Relevant study comparing RP patients to men who choose watch and wait ? High quality studies?

[maley2711]

It seems that most people would want to undergo a particular medical procedure only if there were proven benefits when compared to doing nothing and waiting for additional symptoms to appear before then moving ahead with medical treatments. With that in mind, while doing a search for something else PCa related, I stumbled upon this long-ago initiated study (1989) comparing PCa patients who had RP to those who chose watchful waiting....actually this is/was supposedly a randomized study.....

nejm.org/doi/pdf/10.1056/NE...

In approx 2021, this study was referenced by a PCa Doc at an annual physicians seminar, re managing high risk Pca.

On page 4 of the 11 page PDF linked above, there are cumulative mortality results for both groups of men.....men who agreed to RP and those who chose to watch and wait. The results are broken down to the 3 main risk groups, low to high. I am high risk Gleason 4+5, with no other known high risk factors. When I look at the comparison mortality graphs for both RP and watch and wait high risk groups, there seems to no more than very slight advantage for the RP group. Perhaps someone can point out my error in reading these results? Most notably, even if the results are very similar, this study of just 81 high risk men in each group would actually be inconclusive because of the small number of men followed? Perhaps not relevant today because surgery has improved results since 1990s, and more effective BCR salvage is now SOC? For watch and wait there is no defined diagnostic that guides the decison to undertake ADT or other second-line treatments/drugs? Perhaps regular scans would fill that bill, but RP patients receive salvage before any scan-detected metastasis?

In a later followup not linked here (the same study title), a breakdown of cancer mortality as predicted by other diagnostic findings is given. This breakdown is for RP patients who had pathology results after prostate removal. For post-surgery Gleason 6 men, mortality is VERY low, and Gleason 3+4 patients are little different! Gleason 4+3 patients had 5X the total PCa mortality of 3+4 men, and Gleason 8-9 men had double the risk of 4+3 men.....Other later studies have found double the risk for Gleason 9-10 patients when compared to Gleason 8 patients.

I ponder these study results..meaningful or not with today's treatment updates? For my own case and specific diagnostics, nomogram show extremely low PCa mortality at 10-15 years for similar men who have treatment. The problem is that I haven't located a recommended nomogram that gives a good sense of mortality results for men with same diagnostics who have chosen to watch and wait? One such nomogram, I believe referenced as PREDICT, does show no treatment mortality results, but cautions against reliability for high risk patients. Taking the results as they are, they somewhat align with what I'm seeing in the above study....not a great benefit from treatment compared to initial watch and wait?

My Kaiser Docs have not volunteered to discuss this topic with me...the advice for treatment seems to assume surety as to large benefit from initial treatment. We are now supposedly in an era of evidence-based medicine, so is it not reasonable to expect our providers to volunteer to show us the evidence???? Or is it only common sense to understand that an initial treatment would provide a great survival advantage, and I would be viewed as someone without common sense?

From the start, I assumed I would decide on a treatment and proceed in a short time after diagnosis..no intention to avoid treatment. Certain concerns, including a fainting episode, delayed the decision, as did the fact that both Docs seemed less than enthusisastic in answering my questions about specific aspects of the procedures and the SE probabilities for someone with my medical irregularities.

If anyone can point me to something that clearly shows a significant RP or Radiation treatment mortality benefit for Gleason 4 +5 patients. thank you in advance!!!

[CorreaGlabra]

Hello, the link appears to be broken or incomplete.....

[maley2711 in reply to CorreaGlabra]

Hmmmm...... here is what I ust copied.......

nejm.org/doi/pdf/10.1056/NE...

that works...don't know how my 1st try ended up like that...apologies!

[maley2711 in reply to CorreaGlabra]

Hopefully you wer able to use the corrected link. I think 2 factors maybe the biggest ones to affect the results...the low number of men in each group, and which men were given scans and accuracy of the scans compared to today's tech. For example, today high risk men qualify for PSMA PET scan, as some newly diagnosed high risk men have metastasis found only by PSMA PET......so the treated men today would be less likely to have hidden metastasis than the treated men 29 years ago. I woulld expect a similar study starting now would show more benefit for treatment...but will men nowadays volunteer for watchful waiting??? I have been unintentionally watchful waiting. The other thing that might interest you.....an article by a deep researcher looked at studies of results for men who underwent treatment withing 1-2 months of diagnosis versus men who delayed for a year...in almost all sthose studies, waiting a year was statistically equivalent to immediate treatment...and this applied to all risks...very surprisingly even for the high risk. Thus, I think Docs probably knows this, and in some cases may seem less urgent about immediate treatment than the man expects with his Doc.