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    Old 02-09-2020, 11:33 AM   #16
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by guitarhillbilly View Post
    My diagnosis is: T2a / Gleason Score = 8 / PSA at diagnosis 6.9

    I will avoid surgery anytime I have other choices and that includes PCa. My UR used the database from MSK and the 10 year survival rates for people with my clinical condition at diagnosis was only 3 % different between the folks that chose RP vs RT + ADT.
    These numbers did not deal with the long term residual effects of either choice just mortality.
    For me it was RT +ADT hands down because I don't want any kind of surgery if I have other options.
    BTW, My UR is also a surgeon who does RP's and he let me[with my wife] make the choice.He will be doing my Gold Fiducial Markers and SpaceOAR Gel.
    I'm scheduled for 9 weeks IMRT and 2 years of ADT [Lupron].
    Some of us are willing to bet OUR Life on choices other than surgery.
    No one is saying otherwise, GH. I am just saying that for high-risk men, studies continue to confirm that RP and RT are both valid (witness the choice your uro presented -- my uro/surgeon did the same). Many forum brothers dismiss surgery. Just as avoiding surgery was a factor in your choice, avoiding RT was in mine. My other motivation was wanting to capitalize on early diagnosis having a good chance of making ADT unnecessary for me.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 02-09-2020, 02:04 PM   #17
    IADT3since2000
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by guitarhillbilly View Post
    My diagnosis is: T2a / Gleason Score = 8 / PSA at diagnosis 6.9... I'm scheduled for 9 weeks IMRT and 2 years of ADT [Lupron].
    Some of us are willing to bet OUR Life on choices other than surgery.
    Have you followed information the Board about metformin as what looks like a boost in effectiveness for radiation therapy and also a way to reduce some of the side effects of ADT?

    Jim

     
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    Old 02-09-2020, 11:08 PM   #18
    Insanus
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by guitarhillbilly View Post
    My diagnosis is: T2a / Gleason Score = 8 / PSA at diagnosis 6.9

    I will avoid surgery anytime I have other choices and that includes PCa. My UR used the database from MSK and the 10 year survival rates for people with my clinical condition at diagnosis was only 3 % different between the folks that chose RP vs RT + ADT.
    These numbers did not deal with the long term residual effects of either choice just mortality.
    For me it was RT +ADT hands down because I don't want any kind of surgery if I have other options.
    BTW, My UR is also a surgeon who does RP's and he let me[with my wife] make the choice.He will be doing my Gold Fiducial Markers and SpaceOAR Gel.
    I'm scheduled for 9 weeks IMRT and 2 years of ADT [Lupron].
    Some of us are willing to bet OUR Life on choices other than surgery.

    The question is are you turning a winning hand into a losing hand.

     
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    Old 02-10-2020, 06:44 AM   #19
    IADT3since2000
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by Insanus View Post
    The question is are you turning a winning hand into a losing hand.
    Unfortunately, we are not able to deal in future certainties. Research indicates that the hand chosen has higher odds of success.

     
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    Old 02-10-2020, 07:00 AM   #20
    Insanus
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by ASAdvocate View Post
    From the ASCO publication authored by Dr. D'Amico:

    "study reported in JAMA Oncology, Tilki et al found that patients with Gleason score 9–10 prostate cancer treated with multimodality therapy known as MaxRP (radical prostatectomy [RP] plus adjuvant external-beam radiotherapy [EBRT] with or without androgen-deprivation therapy [ADT]) had similar survival outcomes compared with those receiving another combination regimen called MaxRT (EBRT, brachytherapy, and ADT)."

    I think that adjuvant in medical terminology means "immediately following" (as opposed to salvage). So, it would appear to be an up-front decision.

    But, this is your area of expertise, so please correct me if I am wrong.
    Treatment immediately following does not imply that pathology and genomics are not considered as an intermediate step. Nobody is being wheeled from surgery to radiation.

     
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    Old 02-10-2020, 07:14 AM   #21
    Insanus
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by ASAdvocate View Post
    From the ASCO publication authored by Dr. D'Amico:

    "study reported in JAMA Oncology, Tilki et al found that patients with Gleason score 9–10 prostate cancer treated with multimodality therapy known as MaxRP (radical prostatectomy [RP] plus adjuvant external-beam radiotherapy [EBRT] with or without androgen-deprivation therapy [ADT]) had similar survival outcomes compared with those receiving another combination regimen called MaxRT (EBRT, brachytherapy, and ADT)."

    I think that adjuvant in medical terminology means "immediately following" (as opposed to salvage). So, it would appear to be an up-front decision.

    But, this is your area of expertise, so please correct me if I am wrong.
    Treatment immediately following does not imply that pathology was not first considered.

     
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    Old 02-10-2020, 08:03 AM   #22
    Prostatefree
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Mortality seems a very arbritary, but definitive measure.

    Remember, it will probably take you 3 - 5 years to die from PCa. A 10 year mortality fact means only 5 years of quality life, imo.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    12-8-19 PSA less than 0.02, zero club 3.5 yrs

     
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    Old 02-10-2020, 12:18 PM   #23
    guitarhillbilly
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by IADT3since2000 View Post
    Have you followed information the Board about metformin as what looks like a boost in effectiveness for radiation therapy and also a way to reduce some of the side effects of ADT?

    Jim
    I will ask my UR and Radiologist about Metformin on next visit. Thanks for the info.

     
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    Old 02-10-2020, 01:15 PM   #24
    Michael F
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by DjinTonic View Post
    I'm seeing more papers that are identifying a survival benefit for RP over RT for some subgroups of high-grade (G8-10) PCa, for example this paper for the subgroups with PSA < 10:

    Survival Significance of Patients With Low Prostate-Specific Antigen and High-Grade Prostate Cancer After Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy [2019, Full Text]

    https://www.frontiersin.org/articles/10.3389/fonc.2019.00638/full

    "Conclusion: RP patients with low PSA levels and high GS had better OS compared to either EBRT or EBRT+BT, while RP and EBRT+BT resulted in significantly lower PCSM, compared to EBRT. Moreover, EBRT+BT and RP were associated with similar survival of patients with age of > 70 years old, or PSA levels of ≤ 2.5 ng/ml"

    Djin
    The OP = our esteemed Forum Brother DjinTonic titled this thread: "Advantage of RP over RT for Subgroups of High-Grade PCa"

    I don't believe that Dj intended to stoke the Which is better: RP or RT? debate. The key word is 'Subgroups.'

    This subset of PCa patients i.e. High Gleason with Low PSA is known to have a very challenging and poor prognosis.

    The authors simply did a data dive into the SEER database (2004 - 2013)

    The key speculation is stated in the introduction:

    "Furthermore, low PSA level and high-risk of disease may represent a unique entity with potential dedifferentiation biology (11)"

    Genomics in PCa continues develop, refine and advance at an explosive rate. The objectives are:

    - Identify occult disease that requires treatment

    - Determine the treatment or treatment combinations that will lead to the best possible outcome

    - Avoid any treatment that is not helpful

    The practice of "Personalized Medicine" is now the dominant marketing strategy for a multitude of specialty hospitals. Fortunately, treatment modalities for PCa are evolving to being personalized.

    MF
    __________________
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free =13%)
    Jan '12: Biopsy: 1/12 = G7 (3+4) & 5/12 = G6
    March '12: Robotic RP: Left: PM + EPE => MD excised additional adjacent tissues
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    uPSA Range: 0.017 - 0.032 at 94 Months Post Op: Mean = 0.023 (n = 23)
    LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%) ED = present

     
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    Old 02-10-2020, 02:30 PM   #25
    IADT3since2000
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    A Bit More on the Tilki Study, and What "Immediately Following" Means for Adjuvant Radiation Following Surgery

    [QUOTE=ASAdvocate;5500996]From the ASCO publication authored by Dr. D'Amico:

    "study reported in JAMA Oncology, Tilki et al found that patients with Gleason score 9–10 prostate cancer treated with multimodality therapy known as MaxRP (radical prostatectomy [RP] plus adjuvant external-beam radiotherapy [EBRT] with or without androgen-deprivation therapy [ADT]) had similar survival outcomes compared with those receiving another combination regimen called MaxRT (EBRT, brachytherapy, and ADT)."

    Actually, this is a news account that glosses over the more precise conclusion in the study's abstract: "Conclusions and Relevance

    Results of this study suggest that it is plausible that treatment with MaxRP or MaxRT for men with biopsy Gleason score 9-10 prostate cancer can lead to equivalent risk of PCSM and ACM." (My emphasis) (Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439553/#!po=35.7143) "Plausible" is a much weaker word than the media translation into "found that ... had similar survival outcomes", and that weaker wording recognizes the substantial, to me critical, weaknesses in the study, which I have described in post #13 on this thread.


    Quote:
    I think that adjuvant in medical terminology means "immediately following" (as opposed to salvage). So, it would appear to be an up-front decision.

    But, this is your area of expertise, so please correct me if I am wrong.
    Adjuvant radiation, as opposed to salvage, is done after the patient has recovered from the RP. My understanding is that recovery includes both continence and sexual aspects to an adequate level. I've heard radiation oncologists state that the longer the recovery period, the better results for these aspects, which makes the salvage approach better for these aspects, if it is practical from a cancer control standpoint. This is discussed in "The Key to Prostate Cancer."

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

     
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    Old 02-10-2020, 03:09 PM   #26
    IADT3since2000
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    Smile Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Good News on Survival After Prostate Cancer Diagnosis - Nearly 100% at 10 Years for the Vast Majority of Us

    Quote:
    Originally Posted by Prostatefree View Post
    Mortality seems a very arbritary, but definitive measure.

    Remember, it will probably take you 3 - 5 years to die from PCa. A 10 year mortality fact means only 5 years of quality life, imo.
    I'm not sure of the context of your estimate of 3 to 5 years, but it is generally a gross underestimate of our survival in the current era for the vast majority of patients.

    That pessimistic time frame is actually the prognosis I was given back in late 1999/early 2000 by two respected urologists at major institutions known for treating prostate cancer (and which I found encouraging, as I was thinking I had just months to live: it's all in your point of view). Back in the 1970s, when most patients had wide-spread metastatic disease at diagnosis as there was no PSA test, 5 year survival rates from prostate cancer were dismal, but that is no longer true, and we enjoy the BEST SURVIVAL OF ANY MAJOR CANCER.


    These days, based on SEER data reported by the American Cancer Society, the 5 year survival rate, considering patients of ALL risk levels including the small proportion of patients with widespread distant metastases at diagnosis, is virtually 100%. Moreover, it is about 99% at TEN years, and in the mid-90%s at 15 years! That doesn't mean that patients with distant mets at diagnosis will do anywhere near that well, based on the history of these statistics, which is, by necessity, a rear view mirror. As of the last published statistics, about 30% of patients with distant mets at diagnosis make it to the 5 year point. However, new drugs and techniques, which basically have emerged in the past decade, are likely improving this outlook for patients diagnosed in the past few years for whom five year statistics are not yet available. Other groups, even including those with regional mets, had survival similar to the general averages.

    We patients can be excused for not understanding the survival profile for prostate cancer, but I am disturbed that so many researchers FAIL to understand the implications of the slow-burning fuse that is prostate cancer. There are numerous studies, including very prominent studies such as those on screening initially published in 2009 in the New England Journal of Medicine, that failed to consider the long typical survival profile in their published research. I'll try to step down from my soap box here, which is difficult for me because I find this failure so disturbing.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

     
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    Old 02-10-2020, 03:24 PM   #27
    IADT3since2000
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Whack-a-Mole Deja vu All Over Again - (I suspect)

    Hi DjinTonic, and thanks for providing the link to this study, in your post #1, quoted below.

    I have looked at the abstract, and, prior to looking at the study itself, I'm anticipating that the authors made a very frequent error with those not familiar with patterns of treatment over the past two decades, covering the period of the study (treatment period, or also follow-up) from 2004 to 2013. I know this period very well as I was having to make my own life-at-stake decisions. In short, the error I think I will see, is that surgery was usually offered to patients with much lower risk characteristics than patients offered radiation. That makes studies of survival apples-to-grape fruit rather than apples-to-apples. I looked at the "limitations of the study" text and did not find mention of this issue. I hope to find time to review this study in full. What I have seen is that radiation comes out best when apples-to-apples studies are tallied. A group called the Prostate Cancer Results Study Group actually does that and publishes, with the results rather strongly favoring radiation for intermediate and higher-risk cases.

    Quote:
    Originally Posted by DjinTonic View Post
    I'm seeing more papers that are identifying a survival benefit for RP over RT for some subgroups of high-grade (G8-10) PCa, for example this paper for the subgroups with PSA < 10:

    Survival Significance of Patients With Low Prostate-Specific Antigen and High-Grade Prostate Cancer After Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy [2019, Full Text]

    https://www.frontiersin.org/articles/10.3389/fonc.2019.00638/full

    "Conclusion: RP patients with low PSA levels and high GS had better OS compared to either EBRT or EBRT+BT, while RP and EBRT+BT resulted in significantly lower PCSM, compared to EBRT. Moreover, EBRT+BT and RP were associated with similar survival of patients with age of > 70 years old, or PSA levels of ≤ 2.5 ng/ml"

    Djin
    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

     
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    Old 02-10-2020, 04:07 PM   #28
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Don't confuse OS and overall mortality with PCSM. "Sicker" RT men who die from non-PCa causes have by definition survived PCa. As I've said, if RT men were less prone to die earlier from other causes, some would have died later from PCa, making the RP stats even more favorable.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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    Old 02-13-2020, 01:00 PM   #29
    IADT3since2000
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Midway Point in Analysis of Chinese Study of US Patients with Gleason 8-10 and PSA of Up To 10 - Radiation Looking Better

    This is the study initially mentioned in post #1 of this thread at 02-07-2020, 12:15 PM by Djin Tonic (https://www.healthboards.com/boards/cancer-prostate/1048828-advantage-rp-over-rt-subgroups-high-grade-pca.html). The link to the study, entitled “Survival Significance of Patients With Low Prostate-Specific Antigen and High-Grade Prostate Cancer After Radical Prostatectomy, External Beam Radiotherapy, or External Beam Radiotherapy With Brachytherapy” [2019, Full Text] is https://www.frontiersin.org/articles/10.3389/fonc.2019.00638/full.

    Here’s some very good news for RP patients with high Gleason score patients like the ones in this study (GS 8-10, PSA <=10, N0,M0): despite very aggressive prostate cancer, three out of every four patients (73.5%) in this particular group were projected to be still alive at the ten year point after diagnosis, and it’s likely many of them would live well beyond that point. (Table 2, overall survival) Moreover, the floodgates opened for new drugs in about 2010, with recurrence imaging also improving greatly in recent years, while some of the patients in this study were diagnosed as early as 2004 and would have had limited if any access to the new drugs. Therefore, new and rapidly expanding technology should improve on the survival percentage for future RP patients. (On the possible downside, the projection included a “confidence interval” running from a low of 54.8% survival to a high of 85.5% survival for the true value that would theoretically be determined for survival at 10 years if an extremely large group of patients were included in the study; this suggests that data points were widely scattered, making projection somewhat unreliable, but with a true value that would likely fall within the 55% to 86% range.)

    However, some of the facts in the study support the opposite conclusion than the one in the study, which favored surgery; these facts support an apparent superiority of radiation for such high-Gleason score/PSA <=10 patients, and there are serious questions about the approach taken by the urologist authors in trying to support a conclusion that surgery is the better approach. I hope to have a lot more to say about that when I complete my look at the study.

    For instance, consider the proportions of patients who were alive in their early to mid-70s, specifically at ages 73 for the RP group, 75 for the EBRT group, and 72 for the EBRT+Brachytherapy groups. Remember that these were all patients in the SEER database that covers about 28% of the US population, therefore including all from the US SEER areas, who had a Gleason score of 8-10, a PSA of up to 10, and no detectable nodal or distant metastases (N0, M0), between 2004 and 2015.

    ...........................Survival at.............Overall
    Treatment ..........Average Age:.......... Survival


    RP............................73........ ........74% (73.5%)


    EBRT........................75.......... ......86% (86.3%)


    EBRT+Brachy............72............... .93% (92.5%)


    This table is from Table 2 in the report, with selection to focus on outcomes at nearly equivalent ages. Now there is a twist here, and the authors could cry foul, but it is still a factual and meaningful view of the data, though ignoring one key fact, which I will put below my signature to allow a little suspense and an opportunity for Board participants to try to figure this out as in a "Who Done It". The table shows a clear pattern of superior survival of radiation patients versus RP patients at approximately equivalent ages.


    Now here is data taken straight from Table 2 of the study about Prostate Cancer Specific Mortality (PCSM), and I’m going to use the figures for 3 and 5 years from diagnosis but not for 10 years, because the confidence intervals in the 10 year column are so wide, indicating low-confidence as to the true value of this projection and that the data in the study must be all over the map, not in a clear, fairly tight pattern:


    Prostate Cancer Specific Mortality (PCSM – Dying Due to Prostate Cancer, rounded and exact, the lower the percentage the better)


    ...............................PCSM at................PCSM at
    Treatment................3 Years:..................5 Years


    RP.........................6% (6%)#............16% (16%)*


    EBRT.....................2% (1.9%)#...........5% (5.3%)#


    EBRT+Brachy.........1% (1%)#..............3% (2.6%)#


    #For each of these values the confidence interval is fairly tight, indicating that the true value of the projection is very likely very near the indicated value.


    * For RP, the confidence interval at 5 years is wide, from a true value ranging from 12% to 22%, with 16% projected as the most likely, indicating that data points are widely spread. The CI interval means that the true value could be as low as 12% mortality or as high as 22%.



    It appears that at both the 3 and 5 year points, both forms of radiation have sharply lower death rates, which is counter to the study’s conclusion that RP patients do better. More on that, more reasons why it is probably an unsound conclusion, to follow, time permitting.


    (At ten years, RP shows the lowest mortality, but the confidence intervals for RP, EBRT, and EBRT plus brachytherapy are all very wide, indicating little reliability in the projected averages due to data points being very widely spread from each other. Various factors come into play, such as the increasing age of patients, which causes more deaths from other causes and a decreased ability to see what ages would have been like if death came from prostate cancer; increasing age typically means a substantial decrease in the number of data points upon which to base a projection for death specifically from prostate cancer.)


    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.


    The twist in the first table is that the figures are from 10 years since diagnosis for the RP group and 5 years since diagnosis for the other two groups. In other words, the RP group has five years more since diagnosis than the other two groups, in other words the cancer has more time to cause death. That stems from the fact that the average ages of patients in the other two groups were higher, with those in the EBRT group aged 70 at the start, a key fact which impacts results in the study and should impact interpretation.

     
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    Old 02-13-2020, 01:32 PM   #30
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    See also:

    CUOS 2019: High-Risk Prostate Cancer Debate: Surgery [2019]

    https://www.urotoday.com/conference-highlights/cuos-2019/cuos-2019-prostate-cancer/109672-cuos-2019-high-risk-prostate-cancer-debate-surgery.html

    CUOS 2019: High-Risk Prostate Cancer Debate: Radiation [2019]

    https://www.urotoday.com/conference-highlights/cuos-2019/cuos-2019-prostate-cancer/109671-cuos-2019-high-risk-prostate-cancer-debate-radiation.html

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    11-10-17 Decipher 0.37 Low Risk; 5-yr met risk 2.4%, 10-yr PCa mortality 3.3%
    LabCorp uPSA: 0.010 (3 mo.)…0.015 (1 yr. 6 mo.)…0.015 (2 yr. 4 mo.)

     
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