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Thread: Not great news...

  1. #21
    Moderator Top User HighlanderCFH's Avatar
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    Quote Originally Posted by Nonquixote View Post
    Incidence of secondary cancers caused by radiation treatment of the prostate are actually quite low, according to what I've read. Of course, the longer you live the higher the risk but it is difficult to gauge the culpability of RT because of genetic variants, lifestyle or environmental factors that also increase the risk of secondary cancer. There also appears to be a difference in risk between traditional photon RT and proton RT.

    It has been my experience that doctors tend to recommend what they are knowledgeable about, or what their specialty is. Cutters want to cut, radiation therapists want to irradiate, docs who do HIFU will recommend HIFU, etc. My job is to sort out the bias and determine which modality best fits my QoL expectations for the rest of my life.

    I have the time, I may as well take it and gather as much information as possible before making a decision that will impact the rest of my life in a very significant way.
    Indeed, doctors do tend to recommend their own area of expertise as treatment options, etc. And, in past years, I believe there truly WAS a legitimate concern of external beam radiation triggering secondary cancers 10-20 years down the road.

    This is because the beam, on older equipment, was not as focal as today's equipment and a greater amount of healthy tissue became irradiated. This is why younger patients -- not as far along in their lifespans -- have traditionally been offered surgery over radiation. It is/was to guard against the patient living long enough to be affected by possible secondary cancers.

    However, IF the most modern, up-to-date radiation equipment is used, the incidents of secondary cancers is supposed to be significantly lower. So it's best for an EBR patient to be sure that the most modern equipment is being used.

    With all of that said, it is also true that the cure rates between radiation and surgery are almost exactly the same.
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Seven annual post-op exams 2012 through 2018: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

  2. #22
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    Is this a turning point?

    If outcomes are the same and radiation no longer has meaningful side effects then why consider surgery at all?

    The value of the post surgery pathology is moot if outcomes are the same. Why do I care about knowing more about my cancer if it makes no difference in my long term outcomes and treatment choices? Why do I need to consider follow up radiation as a tool in my arsenal when my inevitable follow up option is now HT? Carrying about this inside look at my cancer matters only for future radiation treatments if I have surgery first now seems a catch-22 circular form of logic? Surgery no longer makes sense.

    This is an honest inquiry. I see the logic of it. Is surgery being sent to the sidelines by improvements in radiation treatments?

    The argument there is an emotional element to the choice and some patients just want it cut out is not medicine but patronizing an uninformed bias in the face of better medical technology.

    PS: I'll save the conversation of PC, in any form, presenting early as a useful diagnostic fact for another day. It too seems to becoming irrelevant in the face of radiation being more effective if only by virtue of no long lasting side effects.
    Last edited by Another; 07-05-2019 at 12:50 PM.

  3. #23
    Quote Originally Posted by Another View Post
    Is this a turning point?

    If outcomes are the same and radiation no longer has meaningful side effects then why consider surgery at all?

    The value of the post surgery pathology is moot if outcomes are the same. Why do I care about knowing more about my cancer if it makes no difference in my long term outcomes? And, carrying about this inside look at my cancer matters only for future radiation treatments if I had surgery first seems a catch-22 circular form of logic? Surgery no longer makes sense.

    This is an honest inquiry. I see the logic of it. Is surgery being sent to the sidelines by improvements in radiation treatments?

    The argument there is an emotional element to the choice and some patients just want it cut out is not medicine but patronizing an uninformed bias in the face of better science.
    Neither RT or RP as a primary treatment is a guaranteed cure. After either, quite a number of men go on to BCR, which is usually treated, because it is not know who among those will go on to recurrent clinical disease (quite possibly metastatic). Knowing as much as possible about your own cancer is a good thing for directing further therapy. RT after RP is usually a smaller total dose than RT for primary treatment. If RT for primary treatment fails, and RT is the choice for a BCR salvage treatment, you are getting quite a lot of radiation.

    There can be short- and/or long-term toxic effects of RT, including a second primary cancer (usually bladder or rectum). Yes the risks of these have been decreasing, but they are not zero.

    The side effects of RP are temporary for many, but not all men. We all know the long-term risks in terms of continence and potency. While you have to choose your poison, they are not identical. Also, the newer the RT method and regime, the fewer years of long-term study we have for it. 15 Years of follow-up data, for example, do not carry the same weight for a 70-year-old vs a 50-year-old choosing his primary treatment. Also, with newer RT treatments, for the first years they often experiment with different regimes to find the optimum, varying the number of sessions (fractions) and dose per session.

    My own uro/surgeon, at the outset of our first of two post-biopsy visits, was very clear about the roughly equal outcomes of RP vs RT. We discussed both in detail, and he was very willing to refer me to an RO.

    Djin
    Last edited by DjinTonic; 07-05-2019 at 12:59 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    2013 TURP (90→30 g) path neg. 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
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015

  4. #24
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    The conversations around side effects of surgery far out weigh those of RT, and an argument to the contrary is easily dismissed with the fact the data hasn't caught up yet.

    Regardless, outcomes are similar means just that for both treatment of cancer and affects from treatment. In the context of that declaration, the less invasive procedure wins.

  5. #25
    Quote Originally Posted by Another View Post
    The conversations around side effects of surgery far out weigh those of RT.

    Outcomes are similar means just that for both treatment of cancer and affects from treatment. In the context of that declaration, the less invasive procedure wins.
    Don't confuse the number of men with some side effect with the severity of the effects. I would never go near RT unless I had to.

  6. #26
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    Then outcomes are not similar if you are saying there is a low risk of highly damaging side effects with RT. I am unfamiliar with this statistic and can it also be dismissed as old data?

    It is an important caveat in a declaration if the outcomes are "almost" the same or similar.
    Last edited by Another; 07-05-2019 at 01:33 PM.

  7. #27
    Quote Originally Posted by Another View Post
    Then outcomes are not similar if you are saying there is a low risk of highly damaging side effects with RT. I am unfamiliar with this statistic and can it also be dismissed as old data?

    It is an important caveat in a declaration the outcomes are almost equal.
    Here is one review paper:

    The role of salvage brachytherapy for local relapse after external beam radiotherapy for prostate cancer [2018, Full Text]

    See the toxicity data in the tables for various salvage treatments after failed RT. Not very good.

    Well, speaking for myself, I would call a new bladder or rectal cancer caused by my prostate treatment highly damaging. See the author's remark below about obtaining "sufficient informed consent." That's a sit-up-and-take-notice conclusion.

    RISK OF SECONDARY BLADDER CANCER AFTER HIGH DOSE RATE BRACHYTHERAPY FOR PROSTATE CANCER [2018, Full Text]

    INTRODUCTION AND OBJECTIVES
    Localized prostate cancer (PCa) is mainly treated with both radical prostatectomy (RP) and radiation therapy. Radiation-induced secondary cancers are possible late-onset adverse events of radiation therapy. The incidence of secondary cancer increases at 10 or more years after completion of the radiation therapy. The secondary cancer varies among the types of radiation therapy, and it has been generally considered that the incidence is lower after brachytherapy alone than that after either external beam radiotherapy (EBRT) alone or brachytherapy combined with EBRT. Our hospital has actively performed high dose rate brachytherapy (HDR-BT) for localized PCa since 1998. Recently, we have frequently experienced the incidence of bladder cancer (BCa) following PCa patients after HDR-BT. However, secondary BCa was only investigated after low dose rate brachytherapy in previous studies, and no study on secondary BCa after HDR-BT has been reported. We hypothesized that there was an association between BCa risk and HDR-BT. In this study, we retrospectively investigated the risk of BCa in patients who received HDR-BT with or without EBRT.

    METHODS
    The subjects were 1,023 patients treated with HDR-BT with or without EBRT for localized PCa between January 1, 1998 and December 31, 2014 at our hospital. The protocol of HDR-BT with EBRT was 24 Gy/4 fractions of HDR-BT combined with 36.8 Gy of EBRT to the prostate region until July 2006 and then after August 2006, the protocol was 18-20 Gy/2 fractions of HDR-BT combined with 39 Gy of EBRT. Only 83 patients (8.1%) were treated HDR-BT alone. RP (including laparoscopic surgery) was performed during the same period in 285 patients. Not all of the patients could be analyzed because the medical records of patients who did not visit the hospital for a long time were not retained. Therefore, this study was a matched case-control study. For this study, the outcome was defined as the development of pathologically demonstrated BCa after local treatment. To exclude synchronous cancers, patients with BCa that developed within 2 years after PCa treatment and patients with a past medical history of urothelial cancer before the diagnosis of PCa were excluded. Among the follow-up patients with PCa after local therapy in our institute, 16 cases of newly pathologically diagnosed BCa as of April 2017 and 128 controls (1:8 matched by both age at the time of PCa treatment and for the follow-up period) were recruited. Logistic regression analysis was performed regarding cigarette smoking (including past smoking history) as a confounding factor.

    RESULTS
    The median age of the 16 patients in the case group at the onset of BCa was 74 (64-87) years old, and all patients had hematuria based upon macroscopic observation. Only one (6.3%) of these patients had been treated with PR, and the other 15 patients (93.8%) had received HDR-BT (including 2 cases; HDR-BT alone). The median time since prostate treatment was 56 (24-160) months. The clinical and pathological diagnosis was non-muscle-invasive BCa in all patients, and these were treated with transurethral resection. No patient died of BCa. In the control group, 36 patients (28.1%) had been treated with RP, and 92 patients (71.9%) had received HDR-BT with or without EBRT. Nine (56.3%) of the 16 patients had a history of smoking in the case group. In the control group, 58 patients smoked cigarettes, 52 did not smoke cigarettes, a history of smoking was not known in 18, and the smoking rate was 52.7% excluding the unknown cases. On logistic regression analysis of local therapy (RP vs. HDR-BT) with the 2 items of history of cigarette smoking as confounding factors, the odds ratio of HDR-BT against surgery was 5.38 (95% CI: 1.02-99.32, p=0.0472) and that of the history of cigarette smoking was 1.16 (p=0.787).

    CONCLUSIONS
    The incidence of secondary BCa after HDR-BT with or without EBRT for localized PCa was about 5 times higher, and the time to cancer development was about 5 years, which is a relatively short time compared to the previous reported. Although almost cases were treated combined with EBRT, the influence of HDR-BT may have contributed to the cancer, indicating that a prospective observational study may be necessary. Although none of the patients had advanced BCa, it is necessary to obtain sufficient informed consent when HDR-BT is selected to treat localized PCa.
    [Emphasis mine]
    Last edited by DjinTonic; 07-05-2019 at 01:59 PM.

  8. #28
    Quote Originally Posted by Another View Post
    Is this a turning point?

    If outcomes are the same and radiation no longer has meaningful side effects then why consider surgery at all?

    The value of the post surgery pathology is moot if outcomes are the same. Why do I care about knowing more about my cancer if it makes no difference in my long term outcomes and treatment choices? Why do I need to consider follow up radiation as a tool in my arsenal when my inevitable follow up option is now HT? Carrying about this inside look at my cancer matters only for future radiation treatments if I have surgery first now seems a catch-22 circular form of logic? Surgery no longer makes sense.

    This is an honest inquiry. I see the logic of it. Is surgery being sent to the sidelines by improvements in radiation treatments?

    The argument there is an emotional element to the choice and some patients just want it cut out is not medicine but patronizing an uninformed bias in the face of better medical technology.

    PS: I'll save the conversation of PC, in any form, presenting early as a useful diagnostic fact for another day. It too seems to becoming irrelevant in the face of radiation being more effective if only by virtue of no long lasting side effects.
    I'm glad to see you asking this question, as I have been coming to the opinion that, with a few exceptions, such as a huge prostate or previous nearby radiation, there really is no risk level for which surgery can be said to be superior to RT.

    This is a topic that I have been tempted to post on several forums, but was hesitant about the blowback. Thanks for opening the door.

    The BCR rates that I see for advanced RT, such as SBRT and PBT are equal or superior to RP. So that leaves the two hypothetical arguments that (1) the post-RP pathology offers some advantage; and (2) that surgery is difficult or impossible if primary RT fails. Both of these points seem weak, as (1) the long term results are no better despite having the post-op pathology; and, (2) that there are several non-surgical salvage treatments for radio-recurrent prostate cancer.

    So, if surgery really offers no advantages, why should any man give it preference in choosing a treatment? Yes, of course, his urologist saying "You have cancer...I can cure you". IMHO. that influence is a big problem.

    Hopefully, at some future time, both cutting and burning will be overtaken by a pill or something of minimal damage. For now, knowing the BCR rates and the side effects appears the main criteria in the RP versus RT decision making.
    Last edited by ASAdvocate; 07-05-2019 at 01:57 PM.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  9. #29
    Djin, Here are some additional studies concerning BT for salvage after primary radiation:

    https://www.thegreenjournal.com/arti...17)30618-7/pdf

    https://www.redjournal.org/article/S...ol:31774-7/pdf
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  10. #30
    Quote Originally Posted by ASAdvocate View Post
    Djin, Here are some additional studies concerning BT for salvage after primary radiation:

    https://www.thegreenjournal.com/arti...17)30618-7/pdf

    https://www.redjournal.org/article/S...ol:31774-7/pdf
    I'm not doubting there are some promising results (the first two papers in your first link conclude that long-term data is needed. Your 2nd link didn't work for me, ASA.

    Study OC-0176 in the first link tries to find an algorithm for determining the men best suited for salvage HDR brachytherapy.

    My point is that choosing RT for primary treatment should be, like RP, a researched choice. My own concern would not be successful primary RT, but rather the cumulative dose if SRT is needed.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    2013 TURP (90→30 g) path neg. 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
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015

 

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