Surgery v. Radiation - Survival

[pjoshea13]

This post is prompted by the recent KwajMike post.

Unfortunately, a newly-diagnosed man has little chance of getting unbiased advice. Studies have shown that the treatment one receives is heavily influenced by whether one seeks help from an oncologist or urologist. Furthermore, there is a tendency for patients to voice support for the choice they made, even if it didn't turn out that well.

Urulogists have a financial interest in surgery. At least one oncologist has claimed in print that urologists know little about cancer. & that it's a peculiar idea that they should be doing surgery. As though the local barber was still doing tooth extractions. A rare instance where we get a glimpse of the partisan split. Where is the AMA in all this? Patients deserve to have good efficacy information.

Dr. Myers, who IMO, has expressed bias against surgery, has warned that "Radiation is the treatment that keeps on giving." (Quoted from memory.) There is increased risk of other cancers. I remember reading, before I made my decision for salvage radiation 12 years ago, that the increased risk only appeared after 5 years. I wasn't thinking that far ahead - LOL. The point is that radiation is not at all less invasive. The attraction of surgery is that there is no down the road treatment morbidity.

Some celebrity urologists claim impossible success. It's possible to do that if patients are cherry-picked. It can be difficult to get facts about the risk to one's sex life. Dr. Freedland has said that sexual difficulties after treatment are a "consequence" - not a potential "side effect". But some sort of recovery is possible for most. In one study, only 5% of men said that sex was like it was before (following surgery).

Ideally, the issue of best treatment would be decided by a study where men were randomly assigned to surgery or radiation. When a man has the choice, he may be influenced by other health concerns. Men opting for surgery tend to be younger & healthier.

Anyway, the best one can do is look at studies that compared survival rates - not biochemical recurrence (rising PSA) but PCa mortality. Ultimately, this must be the most significant statistic.

[1] (2015 - U.S.) The point of this study was that 5-year risk of biochemical recurrence fails to indicate the risk of PCa-specific mortality.

"A total of 13 803 men ... underwent RP {radical prostatectomy}, EBRT {external-beam radiation therapy}, or brachytherapy at two US high-volume hospitals between 1995 and 2008."

"Men receiving EBRT had higher 10-yr {prostate cancer-specific mortality} compared with those treated by RP across the range of nomogram-predicted risks of {biochemical recurrence}"

"After adjusting for nomogram-predicted {5-yr progression-free probability}, EBRT was associated with a significantly increased {prostate cancer-specific mortality} risk compared with RP (hazard ratio: 1.5 ...)"

[2] (2013 - Canada)

"This was a case-cohort study of 2,213 patients in the Ontario Cancer Registry diagnosed between 1990 and 1998 who were either treatment candidates or received curative radiotherapy or surgery. Cases included patients who died of prostate cancer within 10 years."

"We restricted our study population to patients with low- and intermediate-risk disease who are typically considered candidates for either surgery or radiotherapy."

"We observed worse cause-specific survival in the radiotherapy patients ..."

"When we stratified by risk group, we observed no evidence of worse survival after radiotherapy in the low-risk group .., and our overall result was determined by the intermediate-risk group ..." (57% excess risk)

"Adjusted hazard ratios for risk of prostate cancer death for radiotherapy compared to surgery for the entire study population were 1.62 ... and 2.02 ... analyzing by intent-to-treat and treatment received, respectively."

"Overall results were driven by the finding in the intermediate-risk group, which indicated that radiotherapy was not as effective as surgery in this group."

(Maybe the low-risk group shouldn't have been treated?)

[3] (2014 - U.S.)

"Cancer-specific Survival After Metastasis Following Primary Radical Prostatectomy {RP} Compared with Radiation Therapy {RT} in Prostate Cancer Patients"

"Our study consisted of 66,492 men diagnosed with PCa, 51,337 men receiving RT, and 15,155 men undergoing RP within 1 yr of cancer diagnosis. During the study period, 2802 men were diagnosed as having metastatic disease."

"During the follow-up, for the low-risk patients, the adjusted {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 {prostate cancer– specific survival} after metastasis was 76.3% and 63.3% in the RP and RT groups, respectively."

"Following the development of metastases, men who received primary RP have a longer {prostate cancer– specific survival} than men who received primary RT."

[4] (2013 - U.S.)

"Mortality after prostate cancer treatment with radical prostatectomy, external-beam radiation therapy, or brachytherapy in men without comorbidity." This removes a confounding factor - men who opt against surgery because of a comorbidity.

"Treatment with RP {radical prostatectomy} in 4459 men, EBRT {external-beam radiation therapy} in 1261 men, or BT {brachytherapy} in 972 men."

"EBRT was associated with an increase in PCM {PCa mortality} compared with RP (hazard ratio [HR]: 1.66"

"In a large multicenter series of men without recorded comorbidity, both forms of radiation therapy were associated with an increase in {overall mortality} compared with surgery"

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/252...

[2] ncbi.nlm.nih.gov/pubmed/237...

[3] ncbi.nlm.nih.gov/pmc/articl...

[4] ncbi.nlm.nih.gov/pmc/articl...

[CERICWIN]

There are advantages and drawbacks to both radiation and surgery. I've read about, and even know individuals who have had success with both---and also failures and recurrences.

It's difficult to make decisions about the right course of treatment, and it's a highly individualistic thing---there is no "one size fits all" where prostate cancer is involved.

I was very disappointed when my uro told me that the cancerous prostate couldn't be surgically removed----I wish that the cancer could have been cut out of me immediately, but it was invading the bladder and pushing against the colon/rectum wall, so surgery would have meant removing the bladder and a colostomy, and I already had metastases to "innumerable" pelvic lymph glands, spine and sacrum.

If I would have had a choice, I would have chosen surgery--to have the cancer removed immediately, rather than waiting for radiation to work.

There are a number of guys who bitterly regret having had a prostatectomy because of ED and incontinence. They sometimes fail to remember that, if they hadn't had the surgery, it would more than likely would have spread in many cases.

CERICWIN

[ng27868168 in reply to CERICWIN]

CERICWIN.., IMO, your last 2 paragraphs basically say it all, and I agree with them. Certainly not being an expert, but a 75 year old 23 year PC survivor of PC, and a long time facilitator of our Local PC Support Group, I have listened to many expert MD speakers and many more fellow PC survivors who have chosen basically all the options, OR no option which has resulted in both successful and unsuccessful outcomes.

I chose surgery first, (age 52) radiation second, (age 54) hormone treatment (orchiectomy - testicles removed at age 56) which stopped the cancer but gave me daily frequent Hot Flashes for 18 years. ED issues and a severe incontinence issue that were successfully dealt with by an artificial Urinary Sphincter, (age 73). Hot Flashes were finally eliminated by monthly testosterone injections on advice by my Urologist. (age 73)

While it is true that Medical professionals know best, sometimes hearing from those who have gone through and over this bumpy road for years, helps make the choice a little easier.

[Darryl Partner]

Well written summary of the early diagnosis treatment choice quandary.

[David1958]

I always feel bad for the newly diagnosed. They are just like deer in the headlights. They have no idea how they got here or what to do about it. Everyone tells them that the decision on what to do about it is all up to them. As if that is a comforting thing to be told when you are barely coming to grips with the diagnosis. Yes, the sexual performance issue looms large. Every treatment option seems to be a threat to that essential function. As the statistics above show, very few men come out of PC unscathed. I understand the bitterness some men have over the loss of sexual function. I am just damn glad that I do not have PC since I had my prostate removed 5 years ago. If I had done nothing, I would be dead by now. Being alive with no sexual function is a whole lot better than being dead.

.

[BobSherm]

When urologists in New Jersey are becoming partners in radiation practices, the patient doesn't have a chance.