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Medical Forum / Diseases and Disorders / Prostate Cancer / May 2006RP vs RT Comparison
Disclaimer: I post this for information and discussion, not to advocate for / against any treatment position. Also keep in mind that all treatments have improved over the intervening years A while back I posted some work by Tewari and Menon that suggested rather clear differences in PCa-specific survival outcomes between RP, RT and WW cohorts (if you want to find that post, search Tewari within this newsgroup and it should be amongst the top links that appear). Now a second, separate team (Albertsen, who has been something of an RP sceptic over the years) is reporting similar results...Ron American Urological Association Annual Meeting May 20 - 25, 2006 Atlanta, Georgia, USA Publishing #: 652 Presentation Title: Ten Year Outcomes Following Treatment for Clinically Localized Prostate Cancer: A Population Based Study Category: 43 Localized Author Block: Peter C. Albertsen*, Farmington, CT; James A. Hanley, Montreal, PQCanada; David F. Penson, Los Angeles, CA; Judith Fine, Farmington, CT Introduction and Objective: No data from randomized trials are available to compare treatment outcomes among men diagnosed with localized prostate cancer as a result of screening. A retrospective, population-based outcomes analysis of men diagnosed in Connecticut with localized prostate cancer between 1990 and 1992 was performed to estimate prostate cancer specific survival and all cause survival following surgery (n=806), radiation (n=703) or observation (n=114). Methods: Analyses were conducted using an intention to treat perspective. Two approaches were utilized: a proportional hazards model and a classification system separating patients into low, intermediate and high risk disease. The proportional hazards model included Gleason score, pre-treatment PSA, clinical stage, age at diagnosis and co-morbidities. The classification system utilized Gleason score, pre-treatment PSA and clinical stage. Results: After an average follow up of 11.8 years, 11% of the cohort have died from prostate cancer, 4% from other cancers, and 23% from non-cancer causes. Patients undergoing surgery tended to be younger and have a more favorable distribution of histology and lower pre-treatment PSA values when compared to patients undergoing radiation. Patients electing observation tended to be older and had a more favorable profile. After adjusting for differences in patient characteristics, the men undergoing surgery had consistently better cause-specific survival when compared to men undergoing radiation or observation. Survival differences for men with low risk disease did not become apparent until 8 years following diagnosis, for men with intermediate disease, about 4 years following diagnosis and men with high risk disease, almost immediately. The risk of death from prostate cancer for men undergoing radiation versus surgery was 3.2, 2.5 and 2.2 times greater for low, moderate and high risk disease respectively. The risk of death from prostate cancer for men undergoing observation versus surgery was 3.8, 2.3, and 3.3 times greater for men with low, moderate and high risk disease respectively. There was no difference in cause-specific survival between men receiving radiation and observation although there may be a small trend in favor of radiation for men with high risk disease. Conclusions: Patients undergoing surgery for clinically localized prostate cancer appear to have a survival advantage that increases in magnitude over ten years when compared to men electing either radiation or observation. Interesting post Ron. I'm coming up for my 18th month psa reading post RLRP. Sure hope I'll help boost the survival advantage that increases with magnitude for well over 10 years! Hopefully we'll all pass it. B.A. > The risk of death from prostate cancer for > men undergoing radiation versus surgery was 3.2, 2.5 and 2.2 times > greater for low, moderate and high risk disease respectively. > There was no difference in > cause-specific survival between men receiving radiation and observation > although there may be a small trend in favor of radiation for men with > high risk disease. Those are two stunning sentences. IOW, for most PC pts, RT is no better than WW, while RP beats both two- to three-fold. And that's just in survivability alone; add SEs and RT is measurably, sometimes much, worse than WW. It'll be interesting to see if this study is vetted by closer scrutiny and how it impacts the RT "industry". I'd guess the REAL question is whether RT effectiveness has tripled since this group was tested relative to comparable RP and WW improvements. I.P. >> The risk of death from prostate cancer for >> men undergoing radiation versus surgery was 3.2, 2.5 and 2.2 times [quoted text clipped - 12 lines] > impacts the RT "industry". I'd guess the REAL question is whether RT effectiveness has > tripled since this group was tested relative to comparable RP and WW improvements. I agree with all of these sentiments. Unfortunately there are, as you put it, treatment "industries" in the medical profession. There is an RT industry and there's also a surgery industry. Members of each industry have vested commercial interests in promoting their specialty. The statements in the abstract Ron posted are indeed "stunning". I also want to see this study vetted and addressed. It was not published in a peer reviewed journal. To the best of my knowledge, radiation is used at virtually every important cancer center in the U.S. The National Cancer Institute (where I was treated in a clinical trial) has both surgery and radiation departments. So does Johns Hopkins, Sloan-Kettering, M.D. Anderson, the Mayo Clinic and many others. If the abstract Ron posted is correct, all of these top institutions are kidding themselves, or worse, kidding their patients, and have been for decades. If that's true, it is very, very stunning indeed. As a radiation patient, I have a personal interest in things turning out well for radiation. But we all, myself included, have an even stronger interest in learning the truth. So I would like to see this stunning study addressed by the experts and either confirmed or denied. Alan > Disclaimer: I post this for information and discussion, not to advocate > for / against any treatment position. Also keep in mind that all > treatments have improved over the intervening years Understood. > ... The risk of death from prostate cancer for > men undergoing radiation versus surgery was 3.2, 2.5 and 2.2 times [quoted text clipped - 5 lines] > although there may be a small trend in favor of radiation for men with > high risk disease. ... This is a pretty amazing conclusion. I'm not saying it's wrong, but it is amazing. It says that radiation is no better than nothing at all. If the numbers are exactly right, it even turns out that men with moderate risk disease are _more_ likely to die of prostate cancer if they get radiation than if they do nothing at all. Stranger conclusions than this have sometimes turned out to be right, but this is something that the radiation experts should respond to - either to agree or to show that it's wrong. I would like very much to see if this result gets published in a peer reviewed journal. Alan > This is a pretty amazing conclusion. I'm not saying it's wrong, but it > is amazing. It says that radiation is no better than nothing at all. [quoted text clipped - 10 lines] > > Alan Alan, I am pretty sure that Whitmore published an article on PCa death rates in the pre-PSA era. He showed that the PCa death rate for 10 years was 10% for RP, 15% for WW, and 22% for RT. Ed Friedman (snip) > American Urological Association Annual Meeting > May 20 - 25, 2006 [quoted text clipped - 8 lines] > Farmington, CT > (snip) Nothing about which to hyperventilate. As is too often the case with these "retrospective" analyses, the data are old (the latest here being 14 years out of date) and do not reflect the current state of the art. In other words, the article is of no practical use in the real world of 2006. Even if it is correctly reporting the PCa world of 1992, which is not proven. I wonder who pays for such as this. Regards, Steve J "Digressions, objections, delight in mockery, carefree mistrust are signs of health; everything unconditional belongs in pathology." --Friedrich Nietzsche >(snip) >> American Urological Association Annual Meeting [quoted text clipped - 12 lines] > >Nothing about which to hyperventilate. Yeah, and also consider the source. ron, have you been laid lately or is that Vitamin V still not working? Your remarks are unkind. Why not respond by presenting information to support an alternate view or highlight what you perceive to be the flaws in the information presented. Making personal comments about me casts no one in a good light...ron >Your remarks are unkind. Why not respond by presenting information to >support an alternate view or highlight what you perceive to be the >flaws in the information presented. Making personal comments about me >casts no one in a good light...ron This is supposed to be a "support group." In the three years I've been on this board struggling with ALL the issues PCa victims must, all I've heard from you is how I'm going to die because I chose IMRT instead of RP. Thanks a lot. Did it ever occur to you how your obsession with justifying your own personal decision might affect other patients? With support like that, who needs enemies? Let me clue you in: as in religion, there is NO ONE WAY. Everybody is different; all diagnoses are unique; every decision is personal. I am not a disbeliever in science and statistics. I am saying that interpreting the data finally boils down to a personal choice. Just as with religion, true believers and fanatics who are convinced that they have THE answer not just for themselves, but for everybody else, are dividers and are a danger in a pluralistic society. They cause wars and terrorism. But that is another subject... This is a pluralistic group of patients who have made difficult choices of different forms of treatment for a myriad reasons. The only benefit I can offer to others is telling my own story and why I did what I did, and then counseling others with what I know. Not preaching to them. I'm not a doctor. And not making people who have already chosen a treatment second guess themselves and doubt and worry and feel miserable. So, consider my unkind remarks payback. Consider them very personal. Feel the emotion behind them. Then let me tell you what: you killfile me and I'll killfile you. Have a nice rest of your life. Take it easy Doug. Ron really isn't trying to make people feel bad about their treatment choices. He sincerely believes that radiation is a questionable treatment choice and he's trying to bring up issues that he thinks will be of benefit to those of us who still have the decision before us (which is not me - I've already chosen radiation.) If I remember your case correctly, you had radiation quite a while ago and are doing very well with it. I had radiation almost 2-1/2 years ago, and I'm doing very well with it too. Whatever the statistics say, even if the article Ron quotes is correct, it doesn't follow that you or I have not been successfully treated with radiation. I think there's a very good chance that both of us are cured. Alan >Take it easy Doug. > [quoted text clipped - 4 lines] >still have the decision before us (which is not me - I've already >chosen radiation.) I think you are being too charitable. The following very broad generalizations may fairly be stated (if you will indulge me) regarding treatment for prostate cancer: 1) RP is chosen by men who fear death by cancer more than diminution of quality of life. RP - at least for men whose age is 10 years below the limit of their life expectancy - is the preferable treatment for long term cure according to statistics currently available. Moreover, if a recurrence occurs, treatment with radiation is available. The trade off is that the risk of side effect severely affecting quality of life following RP - incontinence and impotence - is greater than with radiation. 2) Radiation is chosen by men who fear diminution of quality of life more than death by cancer (not necessarily including men over the age of 10 years below their life expectancy). Radiation therapy in all its forms is the preferable treatment for men who do not want to risk any degree of urinary incontinence and are hoping for a sex life treatable with Viagra post treatment. The trade off is that the statistics for long term cure are either not available or not sustainable - depending on whom you believe - and treatment choices in the event of recurrence are few and dismal. I do not pretend that these generalizations hold in all cases or even in most. They are just the broad outlines we patients face. So, when listening to ron's messianic pronouncements, my gut tells me that no one would be such a zealous quest to convert everyone else to his point of view unless he was trying to trying to justify bad side effects against the hope of longevity. The rest of us are content with or resigned to our situations and don't preach - we just tell our story. >If I remember your case correctly, you had radiation quite >a while ago and are doing very well with it. I had radiation [quoted text clipped - 3 lines] >successfully treated with radiation. I think there's a very >good chance that both of us are cured. Yes indeed. But you have to admit it makes us radiation guys at least uncomfortable when some people keep taunting us with statistics that can't help but make us fear or doubt our future. Like I need to think about that sh.t. The flip side would be like me taunting ron about his non-existent sex life or wearing diapers --- whoops... :-) > ... The following very broad > generalizations may fairly be stated (if you will indulge me) [quoted text clipped - 21 lines] > I do not pretend that these generalizations hold in all cases or even > in most. They are just the broad outlines we patients face. That sounds like a good generalization. It describes my own case, but with some additional factors that inclined me towards radiation. One was just a fear of surgery. I had a botched surgery once before and I know that a guy with a knife in your innards can do a huge amount of damage and do things that will leave you changed for the worse for the rest of your life. It has happened to a lot of guys in this group. I also questioned the concept of surgery. If your cancer is fully contained in the center of the prostate, the surgeon can be pretty sure of getting it all out. But what if it's slightly over the margins? What if the prostate has a slightly irregular shape? What if there are bits of tumor clinging to the nerve tissues that the surgeon tries to spare? How can he really know that he got it all out? I know that some men have surgery, it doesn't work, then they have radiation, and it does work. What if those men had had radiation to begin with? Maybe they didn't need the surgery at all and would have been cured by radiation by itself. Finally, I was very unimpressed with the surgeon that my HMO sent me to, but was highly impressed with the radiation oncologists I met. So the specifics of my particular access to expertise also inclined me to radiation. And when I had a chance to enter a clinical trial at NCI with doctors that I thought were on the cutting edge of treatment research, it seemed like the best thing to do. I don't regret my decision. If it turns out that my cancer recurs, I may think differently, but even then, it's hard to second guess these things. > So, when listening to ron's messianic pronouncements, my gut tells me > that no one would be such a zealous quest to convert everyone else to > his point of view unless he was trying to trying to justify bad side > effects against the hope of longevity. The rest of us are content > with or resigned to our situations and don't preach - we just tell our > story. We'll have to agree to disagree about his motives. I think he's a good guy, just trying to present what he regards as important data to the group. One of the dangers we have in a group like this is that we could fail to present important information to people for fear of offending someone. I don't think we should do that. I don't think it serves any of us. > Yes indeed. But you have to admit it makes us radiation guys at least > uncomfortable when some people keep taunting us with statistics that > can't help but make us fear or doubt our future. Like I need to > think about that sh.t. I know exactly what you mean. Nobody likes to think he made a bad choice and killed himself. But don't let thoughts like that get under your skin. There's no point second guessing the past either way. I think Curtis and Steve used to always mention that in their advice to the newly diagnosed. You pays your money and makes your choice and from then on it's only the future that counts. Besides, the fact that you've gotten this far is an excellent sign. As I understand it, the rate of treatment failure goes down every year after treatment. Every year without a rise in PSA means that your chance of a rise the next year is lower. Alan >> Take it easy Doug. >> [quoted text clipped - 53 lines] > The flip side would be like me taunting ron about his non-existent sex > life or wearing diapers --- whoops... :-) Not one word of that has ANY relevance to Ron's post. Ron posted a fact, a study result, not a messianistic pronouncement. Anyone who can't read facts without going ballistic would better be served confining his reading to comic books. I.P. >Not one word of that has ANY relevance to Ron's post. Ron posted a fact, >a study result, not a messianistic pronouncement. Anyone who can't read >facts without going ballistic would better be served confining his >reading to comic books. You're a newbie in this n.g. making pronouncements about which you have no clue. usenet hint #1: don't weigh in if you don't know the whole story. usenet hint #2: don't weigh in with a flame if you don't know the person you're flaming. Stick around for a while and maybe these modest tidbits of advice may begin to sink in. Then again, maybe not... > usenet hint #1: don't weigh in if you don't know the whole story. BTW, it seems like we haven't heard about your progress for a long, long time. I'm thinking two years. How's it going?  SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum > Ron really isn't trying to make people feel bad about their > treatment choices. He sincerely believes that radiation is > a questionable treatment choice Believes . . . schmelieves. Since when is posting purported facts relevant to our forum a crime no matter what one believes? The day we can't freely post any PC study, fact, opinion, idea, or question we run across is the day we may as well disband the forum. I didn't perceive any "belief" or axe or insult or slight or ulterior motive in Ron's post; he presented a FACT, a study result, for God's sake. Even if I had known Ron cared about about the differences between RP, RT, ADT, WW, voodoo, prayer, or fried greed tomatoes, I would still not have perceived any ill intent. I.P. > Let me clue you in: as in religion, there is NO ONE WAY. Everybody > is different; all diagnoses are unique; every decision is personal. I > am not a disbeliever in science and statistics. I am saying that > interpreting the data finally boils down to a personal choice. > Just as with religion, true believers and fanatics who are convinced > that they have THE answer not just for themselves, but for everybody > else, are dividers and are a danger in a pluralistic society. They > cause wars and terrorism. But that is another subject... In January 2003, at 54 years old, with a low Gleason and PSA, IMRT was a reasonable choice. There was no clear advantage between IMRT, EBRT, Brachy or RRP. One rule almost all of us agree to is that such decisions should never be second guessed -- by the patient or the news group member. It is your choice how you wish to make it through this life. In May 2006, at 51, with recurrent PCa, a belief in God, His son Jesus Christ, and eternal life is a reasonable choice. Unlike your choice in 2003, there are distinct advantages in these beliefs; not the least of which is that I am looking forward to an afterlife and you're best case scenario is rotting in the ground. It's my choice. That does not make me a fanatic, war-monger or terrorist. >In May 2006, at 51, with recurrent PCa, a belief in God, His son Jesus >Christ, and eternal life is a reasonable choice. Unlike your choice in >2003, there are distinct advantages in these beliefs; not the least of which >is that I am looking forward to an afterlife and you're best case scenario >is rotting in the ground. Great. What a support group. One guy who preaches that if we don't choose his treatment we're gonna die, and another who preaches that if we don't believe his religion we're gonna rot in the ground when we die. Since you people have it all figured out, I guess there's no room - in this life or the next, apparently - for anyone who doesn't see it you way. >>In May 2006, at 51, with recurrent PCa, a belief in God, His son Jesus >>Christ, and eternal life is a reasonable choice. Unlike your choice in [quoted text clipped - 11 lines] > this life or the next, apparently - for anyone who doesn't see it you > way. I really thought you would have quickly realized the hypocrisy of debating Ron about radiation by attacking those with a religious belief. Ron provided an opinion that radiation is less than optimum for battling prostate cancer. You replied with: >> Just as with religion, true believers and fanatics who are convinced >> that they have THE answer not just for themselves, but for everybody >> else, are dividers and are a danger in a pluralistic society. They >> cause wars and terrorism. But that is another subject... You see, Doug? It was YOU who did the preaching. I simply replied to your antitheist rant. The message you should have gleaned my post was, "It is your decision to go with IMRT and no one should tell you that you were wrong, but don't tread on me while asserting your right." >>> Just as with religion, true believers and fanatics who are convinced >>> that they have THE answer not just for themselves, but for everybody [quoted text clipped - 3 lines] >You see, Doug? It was YOU who did the preaching. I simply replied to your >antitheist rant. Antitheist? Where do you get that idea? Have you been getting your religious instruction from I.P.'s comic books? >>>> Just as with religion, true believers and fanatics who are convinced >>>> that they have THE answer not just for themselves, but for everybody [quoted text clipped - 6 lines] > > Antitheist? Where do you get that idea? "Just as with religion, true believers ...." pretty much summed if up for me. But, it is obvious you're not bending on your insult and could care less that I took offense. I will no longer concern myself with the discussion of it. All I really want to know and care about is how is the IMRT working? What is your PSA? I know you are sexually active and continent. How is the disease? Are beating the bastard? SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum >> Antitheist? Where do you get that idea? > >"Just as with religion, true believers ...." pretty much summed if up for >me. I am very much a theist and subscribe to the notion that "God is too big to fit into a single religion." Or "One Truth; many faiths." I repeat: what is dangerous and divisive are those who think that THIER particular "truth", be it religion; political opinion; or, indeed, treatment for prostate cancer; is THE TRUTH. If you have a problem understanding that notion, I refer you to a certain bunch of bloodthirsty lunatics who, under the notion that their interpretation of Islam is THE TRUTH and should be imposed upon the entire world, justify blowing up buildings and killing and maiming innocent men, women and children. >But, it is obvious you're not bending on your insult and could care less >that I took offense. I will no longer concern myself with the discussion of >it. Au contraire. What is truly offensive, and what I am jumping up on my soapbox to object to, is precisely ron's claim that anybody is did not choose RP to treat PCa will die - which is relevant to this n.g. And since YOU want to argue the point - your claim that anybody who does not subscribe to a certain form of fundamentalist Christianity will rot in the ground after death. >All I really want to know and care about is how is the IMRT working? What >is your PSA? I know you are sexually active and continent. How is the >disease? Are beating the bastard? So far, I am beating the bastard. ... I guess we've all said our piece about the parts I've elided. So I'll just remark on the last sentence of your post. > So far, I am beating the bastard. Good for you! I hope you continue to beat it for another 40 years. Alan >> In May 2006, at 51, with recurrent PCa, a belief in God, His son Jesus >> Christ, and eternal life is a reasonable choice. Unlike your choice in [quoted text clipped - 6 lines] > we don't believe his religion we're gonna rot in the ground when we > die. I, for one, plan to rot :-) I can think of worse things :-) SignatureGlowing in the Dark >> Your remarks are unkind. Why not respond by presenting information to >> support an alternate view or highlight what you perceive to be the [quoted text clipped - 31 lines] > > Have a nice rest of your life. Good God! THAT'S your response to someone posting a study result? Don't give it a second thought, Ron. That's one of the most childish things I've seen in this forum. It never even dawned on me that "Consider the source" meant the POSTER. BFP. Big Fat PLONK. I.P. <Snipped> : Don't give it a second thought, Ron. That's one of the most childish : things I've seen in this forum. It never even dawned on me that [quoted text clipped - 4 lines] : : I.P. Good for you, IPF! I am so glad to see that someone supports Ron in his post. Ken Bland > <Snipped> > : [quoted text clipped - 9 lines] > Good for you, IPF! I am so glad to see that someone supports Ron in his > post. I feel strongly about support when it's due. I quit a forum I'd been with for a decade, that meant a GREAT deal to me, when it failed to stand up for people who were unfairly and personally hammered. That's important in personal, "real", life, and it's important in cyberspace. I.P. Doug...I am sorry that you feel such anger and pain. I am sorry if my posts have contributed to this. I have never personally attacked anyone, nor have I ever tried to taunt anyone. I do not believe that "one size fits all". There have been posts where I have suggested that RT, WW and cryo be considered in the mix. I have taken pains not to prosyletize. I have never recommended a specific treatment, nor told a man he has made a bad decision. Independent of whatever I may think, I have been guided by the principle that whatever decision a man makes, that IS the right decision for him. Because of how I am put together, learming about PCa is a method I use to deal with my anger surrounding this disease. When I learn something interesting I try to bring it back and, in one way or another, share it with the group. I know these subjects can be delicate, so I try and choose my words with sensitivity and care. In addition to helping me with my issues, this "learning" has, from time to time, seemed to have been of some benefit to others. When I see this happen, it makes me feel wonderful inside. When I read your comments in this thread, it wipes all that out and then some. Causing other people pain is abhorrent to me. Your pain causes me pain. I hope that after reading this, you might be able to reread my posts and see them in a different light...Ron > Just as with religion, true believers and fanatics who are convinced > that they have THE answer not just for themselves, but for everybody > else, are dividers and are a danger in a pluralistic society. They > cause wars and terrorism. But that is another subject... > So, consider my unkind remarks payback. Consider them very personal. > Feel the emotion behind them. And how is your PSA and general day going? I know, don't ask......LOL >>> American Urological Association Annual Meeting > >>> Author Block: Peter C. Albertsen*, Farmington, CT; James A. Hanley, >>> Montreal, PQCanada; David F. Penson, Los Angeles, CA; Judith Fine, >>> Farmington, CT > Yeah, and also consider the source. Which is suspect . . . the AUA or the authors? I.P. Alan & Steve...I think one of the keys is that this is the second, independent, study to reach these findings. IMO that adds some measure of significance. As to the age of the study, people complain that there is no long term data, then when some appears it is discredited because it is "out of date"...Ron On May 11, ron responded to Alan and me: > Alan & Steve...I think one of the keys is that this is the second, > independent, study to reach these findings. IMO that adds some measure > of significance. Well, not if the data in the first study are as unreliable *today* as those in the subject study. > As to the age of the study, people complain that > there is no long term data, then when some appears it is discredited > because it is "out of date"...Ron > I must respectfully point out that old data are not necessarily the same as long term data. My point is that the data in the subject study are not only old but irrelevant to "the current state of the art." What was offered by way of radiation therapy 14 years ago has little resemblance to what is offered today. I'm still not hyperventilating. Regards, Steve J "The thing is to expect nothing in particular, but (to) be aware of the lack of enforceable guarantees or enforceable contracts with nature/god/entropy as to the condition or durability of our bodies." -- Brian Brunner, PCa survivor, December 12, 2005 on The Prostate Problems Mailing List Thank you, Brian. Steve...You are correct in that all treatments (RP, RT, cryo, etc) have changed significantly over the past 14 years. Treatments will continue to change and evolve until they are 100% curative and have no side effects. Your point will also be true for men treated between 2006-2008 and followed up for a median of 11.8 years, when the data is presented in 2022. How would you propose that "relevant" 10-15 year data be collected when treatments are changing, or would you not collect any long-term data during this time of continual progress?..Ron Common sense would indicate that RT has advanced substantially more than RP in the past 12-14 years, so something else (than the study cited) would have to be looked at to estimate their (current) probable success rates. Snip: > Results: After an average follow up of 11.8 years, 11% of the cohort > have died from prostate cancer, 4% from other cancers, and 23% from > non-cancer causes. Aside from the (debatable) insights this study might provide about treatment options, it's pretty attention-getting that 38% of these 1,623 fellows died in less than 12 years, and more than twice as many of them died from causes other than PCa than from "our" disease. Apparently, one of the most serious side effects of having prostate cancer is the 27% risk of death from something other than the disease. Alex > Snip: >> Results: After an average follow up of 11.8 years, 11% of the cohort [quoted text clipped - 8 lines] > Apparently, one of the most serious side effects of having prostate cancer is the 27% > risk of death from something other than the disease. I'm going with an alternate interpretation here. Prostate cancer is a disease of old(er) age. The fact that so many people with prostate cancer die of other causes is not due to PCa having other risks, it's due to PCa having lower risk of death than many other cancers, heart disease, and other diseases and conditions of old age. Alan > I'm going with an alternate interpretation here. Prostate cancer is > a disease of old(er) age. The fact that so many people with prostate [quoted text clipped - 3 lines] > > Alan Consider also that many men are not candidates for surgery at all. Diabetes, heart conditions, etc. Serious diseases that shorten life. If they wanted treatment, it would be radiation treatment. I don't know where ADT was in 1990. Probably nto used at all. Assume the lower risk went for watchful waiting, the ones who could take surgery did that (I think it was probably more the king-of-the-hill then), and what do you have left? Not only the old, but those who could not have surgery. These may have been men with very high risk who were hoping to get cancer spread as well. This is a strong statement, and we need to think about what it meant in 1990: <snip> Patients undergoing surgery tended to be younger and have a more favorable distribution of histology and lower pre-treatment PSA values when compared to patients undergoing radiation. Patients electing observation tended to be older and had a more favorable profile. </snip> I wonder how, or if, they tried to even out the differences to make the numbers more valid? Here is a quote from Wikipedia (the Radiation THerapy ebook) " There are several reasons for the relatively poor outcomes of conventional 2D RT: * Presence of conventional radiation-resistant clones * Inability of conventional planning techniques to deliver prescribed dose throughout tumor volume * Uncertainities in patient positioning, requiring large safety margins to insure tumor coverage and resulting in significant RT doses to the bladder and rectum" It also states, "Several retrospective studies demonstrated that tumor control is related to dose level, and that doses necessary for local control exceed the 70 Gy maximum tolerated dose." This is the old days. I think 3D conformal was the standard in 1990, but it had serious problems, many of which have been addressed now. Particularly in the planning and delivery department. Now there is software and powerful computers to set up those treatment plans. It was just a different world in radiology back then. > <snip> Patients undergoing surgery tended to be younger and > have a more favorable distribution of histology and lower pre-treatment > PSA values when compared to patients undergoing radiation. Patients > electing observation tended to be older and had a more favorable > profile. </snip> I wonder how, or if, they tried to even out the > differences to make the numbers more valid? The abstract stated: " After adjusting for differences in patient characteristics, the men undergoing surgery had consistently better cause-specific survival when compared to men undergoing radiation or observation." So the authors claim that they did try to compensate for the differences in patient characteristics. > Here is a quote from Wikipedia (the Radiation THerapy ebook) > " There are several reasons for the relatively poor outcomes of [quoted text clipped - 9 lines] > tolerated dose." > This is the old days. I think 3D conformal was the standard in 1990, I'm not even sure that 3D conformal was yet in wide use. The dosage issue is a very important one. The Sloan-Kettering prostate nomogram shows major differences between the lowest EBRT radiation dose they allow for and the highest. See: http://www.mskcc.org/mskcc/html/10088.cfm > So the authors claim that they did try to compensate for the > differences in patient characteristics. We'll never know without reading the entire thing, but I guess that they may consider matching for Gleason and PSA to be compensating. Do you think they compensated for diabetes, heart disease, etc? > I'm not even sure that 3D conformal was yet in wide use. If this is true then there IS NO COMPARASION with the RT of today. > The dosage issue is a very important one. The Sloan-Kettering > prostate nomogram shows major differences between the lowest > EBRT radiation dose they allow for and the highest. See: > http://www.mskcc.org/mskcc/html/10088.cfm >> I'm not even sure that 3D conformal was yet in wide use. > > If this is true then there IS NO COMPARASION with the RT of today. I am not debating the issue either way, but there are certainly comparisons to be made other than the type of aiming procedures. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum > ... > Publishing #: 652 [quoted text clipped - 5 lines] > Farmington, CT > ... I'm hoping that this presentation will be followed up with a peer reviewed paper in a leading journal. If it isn't, then it becomes highly suspect. If it is, then I'm hoping that the authors will give us a lot more about their methodology. Here are some questions I would have about what they did: 1. What are the raw numbers, broken down by age, PSA, Gleason, and crossed with treatment type? 2. What were the adjustments that were made to get the numbers in the authors' conclusions? 3. How many clinical centers were involved, and how many practitioners? I ask that one because it is well known that single center studies are highly biased by the quality of the practitioners at the center. If only a few surgeons and a few radiation oncologists account for the bulk of the treatments, then we may be looking only at a comparison of a few individual doctors against a few individual doctors. This is in fact a common problem of these kinds of comparisons and I've seen it go both ways - at least once with radiation achieving superior results. 4. What are the details of the treatments? Were the radiation patients receiving what is now considered the minimum curative dose of 72 gy? Were they receiving 3D or 2D radiation (2D will not cover the tumor area as well or with as concentrated a dose.) 5. Did any of the patients receive both surgery and radiation? If so, where were they counted in the statistics? 6. Was ADT administered (or not administered) equally to all patients who needed it? How many got ADT? If any of these factors were not properly accounted for, it would be very easy to get wildly inaccurate results. I assume that Albertsen et. al. are reputable researchers. If so, their claims need to be addressed. But because the claims fly so directly in the face of the practice of almost all of the leading cancer treatment centers in the world, I'm not going to take them too seriously until they have been vetted by other researchers. I remember when two guys with reputable credentials thought they had created cold fusion in a test tube in Utah. sh.t happens when attempting to do scientific research. Mistakes can easily be made. Alan >> ... >> Publishing #: 652 [quoted text clipped - 10 lines] > becomes highly suspect. If it is, then I'm hoping that the authors > will give us a lot more about their methodology. [snip] I'm hoping more than the abstract will be available after the conference so we can review it ourselves :-) I just started IMRT last week, so I had a somewhat more than passing interest in the paper. I gave a copy of the abstract to my Radiation Oncologist who became defensive. Curious at the sense of competition between he and the surgeons even though the Institutional policy is "One Team". His comments were that Radiation gets all the "bad cases", ie the ones that for one reason or another are not candidates for RP, and hence such studies are biased to start with. There seems to be some logic to that. He then went into the fact that RT has been steadily improving over the last ten years while surgery has not (in terms of survival rates as opposed to side effects). That almost seems to be self evident: if it is capsule contained, you get it all; if it is not, well... The center I go to does a CAT scan as an integral part of every treatment to make sure the dosage is delivered to the tightest possible area, thus, in theory, minimizing side effects. It strikes me that, since one of the benefits claimed for RT is the ability to target cancer that has penetrated the margin, more precise targeting of the prostate volume to avoid side effects gives up this benefit. That is, the _best_ outcome that can be hoped for is the RP success rate without the nasty side effects. SignatureGlowing in the Dark > I just started IMRT last week, so I had a somewhat more than passing interest > in the paper. I gave a copy of the abstract to my Radiation Oncologist who > became defensive. Curious at the sense of competition between he and the > surgeons even though the Institutional policy is "One Team". Yes, I've seen that defensiveness too. The one surgeon I spoke to was very dismissive of radiation, considering it only to be of value to older patients who might not be able to tolerate surgery. The radiation oncologists I met had apparently heard this kind of thing from a great many of their patients. Presumably almost all of the PCa patients see urologists first, who are themselves surgeons, and who often propose surgery as the best approach. > His comments were that Radiation gets all the "bad cases", ie the ones that > for one reason or another are not candidates for RP, and hence such studies > are biased to start with. Albertsen et. al. claim that they adjusted for that. I'd like to know exactly how. > ... > The center I go to does a CAT scan as an integral part of every treatment to [quoted text clipped - 6 lines] > the _best_ outcome that can be hoped for is the RP success rate without the > nasty side effects. I don't think the purpose of the scans is to get the tightest possible area, it's to get precisely that area that the oncologist believes needs treatment, with as little dosage to other areas as possible. The oncologist need not target just the prostate. My rad onc said she was targetting one centimeter all around the prostate with EBRT, plus HDR brachytherapy in the prostate itself. The trick is, if the prostate is, say, two centimeters in diameter, and the target area is to be one centimeter around it, you want to get the prostate as perfectly centered in that target area as possible, so you get 1 cm on each side of the prostate and not, say, 2 cm on one side and 0 cm on the other, or worse, 2.5 cm on one side and .5 cm of the prostate completely untreated. Alan > My rad onc said > she was targetting one centimeter all around the prostate with EBRT That's SPOOKY, given that the rectum is separated from the prostate by just 2 mm. That's one of the reasons my rad onc advised surgery for me as soon as I told her I considered bowel SEs right near the top of my $#!+ list. I.P. >> My rad onc said >> she was targetting one centimeter all around the prostate with EBRT > > That's SPOOKY, given that the rectum is separated from the prostate by just 2 mm. That's > one of the reasons my rad onc advised surgery for me as soon as I told her I considered > bowel SEs right near the top of my $#!+ list. A year after my radiation ended, they did a proctoscopy (is that what you call it?) on me. The inside walls of the rectum near the prostate looked pretty scarred from the radiation. The doctor said that's what happens and they all look like that. However, although it didn't look great, I haven't noticed any differences in feeling. I don't seem to have hemorrhoids, bleeding or pain, even though I've occasionally had those in the past. Alan > A year after my radiation ended, they did a proctoscopy (is that > what you call it?) on me. The inside walls of the rectum near the > prostate looked pretty scarred from the radiation. Interesting. I'm up for my 5-year colonoscopy. I'll ask him to pay that area particular attention. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum > I just started IMRT last week, so I had a somewhat more than passing > interest > in the paper. I gave a copy of the abstract to my Radiation Oncologist > who > became defensive. Hi, Glowing. Is IMRT your inital treatment. I apologize if you've posted this information before and I've missed it. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum >> I just started IMRT last week, so I had a somewhat more than passing >> interest in the paper. I gave a copy of the abstract to my Radiation [quoted text clipped - 3 lines] > > I apologize if you've posted this information before and I've missed it. Yes. It was the least worst (I hope) of a bunch of bad choices. SignatureGlowing in the Dark >> Hi, Glowing. Is IMRT your inital treatment. >> > Yes. It was the least worst (I hope) of a bunch of bad choices. Yup. It is an insidious disease and no treatment is without serious side effects. I truly hope the best for you. SignaturePSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron 07/03 (1 mo) 8/03 (4 mo), 12/03, 4/04, 09/04, 01/05, 5/05, 10/05, 2/06 PSA .07 .05 .06 .09 .08 .132 Non Illegitimi Carborundum >>> Hi, Glowing. Is IMRT your inital treatment. >>> >> Yes. It was the least worst (I hope) of a bunch of bad choices. > > Yup. It is an insidious disease and no treatment is without serious side > effects. I truly hope the best for you. Thanks. I would probably have gone with RP if my personal situation would have allowed it. Curiously, the Sloan Kettering Nomogram gave a 2% edge to EBRT for my numbers, but that's not why I chose it. Go figure... and then _this_ study comes along :-/ Who to believe? I don't think we have come that far from bleeding, blistering, and purging. I think it's just a craps shoot and we're all fixated on the size and color of the dots on the sides of the dice :-) SignatureGlowing in the Dark > _this_ study comes along :-/ Who to believe? I don't think we have come > that far from bleeding, blistering, and purging. I think it's just a craps > shoot and we're all fixated on the size and color of the dots on the sides of > the dice :-) Hear! Hear! > I remember when two guys with reputable credentials thought > they had created cold fusion in a test tube in Utah. sh.t happens > when attempting to do scientific research. Mistakes can easily > be made. What's this story, Alan? I want to look it up. >> I remember when two guys with reputable credentials thought >> they had created cold fusion in a test tube in Utah. sh.t happens >> when attempting to do scientific research. Mistakes can easily >> be made. > > What's this story, Alan? I want to look it up. See: http://en.wikipedia.org/wiki/Cold_fusion Two physical chemists at the University of Utah claimed they had created a nuclear fusion reaction in their laboratory. Scientific theory at that time held that it was impossible. Nuclei could only fuse at the kinds of temperatures and pressures found in the Sun. Today, most scientists still think that Fleishman and Pons, the two chemists, were wrong and did not produce a fusion reaction, though the controversy is not completely ended and some believers remain. I brought it up because it was a case of someone arguing that standard theory was totally wrong - as Albertsen and the other authors are arguing that the standard ideas about radiation are totally wrong. Alan > Disclaimer: I post this for information and discussion, not to advocate > for / against any treatment position. Also keep in mind that all > treatments have improved over the intervening years > Let's remember this, kids. > A while back I posted some work by Tewari and Menon that suggested > rather clear differences in PCa-specific survival outcomes between RP, [quoted text clipped - 3 lines] > sceptic over the years) is reporting similar results...Ron > I wonder what is Ron's foundation for saying that Albertsen has been a RP skeptic. I've done a little checking and find that Albertsen is a uro on the staff of the University of Connecticut Health Center. He is a surgeon. He has been lead author of a number of articles on a variety of urological topics. See PubMed. However, abstracts of many of the articles are not available on PubMed, which may or may not be relevant but I think is worth knowing. And my other objections to the reliability of the subject paper still stand. Regards, Steve J "What are the facts? Again and again and again -- what are the facts? Shun wishful thinking, ignore divine revelation, forget 'what the stars foretell,' avoid opinion, care not what the neighbors think, never mind the unguessable 'verdict of history' -- what are the facts, and to how many decimal places? You pilot always into an unknown future; facts are your single clue. Get the facts!" --Lazarus Long > American Urological Association Annual Meeting > May 20 - 25, 2006 [quoted text clipped - 52 lines] > > Steve Jordan wrote...snip... > I wonder what is Ron's foundation for saying that Albertsen has been a > RP skeptic. I've done a little checking and find that Albertsen is a uro > on the staff of the University of Connecticut Health Center. He is a > surgeon. Steve...Way back when, when the Swedish studies (Bill-Axelson, Holmberg, et.al.) were just a few years out, they were seeing no difference in biochemical failure, PCa specific mortality or overall mortality between the RP and WW arms. There was a lot of press based on these early findings that intervention in low-risk men produced no survival benefit. Albertsen was squarely in this camp too. He did a retrospective study based on the Connecticut tumor database and drew conclusions similar to the Swedish studies. Here's a press clipping... ----------------------------------------------------------------------------------------------------------------------------- CHICAGO, Illinois (Reuters) -- Men diagnosed with the least dangerous, localized prostate cancer have only a minimal risk of dying from the disease over the following 20 years, one of the largest and longest studies on the issue found on Tuesday. "These results do not support aggressive treatment of localized, low-grade prostate cancer," by surgery or radiation, the report from the University of Connecticut Health Center said. "Surveillance is really the best option for those patients," added physician Peter Albertsen, who led the study. His research, which began with 767 men and covered more than 20 years, also found that the death rate from prostate cancer across the board appears to remain stable beyond 15 years after diagnosis. ----------------------------------------------------------------------------------------------------------------------------- He was a voice in the non-intervention camp for low-risk men. As time went on, the Swedish studies began to see differences in biochemical failure rates, etc between the RP and WW arms. There was a lot of press when those articles appeared, because the earlier papers had served as the mantra of the non-intervention camp. Now too, apparently, Albertsen has made findings similar to the more recent Swedish papers. It's a significant change in position when one moves from "These results do not support aggressive treatment of localized, low-grade prostate cancer" to "Patients undergoing surgery for clinically localized prostate cancer appear to have a survival advantage." ...ron I'd be curious to know how Albertsen accounts for the fact that his earlier study of a large sample of men found no benefit for RP and his later study seems to show a very significant benefit. I wonder if he thinks: 1. The earlier study was flawed. 2. RP has improved significantly. Presumably he does not think: 3. The new study might be flawed. I know that Emerson said that "foolish consistency is the hobgoblin of little minds", but I'm afraid that my little mind would like to see at least _some_ attempt to explain Albertsen's self contradiction. Alan Good question Alan. I've just tacitly assumed that, like the Swedish studies, it has taken time for the trends to finally test significant. When Albertsen talks about "20 years" I suspect this means that he has men in his population that are 20 years post-treatment, but I bet the median follow-up is a lot less (I guess we could look at his papers and see). If I recall correctly, I think it took about 8 years (median follow-up) for the various indicators (bNED, survival) to test significant. Maybe the median is far enough out now that the significant trends finally emerge and test significant in Albertsen's group...Ron > .... A retrospective, > population-based outcomes analysis of men diagnosed in Connecticut with > localized prostate cancer between 1990 and 1992 was performed to > estimate prostate cancer specific survival and all cause survival > following surgery (n=806), radiation (n=703) or observation (n=114). > ... I've been attempting to figure out what sort of radiation would have been applied between 1990 and 1992. >From what I can tell, the standard practice at that time was 2D radiation at a maximum dosage 64 grays. The standard today is 3D conformal (or IMRT, a further enhancement of 3D) at a minimum dosage of 72 grays. Brachytherapy, or brachytherapy combined with 3DCRT, gives effective dosages that are significantly higher than that (I say effective because the effects of the dose have to be measured differently for brachy than for EBRT.) As far as I can tell, 3D did not become widely available until after 1992. I think it was in 1994 that the NCI produced a definitive study recommending it and it was only in 2002 that the NCI began recommending IMRT. 2D radiation relied on a two dimensional x-ray of the pelvic region to determine where to focus the beams. The prostate was not visible in these x-rays. The doctors would guess at the position of the prostate by looking at the pelvic bones in the x-ray and deliver the radiation accordingly. If they radiated too wide a field they could do substantial damage and if they radiated too narrow a field they could miss part or even all of the prostate. So they had to be very careful, make educated guesses, and not use doses that would be too dangerous if delivered outside the prostate. It was already known at that time that more than 64 grays of radiation produced high rates of damage to the bladder, rectum and other structures. It was not well known however that 64 grays is an inadequate dose, and I'm not sure it was even well known that doses below 64 Gy were inadequate, or that the effectiveness of radiation is highly dosage dependent. I suspect that every single man in the study got what would today be considered insufficient radiation, and some may have not gotten any radiation at all on parts of their tumors. So I'm thinking that a study of men treated with RT between 1990 and 92 really isn't helpful in evaluating the effectiveness of modern RT. I am very curious to know if the authors considered this issue and if so, how they dealt with it. It is disturbing to me that this issue is not mentioned anywhere in the published abstract. It strikes me as somewhere between irresponsible and downright unethical that the authors make blanket statements about radiation in the abstract without ever indicating that the radiation treatments they evaluated are so dramatically different from the ones being offered today. Alan |
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