Interesting article to considering what action to take with localized PCa.
ox.ac.uk/news/2023-03-13-st...
Has the references to two studies:
nejm.org/doi/full/10.1056/N...
evidence.nejm.org/doi/full/...
Indicates even people with no treatment having a similar life expectancy.
Problems interpreting ProtecT discussed here:
prostatecancer.news/2016/09...
Patient A lives 20 more years and dies of prostate cancer. His remaining 20 years include the last 5 where he is crippled with painful metastases, taking chemo, hormone therapy, radiopharmaceuticals, and opiates.
Patient B gets definitive radiation, lives 20 more years, and dies of a sudden heart attack. He has no side effects from his radiation, and has been cured.
Both patients have the same survival - which would you rather be?
Well, in some cases that might be true. In other cases it might be false. I certainly wouldn’t discount what you’ve said. People react differently to treatments and there’s no sure path either way.
You could also argue that taking treatments has a decent chance of making you incontinent, erectile disfunction and some other horrific negative side effects towards the individual wrt QOL. I’m not even mentioning any of that. I’m not taking any sides in that discussion. It’s up for an individual to decide.
All I’m doing is posting information so people can make their own decisions.
In terms of life expectancy though, the data from that paper identifies its relatively the same whatever treatment and, as stated, one should not rush their decision… whatever they decide.
My bad. I put the wrong link there. I've corrected it now. See if it changes your mind.
While I have great respect for your knowledge and experience, the example is just a tad biased in one direction. You could just as easily present these two cases.
Patient A stays on active surveillance and lives for 20 years. While his cancer does spread outside his prostate it never metastasizes and patient is able to manage his urinary and sexual function issues throughout this time period.
Patient B has radiation treatment. Patient lives for 20 years and experiences ongoing urinary, bowel and sexual function issues during this time that degrade his QOL significantly.
For men in a low to Int. favorable group, whether you get treatment or not is all about managing risk. The fact is some men can stay on AS and live for many years without going through treatment and avoid dealing with the secondary treatment consequences. Some men who start on AS end up choosing treatment because of anxiety or they are concerned with disease progression based on MRI and/or biopsy results.
As a person in the low-risk group I am going to pursue AS as long as I can, while diligently getting regular PSA tests and periodic follow-up biopsies and MRIs. I have pursued genomic testing and am comfortable with the lower risk profile of my cancer as part of my decision.
Studies like this one do help to inform lower risk patients that choosing AS can be a reasonable option for not just months but over a multi-year period as long as one is engaged in a regular protocol of PSA testing and other measures to monitor disease progression.
My bad. I put the wrong link there. I've corrected it now. See if it changes your mind.
The trial did not do what you are assuming it did.
Thanks for that link. Devils always in the details with these studies. My plan is to follow a protocol more in line with JH/Sunnybrook. Once I have my confirmatory biopsy next year I'll decide whether I stay on AS or pursue treatment.
Maybe, but as you also quoted in your opinion piece...
The bottom line was that all 3 therapies did about the same in preventing death.
Each treatment will have different risk/rewards. People have to decide which treatments, if any, to take themselves.
Yes, they chose the wrong endpoint for the trial. Patients are interested in QOL, pain, and going through ordeals, not just length of life. Choosing the wrong endpoint is a mistake many, otherwise excellent, researchers make when they don't listen to patients adequately. I'm trying to correct it, but turning around their very established thinking won't happen overnight.
Yes it’s not just the end of life. I certainly agree with that. But it’s worth pointing out to people that taking those procedures also can seriously impact your QOL. Erectile disfunction, infections, incontinence and more. The risks are there for whatever path you take.
Agreed, there are risks in all treatments.
I am definitely an example of this. I will go to my death wishing I had not had RARP, but I can't let it destroy my life, although it DID drastically alter my life.
My IMRT had consequences too (though much, much less) and I am having some small issues from my recent SBRT. Sometimes this is like "Whack A Mole." You have to weigh QOL at each step.
My first oncologist thought he was God. Thankfully, with some of what I have learned from you, I can have meaningful discussion with my 2nd oncologist. He actually listens to my side.
I always wondered when the USPSTF did their assessment of the value of screening, they saw "lives saved" as the only benefit. They had not problem counting the "harms" of screening and downstream treatment, but not the benefits of less morbidity short of death as a benefit.
Seems a bit asymmetric to me.
Good point! Heavy reliance on Overall Survival (OS) is a holdover from other cancers, in which it may be unusual to survive 5 years after diagnosis. When I've asked why they choose an OS endpoint, the answer I always get from researchers is "because it's always been done that way."
It slows down research, makes it prohibitively expensive, and often renders it irrelevant by the time we get results. And it confuses patients and doctors alike (as you can see above). Last week, on a doctor visit with a friend of mine, I got into an argument with his RO. She wanted to give him a less-than-curative treatment for his locally advanced PCa. She argued that he will live just as long! The research tells us that! I argued that my friend would rather risk some extra side effects of treatment now, to get a cure. My friend is confused because he really likes her. We will get a second opinion.
I've seen objections to cause-specific mortality as a "surrogate endpoint" because the assumptions seem to be that if you get a benefit in cause-specific mortality but OS doesn't change that the deaths may just be going "somewhere else". I suppose that's possible, but of course any cause-specific benefit is going to get diluted in any OS endpoint.
Don't know if you follow F. Perry Wilson at Yale, but he did have a discussion a couple of weeks ago about that recent JAMA article claiming that the only screen that showed a survival benefit was sigmoidoscopy. He makes some interesting points. I can look for it if you didn't see it.
It is often hard to distinguish cause-specific mortality (CSM) from any-cause mortality. For example, if someone with end-stage PCa strokes out, did his PCa kill him (knowing that cancers increase the risk of blood clots)? An RCT can use CSM as an endpoint only if they arrange for centralized review of death causes.
OS is fine as an endpoint for trials of treatments for mCRPC. But validated surrogate endpoints must be used to finish trials with smaller sample sizes and in shorter time. Trials have to be "powered" for differences in the endpoint they are trying to measure. For oligomet PCa, the question is - does it delay systemic progression? So, rPFS, cPFS, or time to next met are better choices. For non-metastatic PCa, QOL and something PSA-based may be the best choices when the patient is still potentially curable .
Obviously we've heard waaaaay too much about this distinction wrt covid-19.
The first part of this video includes an interview with Dr. Mathew Cooperberg from UCSF on AS. I found it very helpful.
Comfortable Full Bladder for IMRT 20 Treatments
Missing the Target: One biopsy for deciding initial treatment
Help deciding on treatment
Study shows HIFU noninferior to prostatectomy for localized prostate cancer
