Improvements in RP over Time

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ron - 10 Jan 2005 15:58 GMT

In a different thread Steve Kramer asked...
I wonder if that is true of 10 years ago. 1994? I suppose there is not
so much difference between RRP, radiation and HT treatments of ten
years ago. Better, certanly. But so much so that the mortality rate is
changed? I imagine not...snip
---------------------------------------------------------------

For RP at least things have improved over time. This has become known
as the "year of RP factor" and has been discussed in several papers.
Given the long lead time for PCa death, biochemical recurrence is the
most commonly used surrogate end-point for measuring treatment
efficacy. Using biochemical recurrence then to track improvements in
RP outcome over time, Walsh, et. al. (M. Han, A. W. Partin, M. Zahurak,
S. Piantadosi, J. Epstein and P. C. Walsh; J. Urol., 169, 517-523,
2003; the paper can be found at...)
http://www.prostate-help.org/download/jhnomo.pdf
has created a nice graph (p. 519) showing the log [of the relative rate
of recurrence of a (T1c, GS=6, PSA=4-10) man to the relative rate of
recurrence of a (T1c, Gs=5, PSA=0-4) man] vs. time. Between 1982 and
2000 there has been over a 1000-fold improvement in the relative
outcome of these men. In the last 10 years for which there is data,
I'd eyeball the improvement at about a factor of 10...Best wishes and
good health, Ron

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James A. Honeychuck - 10 Jan 2005 18:10 GMT

Thanks for posting this, Ron. First time I've seen this encouraging
information.

jimhoney

> In a different thread Steve Kramer asked...
> I wonder if that is true of 10 years ago. 1994? I suppose there is not
[quoted text clipped - 19 lines]
> I'd eyeball the improvement at about a factor of 10...Best wishes and
> good health, Ron

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Leonard Evens - 10 Jan 2005 21:47 GMT

One quibble. The improvement is probably not the result of improvement
in RP technique but rather in earlier detection of disease because of
extensive PSA testing.

On another point, this probably explains in part the difference between
the predictions of Walsh and Kattan on one hand and other predictions
which are much more pessimistic. There is another thread in which I
commented about this. Walsh's predictions are projections based partly
on the observed improvement. It is what he expects to see in the
future. Other calculators may simply say what has been observed in the
past. But the discrepencies seem to me still to be too large for that
to be the only explanation. It may be that the populations studied are
also quite different in terms of when their cancers were discovered.
If so, that would provide some evidence justifying PSA testing. Or, of
course it is still possible that some of these people just didn't do the
statistics properly.

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ron - 10 Jan 2005 22:38 GMT

> One quibble. The improvement is probably not the result of improvement
> in RP technique but rather in earlier detection of disease because of

> extensive PSA testing.
>
> On another point, this probably explains in part the difference between
> the predictions of Walsh and Kattan on one hand and other predictions

> which are much more pessimistic. There is another thread in which I
> commented about this. Walsh's predictions are projections based partly
> on the observed improvement. It is what he expects to see in the
> future...snip...

Hi Leonard...As to the quibble, Walsh says, "when the relative risk of
biochemical recurrence was adjusted for clinical TNM stage,
preoperative PSA and Gleason score, there was still a significant
decrease in relative risk of biochemical recurrence over time." Kattan,
et. al. (The Journal of Urology 2004; 171(2):692-696; Is Year of
Radical Prostatectomy a Predictor of Outcome in Prostate Cancer?) found
a similar behavior in the data and concluded, "When controlling for
preoperative features, the year in which RP was performed is a
predictor of outcome on multivariate analysis. This effect could not be
explained by stage migration." So both authors had already corrected
for the temporal effects of stage migration (e.g. PSA era effect) and
still found a remaining, unexplained improvement over time. Walsh did
not speculate as to the nature of this variable, although one would
think that surgical technique must be at least a part of it, he /
others termed it the "year of RP factor."

As to your second point, since I know you are interested in dissecting
and understanding the various nomograms, let me mention that the
Hopkins' nomograms project what they expected to see for men treated in
1999...Best wishes and good health, Ron

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Leonard Evens - 11 Jan 2005 04:18 GMT

>>One quibble. The improvement is probably not the result of
>
[quoted text clipped - 33 lines]
> think that surgical technique must be at least a part of it, he /
> others termed it the "year of RP factor.

It could be that earlier detection is differentiating cancers on the
basis of some unknown factor not caught in the usual criteria.
Improvements in technique for the best surgeons, it seems to me, should
play a relatively small role in recurrence rates for similar cases,
although it might in avoiding impotence. But perhaps more better
trained surgeons could make a difference.

Of course, the skeptics will just say that early detection is just
throwing in a lot of benign cancers which would never amount to anything
despite their PSA values, Gleason scores or stages. They would claim
that this improves the figures without actually improving real cure rates.

> As to your second point, since I know you are interested in dissecting
> and understanding the various nomograms, let me mention that the
> Hopkins' nomograms project what they expected to see for men treated in
> 1999...Best wishes and good health, Ron

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Steve Kramer - 11 Jan 2005 00:16 GMT

> Between 1982 and
> 2000 there has been over a 1000-fold improvement in the relative
> outcome of these men. In the last 10 years for which there is data,
> I'd eyeball the improvement at about a factor of 10...Best wishes and
> good health, Ron

My father died from PCa during 1982. I'd agree to a 1000-fold improvement
in treatment.

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Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
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RRP 12/15/2000 G7 (3+4), T3bN0M0
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