 |
 | Home | Contact Us | FAQ | Search & Site Map | Link to Us |
 | Sign In | Join | Other 45 Sites in Network |
Medical Forum / Diseases and Disorders / Prostate Cancer / August 2005Path report back after 8/12 RRP....
Got a little impatient and called Dr. Partin's office this afternoon. He wasn't in, but his nurse...knowing that I was anxious to know, gave me the good news I wanted/needed to hear! ALL negative margins....lymph node dissection, seminal vesicales, and gland. Cancer completely contained to the gland. I know I'm not "free and clear" until 10 years out, but I praise the Most High for His faithfulness throughout the last 6 weeks. Lamentations 3:21-23.....GREAT IS THY FAITHFULNESS! Wow, this is really the week for great news from the "recently chopped"!  SignaturePeter Headland > Got a little impatient and called Dr. Partin's office this afternoon. > He wasn't in, but his nurse...knowing that I was anxious to know, gave [quoted text clipped - 5 lines] > I know I'm not "free and clear" until 10 years out, but I praise the > Most High for His faithfulness throughout the last 6 weeks. The bad news is that you won't be free and clear even after ten years, since the cancer can always recur. The good news is that as time progresses the probability of recurrence keeps getting smaller. With your pathology results, the likelihood of recurrence is pretty small to start, and it is going to get to be small enough to be considered practically impossible probably well before ten years. If you want a milestone, keep two years in mind. Generally cancers which recur after two years have a much better prognosis than those that recur before two years. > Lamentations 3:21-23.....GREAT IS THY FAITHFULNESS! > The bad news is that you won't be free and clear even > after ten years, since the cancer can always recur. A more positive way of looking at the statistics is that after 10 years you will be less likely to die from PCa than a man of the same age who has never been disgnosed with PCa (if I have the numbers right). SignaturePeter Headland > A more positive way of looking at the statistics is that after 10 years > you will be less likely to die from PCa than a man of the same age who > has never been disgnosed with PCa (if I have the numbers right). For a low-risk man (T1c, PSA=4-10, GS+6), the chances for biochemical recurrence within 10 years of RRP is about 5%, according to the Hopkins nomograms. According to Pound, the median time to mets and then to death following biochemical recurrence after RRP is 8 and 5 years respectively. Stretching it out, if such a man recurs in year 10 and then survives 13 more years to death, we could say that such a low-risk man, treated by RRP, has roughly a 5% chance of dying from PCa in the next 25 years. According to the SEER database, an undiagnosed 50 year old man has a 0.76% chance of dying from PCa in the next 25 years of his life. Glad to see all of the numbers so low, but still wish I hadn't drawn the short straw...Best wishes and good health, Ron [ron saying the chances are worse than I think] Ron, you missed my point (because I didn't make it very clearly). My point was that *if you make it to 10 years without recurrence*, your chances of recurrence during the rest of your life are minimal. Your calculations include people who recur within the 10 years after their RP; mine exclude people who recur within those 10 years. In other words, I was saying that you don't have a lifetime of worry ahead of you - the longer you go with undetectable PSA after surgery, the better your odds become. The first PSA test after surgery is the most important one of them all. FWIW, what I read was after 15 years the risk is so very tiny they call you "cured". More likely to die in a road accident, I think. SignaturePeter Headland How does that reconcile with the claim a few days ago that an oncologist pronounced one of us cured because of 22 months with undetectable PSA? I.P. "Peter Headland" <PHeadland@excite.com> wrote > > FWIW, what I read was after 15 years the risk is so very tiny they call > you "cured". More likely to die in a road accident, I think. > How does that reconcile with the claim a few days ago that an oncologist > pronounced one of us cured because of 22 months with undetectable PSA? [quoted text clipped - 5 lines] >>FWIW, what I read was after 15 years the risk is so very tiny they call >>you "cured". More likely to die in a road accident, I think. The oncologist is using different criteria to define "cured". One would have to know just what evidence was being used to support that conclusion. Without that information, it is impossible to evaluate the claim. Peter Headland wrote...snip... > FWIW, what I read was after 15 years the risk is so very tiny they call > you "cured". More likely to die in a road accident, I think. Hi Peter...Here's my take on biochemical recurrence post RP. There was an interesting paper by Swanson a couple of years ago (Eur Urol 2002 Sep;42(3):212-6; Long-term follow-up of radical retropubic prostatectomy for prostate cancer; Swanson GP, Riggs MW, Earle JD, Haddock MG.) in which he followed men for up to about 30 years post-RP (minimum 22.5 yrs.). He found that recurrence was linear over this period of time (BTW, he published a similar paper for RT with similar long-term linear recurrence rates). Of course, this study took men from the pre-PSA era, most had palpable tumors. I didn't find this result particularly "encouraging", so I mentally wrote it off saying low-risk, PSA-era men would somehow have a different (better) outcome. Then came Walsh's paper (the Hopkins Nomograms) with data at 3, 5, 7 and 10 years post-RP. When I plotted the data in the nomograms, I believe I see some flattening in the recurrence curves for high-risk men out at later times, but still, a linear fit works very well (r^2 ~ 0.95). With lower risk men, the data looks very linear with time (r^2 ~ 0.98-0.99). I've been forced to conclude that biochemical recurrence following RP is probably linear with time, and does not fall off appreciably after 10 years. So, if the risk for biochemical recurrence for a T1c, PSA=4-10, GS=6 man is 5% at 10 years following RP, then it will be 10% at 20 years. Linearity would be a worst case scenario; as I said there may be "some" flattening with time. That said, within these sub-categories of men (hi-, medium- and low-risk), there is further stratification according to PSA nadir and rate of PSA increase. Witherspoon's paper (J. Urol. 157:1322-1328, 1997; Sensitive Prostate Specific Antigen measurements identify men with long disease-free intervals and differentiate aggressive from indolent cancer recurrences within 2 years after radical prostatectomy; Witherspoon LR, Lapeyrolerie T) is one example of a number of papers that find evidence of this stratification. As Witherspoon says, "Therefore, in men post RP, if the PSA does not rise above 0.01 ng/ml or does not reach beyond 0.02 ng/ml, the clinical course is usually favorable. The patients whose PSA rose progressively >0.01 exhibited clinical recurrence in 20 of the 66. All patients in the rising PSA group were defined by 30 months post RP. If a detection limit were 0.1 ng/ml (not 0.01), only half of these patients would have been detected at 24 months. Of the last 66 with progressive rise in PSA, all had values of >0.01 ng/ml at an average of 7.3 mos post RP +/- 6.8 mos." To my way of thinking, these studies highlight another advantage of the ultrasensitive PSA test, risk group definition by 30 months. These studies have been small, typically 100-200 men, so I don't believe there is complete defintion at 30 months, that is, I'm sure you can still fail if your PSA is <0.01 at 30 months, but the failure odds for this sub-type are reduced. So while I think recurrence continues at more or less a linear rate for the rest of our lives, depending on your post-op PSA characteristics your chances for recurrence are increased or decreased from the general rates applied in various nomograms...Best wishes and good health, Ron "ron" <oitbso@yahoo.com> wrote > > I think recurrence continues at more or less a linear rate for > the rest of our lives, depending on your post-op PSA characteristics After -- sometimes before -- the numbers shake out in any analysis I perform, I like to set the physics and math aside and divine a bottom line trend as an independent reality check. This one-minute gut feel has worked well for me in some otherwise very technical problems, but in engineering as opposed to medicine. Here goes: Might this linear recurrence rate, rather than a surge which falls off in a few years (Poisson distribution, as is my colon cancer recurrence expectation?), imply that a "successful" RP essentially resets our PC clock to near zero by eliminating our detectable cancer, but eliminates neither every cancer cell nor our individual tendencies to propagate it? i.e., If our immune system was inadequate to stop the first bout with PC, why should we be able to resist its second attack any better once the cells missed in our first treatment grow to reach "critical mass" again? Maybe we all have our individual PC growth rates, and a "17-year recurrence" simply implies something like "Our first "case" of PC went non-zero (i.e., "began") 17 years ago and we just reset the clock". But who was looking 17 years ago at age 45 to spot that first PSA emergence? If this is true, what useful information could it provide? Well, if every man tracked his PSA from, say, puberty, supersensitive PSA tracking may lay down a trend which might repeat beginning the day we walk out of the hospital after our initial PC treatment. Example: A guy's PSA takes 11 years to progress from its initial verified non-zero reading to something warranting treatment, say, 4.0, at which he has a successful RP. MAYBE this implies a PSA recurrence could take another 11 years to become important. If that first climb took from age 41 to age 65, maybe an expectation that it may take ANOTHER 24 years after RP to get serious would justify WW in his case. Or not. I.P. About recurrence, I.P. interestingly speculated: "If our immune system was inadequate to stop the first bout with PC, why should we be able to resist its second attack any better once the cells missed in our first treatment grow to reach "critical mass" again?" Along that line of thinking... maybe our immune systems can change (better diet, vitamins, etc.) and we can do a better job of fighting things off. Or not. Ron B. Chicago > About recurrence, I.P. interestingly speculated: > [quoted text clipped - 6 lines] > maybe our immune systems can change (better diet, vitamins, etc.) and we > can do a better job of fighting things off. Continuing the thought... I concur that we can better influence our immune systems, especially when we know that we have something for it to fight. I never took a pill in my life on a daily basis, but now take a dozen. I walk, which I never did. And I changed my diet ever so slightly. Don't know if it helps fighting the bastard, but don't know if it don't. >> About recurrence, I.P. interestingly speculated: >> [quoted text clipped - 16 lines] > changed my diet ever so slightly. Don't know if it helps fighting the > bastard, but don't know if it don't. I changed my diet very dramatically 20 years ago, have always gotten huge amounts of exercise, have taken a few basic supplements plus a MVMM pill for decades, and have never smoked, drank, or lived in a city or any other polluted area. I also get 8 hours' sleep most nights (the chronically sleep-deprived -- defined as < 7 hours a night -- may as well smoke*, considering the harm it's doing them.) But I'm also 20 years older now, so must presume my immune system has probably declined since I was 40. May it all balances. Who knows? * Yeah, I know . . . prove it. I'll have to get back on that. I, also, assume it's an overstatement, but can't recall the exact figures right now. I.P. > considering the harm it's doing them.) But I'm also 20 years older now, so > must presume my immune system has probably declined since I was 40. Excellent point! The immune system gets better and better to a point (probably 40) and then gets less and less effective. I suspect the straight-line decline is impossible to overcome with supplements. > the risk for biochemical recurrence for a T1c, PSA=4-10, > GS=6 man is 5% at 10 years following RP I meant to pick you up on this in your previous post. I think it is somewhat unhelpful to use pre-operative figures like those in discussing these issues, because biopsies are so imprecise. Far better to take the post-op pathology and first post-op PSA. The Sloan-Kettering nomograms (http://www.mskcc.org/mskcc/html/10088.cfm) include a post-operative set (click on "change treatment stage"). The study you mention looks at early post-op PSA; did it also stratify based on pathology? In any event, there seems to be be a correlation between early biochemical "failure" (rising PSA) and outcome (well, duh, if PSA rises quickly it's likely aggressive, if it takes 10 years it's probably indolent. So your risk of dying from PCa gets better the longer you stay "undetectable" for multiple reasons: 1. Later recurrence correlates with less aggressive cancer. 2. You are getting older, so you are more likely to die of something else first. 3. By the time it recurs, there will be a cure. SignaturePeter Headland Peter Headland wrote...snip... > I meant to pick you up on this in your previous post. I think it is > somewhat unhelpful to use pre-operative figures like those in > discussing these issues, because biopsies are so imprecise. Far better > to take the post-op pathology and first post-op PSA. Perhaps things have a way of averaging out in large studies. Using pre-surgical staging, the recurrence risk for a T1c, PSA=4-10, GS=6 man is 5% at 10 years post-RP; using post-surgery pathology the risk for such a man is cast as 6% (same reference). I was just responding to your assertion "if you make it to 10 years without recurrence, your chances of recurrence during the rest of your life are minimal", which I believe, as explained above, is incorrect...Ron T1c is not a meaningful post-surgery pathology result. By definition it must be T2x or more. FWIW, the Sloan-Kettering nomograms put the risk for those of us with good post-op pathology and pre-op PSA <10 at about 1% (+/- 8%, though). SignaturePeter Headland "Peter Headland" wrote. > FWIW, the Sloan-Kettering nomograms put the risk for those of us with > good post-op pathology and pre-op PSA <10 at about 1% (+/- 8%, though). Now that's a new one on me and my S-K-trained uro-oncologist. I went into the OR with an 8.7, came out with negative margins, and am given about a 10% chance of making it five more years because of my Gleason 8 . . . and that's not counting my more threatening colon cancer. (My zero PSA keeps bumping that 10% up, thank goodness.) What's wid dat? I.P. (Is it any wonder I say we should "get on with our lives" rather than wallowing in decimal points?) > I went into the OR with an 8.7, came out with negative > margins, and am given about a 10% chance of making > it five more years because of my Gleason 8 I don't get it - neither the Sloan-Kettering nomograms (interactive, instructions given previously in this thread) nor the (less optimistic) Johns Hopkins ones (at http://www.cancer.prostate-help.org/download/jhnomo.pdf) appear to give you such a bad prognosis (though I have forgotten your precise path. results). I know you don't normally like to wallow in the numbers, but take a look for yourself (and ideally let us know the results). Maybe your uro. needs to catch up with the latest literature? SignaturePeter Headland >> I went into the OR with an 8.7, came out with negative >> margins, and am given about a 10% chance of making [quoted text clipped - 10 lines] > look for yourself (and ideally let us know the results). Maybe your > uro. needs to catch up with the latest literature? I'll check again when I have some more time, but . . . 1. I've accessed all the nomograms I've found with my G=8, PSA=8.7, seminal vesicle involvement, PSAV > 2.0 figures, and my odds of avoiding recurrence for 5 years have generally run something like 15%. 2. My oncologists wallow in the literature, both reading and writing it. I.P. You're right in that the S-K nomogram is far more optimistic than the one I had used in my research, the VA's prostatecalculator.org. When I did my initial research, I couldn't access S-K's nomogram, perhaps because of my malware filters. But I accepted that because the VA's calculator has been described (I don't recall the source) as the largest and most accurate nomogram available. It gives me a 15% chance of 7 years w/o PSA recurrence with its broad categories (e.g., PSA 4-10, Gleason 8-10). If I do some interpolation using my numbers (low end of Gleason range, higher end of PSA range), the chances range from 6% to 30%. But none of those take into account my PSAV of 2.2 or whatever it was -- a bit over the magic 2.0 --- which reportedly increase my odds of dying FROM PC tenfold, and sooner rather than later, I presume. The J-H charts fall between those extremes, but then say newer data gives me more optimism . . . not counting the PSAV of 2.2. My S-K alumnus uro has said several times my odds of staying relapse-free for five more years are worse than a coin toss. (Sorry if my "making it 5 more years" implied SURVIVAL for 5; I meant PSA-free.) With such wide variations in the nomograms and my PSAV > 2, I can't get too excited about whether my PSA relapse odds are 10% or a coin-toss (50%). The bottom line is that my PSA is going to rise again when it wants to -- or not at all if I make an end run around the odds -- depending on countless factors. The so-called "most-accurate nomogram", plus my PSAV, says it is very highly likely to occur within a few years. Thus my 10% 5-yr PSA-free comment. The main impact of all these numbers? I buy fewer durable goods (e.g., our next vehicle purchase will be based on my wife's needs, not mine). I'll get my 'Vette if I'm PSA-free when we need our NEXT vehicle. But since my colon cancer is by far my more immediate threat and its SEs present the greater nuisance (way too much paperwork), the PC numbers debate won't make a whole lot of matter until my CC remains dormant for a couple more years. I.P. >> I went into the OR with an 8.7, came out with negative >> margins, and am given about a 10% chance of making [quoted text clipped - 10 lines] > look for yourself (and ideally let us know the results). Maybe your > uro. needs to catch up with the latest literature? > my PSA is going to rise again when it wants to -- or > not at all if I make an end run around the odds I am sending waves of destructive thoughts towards your PCa cells (if any there be) at this instant - if you feel a mild tingling in you groin, do not be alarmed! ;-) SignaturePeter Headland >> my PSA is going to rise again when it wants to -- or >> not at all if I make an end run around the odds > > I am sending waves of destructive thoughts towards your PCa cells (if > any there be) at this instant - if you feel a mild tingling in you > groin, do not be alarmed! ;-) Damn. I thought that was something else. Thanks. Every little bit helps. I.P. Peter wrote: "I am sending waves of destructive thoughts towards your PCa cells (if any there be) at this instant - if you feel a mild tingling in your groin, do not be alarmed! ;-) Peter, if you can ever get those waves to give more than a "mild tingling" in the groin...I think that you'll have a lot of takers for your thoughts. :-) Ron B. Chicago I doubt anyone knows what the hell is going on. For instance, I recently read an article in a respected journal (my wife subscribes to them) that stated the odds for recurrence for all surgically treated patients is about 30% at 10 years. The curve is very linear between 0 years and 10 years. There is no indication the "linear" curve is going to flatten out beyond the ten year mark. A similar "linear" curve has men with one bad pathological outcome such as seminal vesicle involvement going to 50% chance of recurrence at 10 years. This jibes somewhat with what my uro said was a 30% chance of recurrence at five years with a possible positive margin. I'll try to find the article. Dave Perry > all surgically treated patients What does that mean? The average of everyone who has surgery regardless of clinical stage, pathology, PSA, etc.? Not a very useful number, if so, and it doesn't seem to contradict any of the stratified studies which we have been discussing. SignaturePeter Headland > T1c is not a meaningful post-surgery pathology result. By definition it > must be T2x or more. Yes, for the example I cited, it was pT2, pathological Gleason and pre-op PSA. > FWIW, the Sloan-Kettering nomograms put the risk for those of us with > good post-op pathology and pre-op PSA <10 at about 1% (+/- 8%, though). The SK nomograms, which I believe were created and updated by Kattan, have issues which are often discussed in other PCa NGs. The largest concern is that since no studies can directly compare RP and RT (other than SI+EBRT) populations using the same definition of failure, the SK nomogram is one man's scientific opinion of what the world looks like. It is not hard data...Ron > Perhaps things have a way of averaging out in large studies. Yes, but since none of us here is a large study, it isn't helpful to use our pre-op numbers - those of use who have had RP all know precisely what our post-op pathology was (at least, I hope so). Even those of us who had identical pre-op numbers now have a wide spread of risks based on our post-op pathology. SignaturePeter Headland > > Perhaps things have a way of averaging out in large studies. > [quoted text clipped - 6 lines] > -- > Peter Headland Now it's my turn to say, I should have said it better. In large studies pre-op data doesn't lead to different conclusions than post-op data. The example I cited above where there was a 1% difference in outcomes at 10 years for pre- vs. post-op predictions is an illustration of this. Pre-op nomograms based on large populations appear to predict quite well. Hence the Partin Tables, hence the Hopkins nomograms (with pre- and post-op tables that compare favorably)...Ron > I was just responding to your assertion "if you make it to 10 years > without recurrence, your chances of recurrence during the rest of > your life are minimal", which I believe, as explained above, is > incorrect My original post spoke of the risk of dying, not of having biochemical recurrence; when I clarified what I was talking about, I inadvertently switched to talking about recuurrence (because that what what you were telaking about). I reverted to the risk of death later on. Sorry for causing confusion - it is definitely risk of death to which I am referring, not absolute PSA levels. SignaturePeter Headland Please excuse my ignorance, If after having a RRP where does the recurrence happen if the prostate has been removed? Ben T >> Got a little impatient and called Dr. Partin's office this afternoon. >> He wasn't in, but his nurse...knowing that I was anxious to know, gave [quoted text clipped - 16 lines] > >> Lamentations 3:21-23.....GREAT IS THY FAITHFULNESS! Cancerous prostates slough off cancer cells for years, maybe decades, before becoming detectable. The primary path of those cells is into the blood stream, whose primary path is the rest of our body. So by the time we're detected and treated, cancer cells are widespread. As long as their immediate, microscopic environments are sufficiently inhospitable -- thanks in part to our immune system -- they die or remain dormant. Then one day, at one spot, that environment becomes favorable, and a cluster of cancer cells flourishes, then grows large enough to produce measurable PSA, then becomes symptomatic. A favorite (but by no means exclusive) target is bone, which "turns over", i.e., is replaced, about every decade throughout or lives, and is thus (and for other reasons) a good growth medium. And since bone can't easily expand as that cluster of cells grows, intra-bone pressure soars, producing extreme pain. Pleasant thought, isn't it? I.P. > Please excuse my ignorance, > If after having a RRP where does the recurrence happen if the prostate has > been removed? I.P. I thank you very much. That clears up a lot, trying my best to understand. Ben T > Cancerous prostates slough off cancer cells for years, maybe decades, > before becoming detectable. The primary path of those cells is into the [quoted text clipped - 17 lines] >> If after having a RRP where does the recurrence happen if the prostate >> has been removed? Read. READ. Books. Hospital and university and gov websites, plus others recommended by this forum. Ask (and realize that any one patient's experience is purely anecdotal . . . a statistical base of one). Start a file of info relevant to your case. Second guess every piece of data you find relevant to your important decisions. Consult specialists of several different fields relevant to your case. Your confusion will grow rapidly, then within mere months, it will fade as a clear picture of your own best course emerges. And be glad this is a slow-growing beast which gives us TIME to both create and clear the haze; many other types of cancer don't afford that luxury. But know when to stop. You don't want to wallow in this stuff after you've made a decision and taken action, and before recurrence. In that vein, I've not even read the last portions of my dozen cancer books, the parts which detail our second-treatment options; I'll read them when my PSA starts climbing again. Until -- maybe even after -- then, I have a life to live. I.P. > I.P. > I thank you very much. That clears up a lot, trying my best to understand. USC, The series of good news reports usually starts with the path report. Celebrate! Steve U
|
Reply to this Message |
 Sign In
 Join
 My Latest Posts My Monitored Threads My Blog My Photo Gallery My Profile My Homepage Start New Thread Enable EMail Alerts Rate this Thread
|
©2008 Advenet LLC Privacy Policy - Terms of Use
This website includes both content owned or controlled by Advenet as well as content owned or controlled by third parties.