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  • Advantage of RP over RT for Subgroups of High-Grade PCa

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    Old 02-07-2020, 09:15 AM   #1
    DjinTonic
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    Advantage of RP over RT for Subgroups of High-Grade PCa

    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
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    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    Old 02-07-2020, 10:58 AM   #2
    ASAdvocate
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    I think that we have debated this study before. Basically, what they are saying is that:

    "However, in the competitive risk model after adjusting for the patient's marital status, age at diagnosis, race, PSA level, clinical T stage, and GS, no significant difference was found in PCSM for patients treated with RP vs. EBRT + BT"

    And:

    'it was found that RP still had a better OS in patients who were ≤ 70 years old, when compared with radiotherapy, while EBRT+BT and RP had the same prognosis in patients with >70 years old."

    So, once we eliminate EBRT monotherapy for these higher risk patients, we find no PCa mortality differences between RP and EBRT + BBT for patients of any age range.

    What the authors conclude is that there is an OS advantage for RP in patients under age 70. But, as we have previously discussed, some men are disqualified from RP due to other serious health issues. Since the SEER database does not include that data, we are left having to assume that unhealthy men simply die sooner than healthy ones, and that the study's conclusion is weakened by that lack of data.
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    Old 02-07-2020, 11:10 AM   #3
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by ASAdvocate View Post
    I think that we have debated this study before. Basically, what they are saying is that:

    "However, in the competitive risk model after adjusting for the patient's marital status, age at diagnosis, race, PSA level, clinical T stage, and GS, no significant difference was found in PCSM for patients treated with RP vs. EBRT + BT"

    And:

    'it was found that RP still had a better OS in patients who were ≤ 70 years old, when compared with radiotherapy, while EBRT+BT and RP had the same prognosis in patients with >70 years old."

    So, once we eliminate EBRT monotherapy for these higher risk patients, we find no PCa mortality differences between RP and EBRT + BBT for patients of any age range.

    What the authors conclude is that there is an OS advantage for RP in patients under age 70. But, as we have previously discussed, some men are disqualified from RP due to other serious health issues. Since the SEER database does not include that data, we are left having to assume that unhealthy men simply die sooner than healthy ones, and that the study's conclusion is weakened by that lack of data.
    The demographic happened to be mine, G8-10, PSA <10, < 70 yr, good general health. I'm pointing out that RP is far from dead as a treatment and their may be cohorts who are well-served by it. One can draw whatever conclusion one wants, but IMO RP is hardly off-putting for men in my shoes. As far as QOL, I'm dry, have potency issues (with silfenafil, which I started toying with for BPH a few years before my RP), and orgasms are dry, but a bit more intense than before surgery. Not too bad.

    The study I cited states

    "There was no statistical difference in [prostate cancer-specific mortality] between RP and EBRT+BT."

    If, as you say, a larger number of less-healthy men are doing RT, then they are probably dying earlier from non-PC causes. If they lived longer, deaths from PCa would go up, and the balance would be more in favor of RP!

    My uro/surgeon was correct in his first piece of information in my first post-biopsy visit: I would have to choose between two treatment paths with basically equivalent outcomes for my status.

    Djin
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    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, negative 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)
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    Old 02-07-2020, 11:36 AM   #4
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    [QUOTE=DjinTonic;5500991

    If, as you say, a larger number of less-healthy men are doing RT, then they are probably dying earlier from non-PC causes. If they lived longer, deaths from PCa would go up, and the balance would be more in favor of RP!

    Djin[/QUOTE]

    Interesting logic. The flip side is that, if more of the unhealthy men were allowed to have RP, then the OS balance could tilt in favor of EBRT+BBT.

    But, I think that we can agree that most men in this risk category will increasingly be doing combo treatments "MAXRP" and "MAXRT" which will likely improve the PCSM, but at some cost to QOL for many.
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    Old 02-07-2020, 11:46 AM   #5
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by ASAdvocate View Post
    Interesting logic. The flip side is that, if more of the unhealthy men were allowed to have RP, then the OS balance could tilt in favor of EBRT+BBT.


    But, I think that we can agree that most men in this risk category will increasingly be doing combo treatments "MAXRP" and "MAXRT" which will likely improve the PCSM, but at some cost to QOL for many.
    I don't follow that if the RP OS dropped because of non-PC related deaths, why that would affect PCa-specific deaths. In fact it would lower that rate -- more of these unhealthy men would die before their PCa could kill them.

    For my cohort, whether or not you need MAXRP is not an up-front decision -- it waits until the results of the RP are known. I believe the PSA < 10 captures a nice chunk of men like me, with prostate-confined disease, who will be pT2. Aren't most high-grade men getting MAXRT with ADT up front?

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    Old 02-07-2020, 12:35 PM   #6
    ASAdvocate
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by DjinTonic View Post
    I don't follow that if the RP OS dropped because of non-PC related deaths, why that would affect PCa-specific deaths. In fact it would lower that rate -- more of these unhealthy men would die before their PCa could kill them.

    For my cohort, whether or not you need MAXRP is not an up-front decision -- it waits until the results of the RP are known. I believe the PSA < 10 captures a nice chunk of men like me, with prostate-confined disease, who will be pT2. Aren't most high-grade men getting MAXRT with ADT up front?

    Djin
    From the ASCO publication authored by Dr. D'Amico:

    "study reported in JAMA Oncology, Tilki et al found that patients with Gleason score 9Ė10 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.
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    Old 02-07-2020, 12:50 PM   #7
    DjinTonic
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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 9Ė10 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.
    AFAIK, if you have no evidence of mets or truly advanced local disease (such as invasion of the bladder or rectum seen on imaging), a decision about adjuvant treatment (RT, ADT, or both) always depends on the path report and post-op PSA. Since I didn't get any adjuvant treatment after RP, there was certainly no reason to start it before surgery. (There is going to be a minimum healing period of several months, anyway.)

    I believe the comparisons you cite are for those men (probably the majority) who do get/need MAXRP, and is comparing that treatment against MAXRT. In fact, Dr. D'Amico very firmly believes that G9 or 10 men with even ONE major adverse finding (SVI+, EPE+, SM+, LNI+) should be told that adjuvant treatment is part and parcel of their primary treatment! (Of course persistent PSA would be another trigger for adjuvant).

    I recently asked my uro/surgeon whether he would have advised adjuvant for me if I had the same path report but with the sole addition of lymphovascular invasion (LVI+), the one major adverse finding that is located within the prostate. And he said yes.

    So MAXRT is determined by the biopsy report, imaging, and, I expect PSA to some extent. MAXRP may be seen as very likely prior to surgery, but one has the pathology on the whole prostate, lymph nodes, and post-RP PSA to make the determination.

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    Old 02-07-2020, 01:09 PM   #8
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Djin,

    Dr. D'Amico has been spreading the word that RP followed by RT is just as effective for high risk men as an RT combo (EBRT + BBT).

    Think about that. He is a radiologist, and gets business whether RP or RT is chosen as the treatment plan. Hmm....
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    Old 02-07-2020, 01:11 PM   #9
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by ASAdvocate View Post
    Djin,

    Dr. D'Amico has been spreading the word that RP followed by RT is just as effective for high risk men as an RT combo (EBRT + BBT).

    Think about that. He is a radiologist, and gets business whether RP or RT is chosen as the treatment plan. Hmm....
    OK, but we have to trust somebody! If we can't trust the surgeons for reliable info about RT, and we can't trust the radiologists... we be doomed! And, hey, you mentioned Dr. D'amico first!

    Djin

     
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    Old 02-08-2020, 04:03 AM   #10
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Only 17% of all men are screened yet urologists have all the business they can handle. PCa healthcare providers do not need to mislead to get business. Bad ones may have to.

    The use of cynicism and resignation about doctors as evidence of bias is not convincing. Stick to the data.

    I'll take my outcome from surgery every day of the week over radiation.

     
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    Old 02-08-2020, 08:16 AM   #11
    Terry G
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    I agree with sticking with the data. However, if I were one of the unlucky guys diagnosed with high risk prostate cancer I would investigate not only surgery but the other options as well. Possibly I rely on the information I find on prostatecancerfree.org. For high risk guys the data there suggests the various radiation treatments may be more effective at providing a cure. The study being discussed here is one new data point. I wonder what improvement in surgery has occurred in this particular data to influence the positive outcome compared to older studies.

    I donít believe urologists or radiation oncologists purposefully skew data. However very few of them know much about the otherís specialty. Thatís why I believe itís so important to investigate all of your options and select the one that fits your specific situation. For some guys the risks of loss or reduction of sexual or urinary function may not be a big deal compared to the need to get it out or the need for a pathology report. That said I think there is more data suggesting that surgery alone is not the best option for high risk PCa.
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    Old 02-08-2020, 10:01 AM   #12
    Gary I
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by Prostatefree View Post
    ....I'll take my outcome from surgery every day of the week over radiation.
    My surgery was less than than successful, yet I agree. As I say, there are no silver bullets, and I would put much more weight on physicians advise, researchers who have been through it, in-depth clinical studies, and Walsh's textbook than I would on theoretical third hand advice from those who have never had to pull the trigger.

    I've been seen by Bal Carter, at Johns Hopkins, who is very experienced and extremely even handed, and by Tony D'Amico, at Harvard, the dean of radiation therapy, who is most aggressive about RT and hormones, and is much less even handed, from my experience.

    After all is said and done, it still becomes a leap of faith.
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    Old 02-08-2020, 02:09 PM   #13
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Not Impressed with the Tilki 2019 study: Surgery vs Radiotherapy in the Management of Biopsy Gleason Score 9-10 Prostate Cancer and the Risk of Mortality

    Link to study and title: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439553/#!po=35.7143 "Surgery vs Radiotherapy in the Management of Biopsy Gleason Score 9-10 Prostate Cancer and the Risk of Mortality"

    My first take was that maybe I have really missed something about the effectiveness of surgery for especially high Gleason score cancers. I was impressed that Dr. D’Amico, whom I greatly respect, was the senior author for this paper (but not the quarterback, in other words, the first author). I also noted that professional statisticians were involved. But I am convinced that patients with high-risk cases, especially Gleason 8 and higher, have considerably better odds of success with radiation. I see problems with this study, and the upshot is I see nothing here to alter my favorable assessment of radiation plus ADT over surgery for high-risk cases, and I see inadequate data here to assess whether surgery plus EBRT plus or minus ADT can match EBRT plus brachytherapy plus ADT in a modern setting. I would not call this a “nothing-burger study”, but I am not impressed and am disappointed. That’s my bottom line and the details follow from my viewing point as someone with 225 undergraduate hours in statistics and experimental design plus graduate work, a lot of complementary math, and a career in analysis. I would appreciate comments, especially by those with a similar background, including Djin Tonic and Skipper3.

    Here is the study objective: “To investigate whether treatment of Gleason score 9-10 prostate cancer with MaxRP vs MaxRT was associated with prostate cancer–specific mortality (PCSM) and all-cause mortality (ACM) risk.” My bottom line, subject to rebuttal by others, is that this study was not able to effectively determine whether there was a meaningful difference between these approaches that is relevant to our current situation with modern technology. My reasoning follows.

    First off, “Operational Definition”: This is a term meaning the way you define what you are seeking to examine in operational terms, such as what you look for and how you look for and analyze it. In this case, basically, MaxRT was defined as a combination of EBRT+brachytherapy+ADT at one institution treating patients between 1992 and 2013. Ouch! There is the first glaring problem. EBRT back in the early period was often inadequately dosed because it could not be done safely due to unintended damage to other organs, such as the rectum and bladder. Seeds could correct under dosing to the prostate without the collateral damage outside the prostate, but, with limited imaging capability in the earlier years, seeds were often misplaced, causing both internal and external problems as well as decreasing effectiveness. It is not clear that these issues were effectively addressed, and the upshot is that the study results for radiation were likely unfavorably influenced by these problems. The earlier limited effectiveness of radiation was a very big deal to me, leading me to gamble on postponing my shot with radiation from 2000, when it looked shaky and discouraging, to 2013, when I took my shot, several years after radiation and associated technologies were looking quite good and promising. (Preview: the paper states that all radiation patients were treated with IMRT, which puts the stated time frame into question.)

    Moreover, and more serious, pelvic radiation was not known to be helpful back then, and given the problems with technology in the early years of this study, “conventional” and “conformal beam” therapy would have been used, which are known to be inferior to IMRT, especially image guided IMRT, which really did not come into its own at most radiation facilities until around 2007 or later. These days, Gleason 9-10 patients would typically get doses of pelvic radiation. Per the complete paper, pelvic radiation was at the discretion of the doctor, and no data regarding pelvic radiation are in the paper, which is most unfortunate. These days, pelvic radiation, in my opinion with some good backing in research, is important for men with higher-risk cases.


    Also, while the cohorts (separate study groups) look large at first glance, this is a VERY small study considering that it stretched over so many years (1992 – 2013 for treatments, 22 years) with major changes in radiation technology over that time. There were only 88 patients in the MaxRP group (with only 50 also receiving ADT, and with hundreds more getting RP without EBRT, which was not the focus of the study and somewhat distracting), and only 80 patients in the MaxRT group. Averaged over 22 years of treatments, that means about 4 per year in each group received each treatment over a period in which radiation technology began improving greatly in the latter half of the study, with some changes, mainly robotic surgery, on the RP side. Generally, unless there is an extremely strong impact on outcomes from the treatments in a study, such small studies are going to result in a large scattering of results away from the “average” result. That shows up in what statisticians call the “confidence intervals” (CI intervals). We see it here in very wide CIs of .49 to 3.64 for MaxRP vs. MaxRT for prostate cancer mortality and .36 to 1.81 for All Cause Mortality (ACM). To use highly technical, arcane language, the results were spread all over the map.

    Another problem, which severely aggravates the already inadequate numbers of patients in the study in each group, is that the average (median) follow-up for this very long study is remarkably short, an average of only 4.78 years in the MaxRP group and only 5.51 years in the MaxRT group, with one quarter of patients in each group having substantially shorter follow-up. (There is an associated problem, though not as crucial, as there is substantially less time to observe deaths in the MaxRP group, as the authors note in the discussion section.) So if we reduce the 88 patients in the MaxRP pool by 24% due to grossly inadequate follow-up of less than 4.01 years, we get only 67 MaxRP patients with even a semblance of adequate follow-up of just 4.01 years or longer, but with only 24% going beyond 6.05 years. For Max RT, with an average of 5.51 years, with a quarter (24%) of the small number of patients in the study having a follow-up of less than 2.19 years, if we reduce the 80 patients in the MaxRT pool by 24% due to grossly inadequate follow-up, we get only 61 patients even approaching a semblance of adequate follow-up, with only a quarter (24%) having a follow-up of longer than 6.95 years. So about 3 patients in each group were treated, on average, each year. Now back in the early years of the study survival of men with GS 9-10 cancer was shorter than it is now, but probably not greatly shorter, and today, for GS 9-10 men who do not have distant metastases at the outset, my impression is that most are going to considerably outlive this range, which means that this study lacks the power to see a real impact of even a modern combination of surgery/EBRT/ADT versus brachytherapy/EBRT/ADT. Short follow-up, looking inadequate to me, compounds the critical “garbage in/garbage out” problem.

    Okay, the foregoing is mostly what I saw in the abstract. Now I’m looking at the complete paper.
    Additionally, the duration of ADT was an average (median) of only 6 months, a duration now known to be grossly inadequate in support of radiation for high risk patients, where a range of 18 to 24 months is now probably standard of care, with some doctors advocating 36 months. And, the paper tells us that at least 75% of the patients had a duration of only 12 months or fewer. This undercuts the effectiveness of modern radiation for high-risk patients. (Patients who had MaxRP group who had ADT, not all did, had longer ADT, averaging 8.6 months for all, but with those where pelvic lymph nodes were positive averaging 14.45 months, with more detail in the paper.)

    The paper says that EBRT was IMRT, which seems odd for the early years of the study as IMRT was not widely available. When I was offered radiation by Johns Hopkins in the first half of 2000, they were offering conventional radiation with maybe a bit of 3D conformal radiation, which was then the big new thing. IMRT was not yet in the picture at Johns Hopkins in 2000. I’m thinking the authors glossed over this anachronism, though it is conceivable that the Chicago Prostate Cancer Center was in the forefront of pioneering IMRT; a quick check of PubMed suggested that could be the case.

    Notably, no patient was lost to follow-up.

    This study is not an apples-to-apples comparison: while all patients had challenging cancer with Gleason scores of 9 or 10, overall the radiation group had considerably more challenging cases. Tumor staging indicated sharply higher tumor stage in the MaxRT group: 34 in the T3/T4 stages vs. 4 in the RPgroup in this key stratum which indicates unconfined prostate cancer, with about 1.5 times the number of T2 patients in the RP group compared to the RT group, meaning lower risk in the RP group, and 3 times as many T1c patients in the RP group, also meaning lower risk for the RP group. There were noticeably higher Gleason scores in the MaxRT group, especially Gleason 10, which made that group more challenging. In short, the RT group was made up of patients with substantially more challenging cases overall.

    I noted distracting data and references for other men treated at the RP center who were not treated with MaxRP but just had other therapy that involved an RP. That made interpretation of MaxRP versus MaxRT more difficult, but still possible, and, for those interested in whether they should also have radiation, the statistics are useful, almost a study within this study, and probably more of an apples-to-apples RP versus MaxRP comparison, though I did not do more than skim that, than the MaxRP versus MaxRT comparison. “The clinical significance of these observations is that they provide evidence to support the importance of adding both adjuvant EBRT and ADT after RP in men with biopsy Gleason score 9-10 prostate cancer to reduce the risk of PCSM and ACM so that their outcomes may become comparable to those of men undergoing MaxRT.” Also, surgical margins were overwhelmingly present for the RP patients. In other words, if you want to have surgery for Gleason 9-10 cancer, stand by for adjuvant or salvage radiation and ADT, and that means an adverse synergy of side effects from all three (RP, RT, ADT) rather than just from radiation and ADT.

    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.

    Last edited by IADT3since2000; 02-10-2020 at 12:54 PM. Reason: Deleted typo "a" before distracting data. Added link to study.

     
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    Old 02-08-2020, 02:27 PM   #14
    DjinTonic
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    I believe the study also looked at PCa-specific outcomes, not just OS, so the sicker-population getting RT question doesn't weigh as much (If the sicker men didn't die earlier from non-PC causes, they would probably increase the numbers dying from PC.)

    Hopefully, I can keep "standing by" for SRT and ADT until I die from another cause. If I do ever encounter BCR, it might be that SRT without ADT would be advised for recurrence in the fossa alone. In any case, I have no adverse urinary or potency outcomes from my RP, so there is nothing to "add" to future side effects.

    I'm not saying surgery is the "winner" for this cohort, but rather that the summary (and snarky) dismissals in other forums (especially when some of these men are dealing with the effects of long-term ADT, and radiation proctitis and cystitis) is not supported by comparative studies.

    For most high-risk men, decisions about the need for adjuvant treatment are made after the path report and post-RP PSA level. This is built into the MAXRP issue. For some, MAXRT is, I think, overtreatment, but for whom?

    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, negative 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
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    Old 02-09-2020, 10:11 AM   #15
    guitarhillbilly
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    Re: Advantage of RP over RT for Subgroups of High-Grade PCa

    Quote:
    Originally Posted by Terry G View Post
    I agree with sticking with the data. However, if I were one of the unlucky guys diagnosed with high risk prostate cancer I would investigate not only surgery but the other options as well. Possibly I rely on the information I find on prostatecancerfree.org. For high risk guys the data there suggests the various radiation treatments may be more effective at providing a cure. The study being discussed here is one new data point. I wonder what improvement in surgery has occurred in this particular data to influence the positive outcome compared to older studies.

    I donít believe urologists or radiation oncologists purposefully skew data. However very few of them know much about the otherís specialty. Thatís why I believe itís so important to investigate all of your options and select the one that fits your specific situation. For some guys the risks of loss or reduction of sexual or urinary function may not be a big deal compared to the need to get it out or the need for a pathology report. That said I think there is more data suggesting that surgery alone is not the best option for high risk PCa.
    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.

     
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