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Medical Forum / Diseases and Disorders / Prostate Cancer / July 2006Long-Term RP Study
We often talk here about the paucity of long-term PCa data. This single-institution study looked at the outcomes of consecutive men who had an RP at this institution over a 40 (!!) year period. From this data, the authors were able to determine various statistics for men 25 years past RP. The study ran from 1954-94, so today's techniques are improved and the average man today is less advanced than the average man in this study (I suspect). So perhaps these numbers represent "lower limit / worst case" 25-year outcomes for the average RP man today. Here's a little table I created from the data in the abstract. 25-Year Averages: Range Average Prostate cancer specific survival 99.0% to 81.5% 90.25% overall survival 93.5% - 19.3%, 56.40% psa progression-free survival 84.8% - 54.5% 69.65% local progression-free survival 95.3% - 87.8% 91.55% distant progression-free survival 95.9% - 78.2% 87.05% The abstract follows as well. It would be nice if biochemical failure rates (100% - psa progression free survival) were higher, but PCa specific survival doesn't look bad. If we could only stop dying of other things we'd be OK...ron J Urol. 2006 Aug;176(2):569-74 25-year prostate cancer control and survival outcomes: a 40-year radical prostatectomy single institution series. Porter CR, Kodama K, Gibbons RP, Correa R Jr, Chun FK, Perrotte P, Karakiewicz PI. Department of Urology, Virginia Mason Medical Center, Seattle, Washington. PURPOSE: We report on 25-year cancer control and survival outcomes after radical prostatectomy in a single center series of patients treated during a 40-year period. MATERIALS AND METHODS: Between 1954 and 1994, 787 consecutive patients underwent radical prostatectomy at Virginia Mason Medical Center in Seattle, Washington. Kaplan-Meier 25-year probabilities of prostate cancer specific, overall, prostate specific antigen progression-free, local and distant progression-free survival were determined. Multivariate Cox regression models addressed prostate cancer specific mortality. RESULTS: Prostate cancer specific survival, overall survival, prostate specific antigen progression-free survival, local and distant progression-free survival ranged from 99.0% to 81.5%, 93.5% to 19.3%, 84.8% to 54.5%, 95.3% to 87.8% and 95.9% to 78.2%, respectively. In univariate analyses pathological stage, surgical margin status, pathological Gleason sum, delivery of hormonal therapy and radiotherapy represented statistically significant predictors of prostate cancer specific mortality (all p </=0.001). In multivariate analyses only Gleason sum (p = 0.03) and delivery of hormonal therapy (p <0.001) remained significant. CONCLUSIONS: This is one of the most mature radical prostatectomy series. It demonstrates that long-term biochemical cancer control outcomes after radical prostatectomy might be suboptimal. However, local and distant control outcomes are excellent, and cancer specific mortality is minimal even 25 years after surgery. PMID: 16813891 I think this indirectly points out the fallacy of treating PSA. Obviously, many of the men still alive after 25 years had detectable PSA. And from what we know about the timing of biochemical failure, they probably had it for years. This is some support for the traditional notion of not freaking out over detectable PSA and not worrying about it until clinical symptoms appear. However, I suspect this might be different in men w/ aggressive G.S. 8-9 PCa. Bill Denton RP 2/12/02 PSA .93 Memphis Interesting Article in LA Times. Today. Many men and Dr.s look at watchful waiting, and leave the prostate alone. Of course the article say's that if a man has agressive cancer he needs to treat. My question is how do you know if it is agressive or ok to left alone. I know the answer in my case. At 49 I was Dx'd with agressive cancer. I had PSA of 7, and and gleason 3/5 or 5/3.... anyway, I had RP in 1999. My PSA was diagnosed @ 6....If I waited I wonder what I would be like today? I am fine now, and such and do not have any major problems, but these articles make a person wonder. Hummmmmm John Loomis RP @ 49 in 1999 PSA OK Erection OK No leaks.........Hurray. >I think this indirectly points out the fallacy of treating PSA. > Obviously, many of the men still alive after 25 years had detectable [quoted text clipped - 8 lines] > PSA .93 > Memphis > I think this indirectly points out the fallacy of treating PSA. > Obviously, many of the men still alive after 25 years had detectable [quoted text clipped - 3 lines] > worrying about it until clinical symptoms appear. However, I suspect > this might be different in men w/ aggressive G.S. 8-9 PCa. This paragraph brings up (again) my curiosity about treatment, overtreatment, etc. My husband had G7 from two labs, one a specialist lab. Also minimal % of cores. However, with the RP, we discovered the actual Gleason was 9, and the cancer was extensive. Since he started with a G7, that pretty obviously needed treatment of some sort. But what about the guys who find no cancer on biopsy, or have a G6? Conceivably, if their experience was similar to ours and they had an RP, they could find their G6 was really a G8. Somehow, people need to look at the *other* indicators, not so much the actual PSA or biopsy results. Takes more attention, though, than just waiting for a *4*. And you were talking about biological recurrance, I think. A detectable PSA after primary treatment. Its hard to figure. A really, really tough call. One I wouldn't care to make for anyone else. Even with me, all my hours researching this disease. Every so often, I just go to Steve and ask him what he thinks. Whatever he says goes, and I'm relieved. I'm glad too that I don't have to make those decisions. That vaccine, is it Provenge? is about twice as effective as Taxotere, which as we know is our shining star (dim as it is) for systemic PCa. So I do feel that real cures are coming. The thing about the vaccine is that (I think) the SEs would be far less than the treatments we have now. laurel Let me be a little clearer. I am NOT talking about WW as an alternative to primary Tx, although that may be warranted in many cases, but after primary Tx. This study dealt w/ men who had RPs. Any (relatively) young man like John w/ any G.S. 5 PCa needs some Tx, although not necessarily local. And you are right, Laurel, since the pathological staging is often worse than clinical, that has to be considered when thinking about the WW option. Other diagnostic clues must be looked at. I think WW should be followed only so long as there is no evidence that PCa that was thought to be very early and very slow-growing begins to crank up. My point is that some docs are quick to start salvage Tx when all they may be doing is treating PSA level. This study shows that in many cases detectable PSA does not translate into fatal PCa. Indeed, it shows that the greatest threat to a man having an RP is dying of something else! The best I've seen re Provenge is a few extra months. However, and this is my pet peeve, they've only tested it in advanced cases. Who knows what would happen if new treatments like Provenge and GVAX were offered alongside RT and ADT as adjuvant/salvage Tx rather than last-ditch. I volunteer to take it NOW! Bill Denton RP 2/12/02 PSA .93 Memphis The term WW should be reserved to those that decide to avoid treatment until symptoms appear or simply decide not to be be treated by a recognized primary treatment. Once treated those patients should not be considered to be on WW. Usually, treated patients are followed for tx results by blood or imaging tests. To mix one that has been treated with the others that haven't can create a problem for those in the decision making process as they evaluate tx results. RalphV azustoo.org > Let me be a little clearer. I am NOT talking about WW as an alternative > to primary Tx, although that may be warranted in many cases, but after [quoted text clipped - 21 lines] > PSA .93 > Memphis > Let me be a little clearer. I am NOT talking about WW as an alternative > to primary Tx, although that may be warranted in many cases, but after You were clear, it was me. After our experience, I question all staging. Its a trigger for me, I guess. So the question comes up, and I am making it all about our humongous six months' experience with PCa. Sorry. I realize what you were talking doesn't apply in that sense. It does apply, in that Steve had positive margins (bladder neck) and positive lymph. Right now he is doing RT and ADT. We saw great results with the ADT (PSA undetectable, T plenty low enough after 3 months), so expect that there will be no nasty suprises (how can I say that? This is PCa. All about nasty surprises.) before the ADT ends in 2 years (more or less). Hopefully, of course, his PSAs will all stay undetectable by any test, and the issue won't come up. But, it could. So then what? It goes back to my original comments about tough, tough calls, and gratitude I am not faced with them. In this case, it would be rising PSA after primary + salvage treatment. But, and this is a big butt, the issue is the same. PSA <> cancer. Period. But it is about the only marker we have. At least until identified bone mets, or something. Which many feel is allowing it to go far too far before treatment. So paying attention to PSA re PCa is not entirely rational, but then, ignoring your only indicator is not rational either. What do you do? I would like to point out that while many men live and die (of other causes) with prostate cancer, it is an ugly disease to die from. Just because some men at 15 years had detectable PSAs but weren't dead yet doesn't mean that they were symptom free or living a good quality of life. They may have been, but you don't know from the bare #s. > they may be doing is treating PSA level. This study shows that in many > cases detectable PSA does not translate into fatal PCa. Indeed, it > shows that the greatest threat to a man having an RP is dying of > something else! Good. This might say something about the value of RP and debulking, with and without eradication. And with our without eventual biological failure (which does not necessarily but *may* translate to clinical failure.) > The best I've seen re Provenge is a few extra months. However, and this > is my pet peeve, they've only tested it in advanced cases. Who knows > what would happen if new treatments like Provenge and GVAX were offered > alongside RT and ADT as adjuvant/salvage Tx rather than last-ditch. I > volunteer to take it NOW! Bill, yes, the numbers were like 5 months for Provenge and its maybe 2 1/2 months for Taxotere. They are doing trials now from live men, not dead men, like the original trials. When they woudl only test a treatment on men who basically qualified for Hospice, it looks bad. Like, who cares about an extra two months in the pits of prostate cacer death? But they are now doing trials in earlier stages of the disease, so we will see more rational #s. On the other hand, the men in earlier stages have longer to live anyway, and if the treatments increase their life span, we're looking at a followup of decades. So we may not see numbers before the treatment options have made another quantum leap anyway. You could look at it another way. Its not really more valid, but its not less valid. Say a treatment gives a dying man 3 extra months. Well big whoopie. Its not 3 months of feeling good, after all. Still, if his life expecancy was three months, and he lived six months, you *doubled* his life expectancy by the treatment. This is fallacious but not any more so than someone who says that three months is insignificant. These were dying men. I hope I am not sounding argumentative, I really appreciate your valuable posts and am only just running a train of thought here. best regards, laurel Damn, I don't know how I missed that Proveng trial. I can't even find it on the NCI site. It may have been that I did not qualify at the time they were recruiting. My luck. The med-onc I saw at Vanderbilt changed my way of thinking a bit. PSA may be the best/only bio-marker we have but he looks at clinical indications as well. For example, in my case it was as illuminating to him that I "only" had PSA of .93 4 years post-RP w/o any Tx and no evidence (last time we checked) of disease progession other than PSA. That indicated to him that (at least so far) my PCa was not growing very fast and did not need drastic Tx. That could be about to change but the point is that they do have other things to look at. He said he has Pts who have had double-digit PSA for years w/o symptoms. Bill Denton RP 2/12/02 PSA .93 Memphis They're recruiting now. Phase III. http://www.clinicaltrials.gov/ct/show/NCT00065442 > Damn, I don't know how I missed that Proveng trial. I can't even find > it on the NCI site. It may have been that I did not qualify at the time [quoted text clipped - 14 lines] > PSA .93 > Memphis Bill: "The best I've seen re Provenge is a few extra months. However, and this is my pet peeve, they've only tested it in advanced cases. Who knows what would happen if new treatments like Provenge and GVAX were offered alongside RT and ADT as adjuvant/salvage Tx rather than last-ditch. I volunteer to take it NOW!" Laurel: "When they woudl only test a treatment on men who basically qualified for Hospice, it looks bad. Like, who cares about an extra two months in the pits of prostate cacer death? But they are now doing trials in earlier stages of the disease, so we will see more rational #s." Bill: "Damn, I don't know how I missed that Proveng [sic] trial." Laurel: "They're recruiting now. Phase III. http://www.clinicaltrials.gov/ct/show/NCT00065442 " Laurel, look at that trial - it is for men w/ HORMONE-REFRACTORY METASTATIC PCa! That's exactly what I said - it s only offered in advanced cases; that don't do crap for me. Yet. Bill Denton RP 2/12/02 PSA .93 Memphis |
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