancer fully prostate contained - surgery gives a nice opening for millions of cancer cells (think seeds) to enter the bloodstream during the surgery. Radiation not so much, but radiation is more effective for high-risk patients if ADT is combined with it - in preventing spread/recurrence.

From your bio you had a prostatectomy 2 years ago and based on your PSA results are doing well 2 years after. Good for you - but that still doesn't change the numbers from the study referred to.

[MrProstate in reply to Don_1213]

All I am saying is that an apples to apples comparison is the only appropriate way to draw a conclusion.

If you use surgery plus adt versus radio plus adt then you might have a valid comparison.

Alternatively surgery with chemo versus radiation with chemo would probably be equally valid.

Anything other than an apples to apples in your treatment arms introduces biases that preclude valid conclusions about surgery versus radiation.

It may facilitate other conclusions but it provides negligible evidence about a strict surgery versus radiation comparison.

I mean did they compare surgery with ADT and the arm that received Radiation with ADT?

[London441]

Definitive data on this probably isn’t happening soon, and I agree that there are enough confounders besides just the markedly different treatment combinations.

But this:

‘I don't think you'll find any oncologist (medical, urologic, radiation) who would suggest a man with G9 or G10 PCa is going to do well without the additional treatment.’

Urologic surgeons perform RP on G9 patients all the time. Many sending them home with a rosy ‘we got it all’. Far too often they did not.

[Don_1213 in reply to London441]

That is the unfortunate truth. The honest ones usually plan for follow-up radiation depending on what they find.

[ron_bucher]

Why wouldn’t the main conclusion be that it was ADT that made the difference?

[Don_1213 in reply to ron_bucher]

Because the difference in results was still there (a bit less - about 12% I believe) when no followup treatment was done. ADT makes a difference, but not all the difference.

[j-o-h-n]

They're now talking about prostate transplants....(women first)....

Good Luck, Good Health and Good Humor.

j-o-h-n

[ron_bucher]

Seems to me like a very confusing/convoluted presentation of data from two different studies, neither of which compared RP with radiation.

[MrProstate in reply to ron_bucher]

Exactly

[groundhogy]

There are many peer reviewed papers showing that RA is is a bad idea if you have higher risk cancer… if your gleason score is on the higher end.

The reason is this. The distance between the prostate and surrounding organs/tissues is only millimeters. So they can’t remove all kinds of margin tissue for safety.

Then the problem of micro-mets. After a time PCa cells will migrate out around the capsule edge. The prostate capsule is more of a porous membrane than it is a thick impenetrable barrier. The micro mets can be around the capsule.

So for high risk patients, there is more chance that there are PCa cells along the capsule membrane. When the surgeon goes in, he cant take out any extra margin so PCa cells get left behind.

Compare this to breast cancer. If the surgeon sees a little cancer dot in the breast, he can take the whole breast out. Thats like an inch or more of tissue margin.

With radiation, sometimes these PCa cells that accumulate at the prostate edge can be mopped up.

This accounts for the increased effectiveness of radiation for higher risk.

It gets even better with brachy boost. With external radiation, they have to quit at some point because they are dosing your other organs with a small amt of radiation while focusing on the prostate. With internal seeds, the radiation emanates from within the prostate and does not pass through other organs. So… they can dose the cancer cells even higher than external rad alone.

[Don_1213 in reply to groundhogy]

If you read my bio - I had 45 IG/IMRT/ARC treatments over 9 weeks. And 18 months of ADT (starting a month before radiation)..

I can't imagine having an RP today.. I was over 70 with a Gleason-10 (rang the bell on that..) The radiation was over the entire prostate bed, with a boost to the prostate and tumor. The lymph glands in the region were fried.. Margins were taken into account. The thinking of my radiation oncologist was with the advanced linac (the latest Varian Edge, less than 6 months old at the time) precision, they could apply a dose equal to IGRT and brachy with the same sort of local accuracy that brachy provides. Total was 84 Gray.. which was the highest dose used at the time. It's been 4 years, no recurrence, and the supplementation is only bringing the T level up to what a healthy male my age would normally have.

I think that's the important point - which Morgantaler makes.. he told a little story: If he had two identical twins who had identical diagnosis for prostate cancer, and they received the same treatment, and after some time one twin had a T level of 500 and was happy and having sex and doing things that men like to do - and the other twin had a T level of 100 and was unhappy, couldn't get an erection, was depressed over his lack of male-ness. If the twin with a T of 100 asked the doctor to prescribe something for his brother that would bring him down to the T level of 100 like him so his twin could experience the suffering he did - what would the answer be? The answer obviously was to supplement that twins T until it gets to the same level as his brother.

Please provide some links to the peer-reviewed studies you mentioned. And I'd suggest you listen to the Morgantaler talk that is the YouTube link I provided above. He's not a radical out there MD - he's recognized as one of the best urologists in the Boston area... and teaches at Harvard medical school.

[groundhogy]

sorry in first sentence replace RA with RALP

[groundhogy]

Look up Dr Peter Grimm. He compiled articles and treatment success rates over the years and published graphs to help men navigate these treacherous waters.