Is prostate surgery still relevant?

I am currently going through 39 radiation treatments for a chemically recurrent prostate cancer. While looking at my own situation and researching others, I keep asking if a primary treatment of surgery is even defendable anymore.

Over 35% of surgery patients have a chemical reoccurrence within 10 years. I would guess that most of that 65% that do not come back were low Gleason cases. Maybe some of those low Gleason cases should never have been treated anyway? Maybe the higher Gleason cases (8+) could have been better treated with BT or RT?

I do not know what the current thinking is regarding this issue. Prostate surgery is big business, but so is radiation therapy. The medical establishment fights to protect their share of profits, but what about the patients.

I have 3 friends who had BT or HT at the same time (9 years ago) that I had surgery. They never had the erectile or urinary problems I do, and their cancer has not come back. Makes you wonder.

Wouldn't that be salvage surgery?

If so, not a good idea

Mel

you are a G8, G9 (me) or G10 and somehow it's still contained withing the prostate, surgery is certainly relevant, as it would be a cure.

Although mine ended up not being contained, I strongly believe that removing it has increased my chances for further treatment to be successful.

NKinney said...

lifeguyd said...
Over 35% of surgery patients have a chemical reoccurrence within 10 years.

First of all, I recognized that the question you ask might be answered/replied-to on many different "levels." I'll pick one...


What I believe is NOT "relevant," or meaningful, is the statistic you quoted above. I do believe it is probably correct...but it is not relevant.

Every patient's INDIVIDUAL case characteristics ARE relevant to their individual treatment choice. Those case characteristics are often aggregated together in the NCCN Risk Category.

So, for example, LOW-RISK CASES are the most frequently occurring case. The majority of men in this category seek an agrressive treatment (surgery or radiation) despite the undisputed evidence that treatment does NOTHING to prolong their lives. There are a small percentage of men initially categorized as LOW-RISK who undergo an aggressive treatment (surgery or radiation) who then progress to a higher-risk category.

On the opposite end of the spectrum is HIGH-RISK CASES (such as yours). While this is a small percentage of all newly diagnosed cases, in direct response to your question there are reasons for men in this category to pursue surgery as their primary (first) treatment...but it depends on the specific details of their individual cases, not one-size-fits-all. For example. in some cases of advanced disease it may be appropriate to "de-bulk" the tumor—to surgically remove as much as possible first—before moving on to other supplementary treatments which are typically needed for HIGH-RISK CASES. For others in this risk category, particularly those with characteristics on the lower-end, they may to roll-the-dice for the possibility of a complete cure with surgery (placing a bet that the PC has NOT spread). That probability is low but not zero, and so some in this category may feel it is worth the risk. Individual case characteristics matter, even within a risk category.

It's those in the middle risk category, the INTERMEDIATE-RISK CASES, and particularly those in the unfavorable (4+3) half of this category for whom that probability (of a complete cure by surgery) is more "relevant" to consider. The additional details of one's individual case, including but not limited to age, will also be relevant to the treatment choice.


Your original question implies a one-size-fits-all approach. Wrong approach...for everyone.

Good points. I was in that category which rolls the dice, hoping against the odds for a surgical cure. Based on my vastly experienced surgeons DRE combined with the various tests. G9 or not, he felt there was a fair chance of still being contained. I was not.

OK, but here is a question: what are the #s showing as to my chances of survival for 5-10 years had I chosen RT(and radiated the margins) instead, compared to surgery? (5yr/96.4%, 10yr/89.5% for surgery, high risk guys in one large study) Are they equal or maybe even superior for RT?(pretty darn high already for surgery)

What are the odds of PC specific survival at 15, 20 and 25 years comparatively for RT(for high risk:82.0%, 72.9%, and 68.8%, respectively for surgery from same study)? I don't think we even have those studies for RT yet, do we? Certainly not for 20 and 25 years.

Notice these #s are for PC specific survival, not BCR. These #s are pretty darn good IMO, but I suspect the most current 5-15 year #s are at least as good and maybe better for RT. I guess we can't know yet about 15 yr+. But I'm pretty sure the early SEs are much less devastating, and maybe even the later SEs, on average anyway. Not that horrible SEs can't happen even with RT, but I think the % is much lower.

But having these immediate- and probably for a lifetime- SEs from surgery, I would do it different unless the #s wre way better for surgery. If I could of known then what I know now, I would not be having that surgery. I would take my chances on the RT. And since I would have also radiated my margins, my odds would probably be even better, at least for the next 5 or 10 years. And the odds are that those 5 or 10 years would have been more pleasant ones. IMHO, just based on the prism through which I now see things, I don't think I could ever vote for surgery. I do not see the advantage for me.

I agree with what is said, but being diagnosed with cancer is like Russian roulette. For the vast majority prostate cancer lives within the bell curve, but every now and then there is an outlier. Many people makes a decision on treatment to error on the safe side.

Even G6 can become life threatening. A recent post shows that cancer doesn't always conform to the norm.


www.healingwell.com/community/default.aspx?f=35&m=3503324

So much for the "Gold Standard". This phrase was coined by surgeons. Many doctors and others do not consider surgery to be the "Gold Standard" because we see and experience the successes of other treatments. My urologist-surgeon and two other urologist-surgeons clearly said they would not operate on me because they did not assess that surgery would be curative. I am very thankful they were open minded to all treatments and not biased to surgery, though all were surgeons. My treatment has kept me cancer free for five years after a high risk diagnosis. I was apparently successfully de-bulked by radiation and I have every expectation that I will remain cancer free and thankfully side effect free for many years.

Among my father's many pieces of advice was to "do what it takes to stay out of court and off of the operating table". I certainly recognize there are many instances where surgery is clearly the best treatment and have had several surgeries on that basis. I also recognize there are many situations where surgery is not necessarily the best option and in my opinion, PCa is one of those.

Often we look to science fiction to understand the future. Interesting that on Star Trek they never used surgery to treat people and Cling-ons, and others. Apparently surgery was a bit old fashioned.

JNF-- give it a break.

Such dogmatic statements that surgery is always the worst choice in PC is simply not true.

In YOUR case, it was not the best choice.

Mel

Of course every case is unique, that does not mean that overall statistics are not relevant at all. They give one some guidance..otherwise you could never make a decision because nothing is totally relevant to your unique case.
As far as onerous side effects form surgery.....they don't call it radical for no reason...there is a lot of cutting and pasting and removal of important parts...like one sphincter,for example. Sure some guys do well, mostly younger but old guys aren't going to recover from surgery of any kind very quickly...urinary toxicity aside. Many are not ever going to recover...you know, the "new normal". In keeping with the notion of no relevancy...not all of us consider "essentially continent" continent...continent means no leaking, ever, not the "new normal" so in that instance the incontinence rates are almost certainly irrelevant. Going to the gym a few hours a week and a desk job probably lend themselves to "essential incontinence". Working at farming, sheep shearing and dog training like I do almost certainly do not.

I took a gamble on surgery with a PSA of 23. I'm sitting here 6 years later with a <0.02. I'm calling that a clean cure.

The nomograms say I have a <3% chance of recurrence in 10 years. That is half the odds of me having heart trouble over the same period.

Yep, I have ED. But I still feel pretty good about my decision.

Jeff

I don't know that it's generally accepted in the scientific/medical community that G6 cancers mutate into G7 cancers let alone G10 is it ?

Follow-up comments to several who posted after me yesterday…

lapilot said...
Even G6 can become life threatening. A recent post shows that cancer doesn't always conform to the norm.

One never generalizes (should never generalize) with only a sliver of information. What were the other case characteristics? What prostate cancer expert pathologist provided the second opinion biopsy reading? After sorting through those important details, one must recognize that there are a small percentage of cases for whom no treatment stops the progression. This most often comes up in discussions about Active Surveillance in this context: essentially the same small percentage of men initially presenting with low-risk cases who go on AS end up dying from PC as their low-risk counterparts who sought immediate treatment. There is a rare strain of PC which no treatment solution has been found to stop it.

sheepguy said...
Of course every case is unique, that does not mean that overall statistics are not relevant at all. They give one some guidance..otherwise you could never make a decision because nothing is totally relevant to your unique case.

No. The overall, combination of all cases into the 35% overall BCR rate is completely meaningless to any one individual making a treatment decision. Completely meaningless…except to someone who doesn’t take the time or energy to understand or educate themselves about their own case of PC. (See “Step #1” of the sticky thread “Newly diagnosed…” It’s labeled “Step #1” because that’s how important it is…it’s the very FIRST thing a newly diagnosed man should do. Only AFTER you complete "Step #1" you will understand you risk category, and only then begin to understand which possible treatment path might be appropriate for you...and then it becomes clearly obvious that the aggregated numbers are meaningless.)

The direct comparison one would make to your statement is that the overall rate of mortality for all cancers is 211.6 per 100,000 (for men, in the US). So if you get diagnosed with cancer, does that mean you’re going to die? No. It depends on your individual case, and you would never look at that overall aggregated number and think it applies to you or make any decisions based on this. The different constituent components (different types of cancers) contribute to that aggregated number of 211.6 in very different ways. If you are studying health policy, it would be a useful number; if you just got diagnosed with cancer, it is completely meaningless.

Similarly, within prostate cancer surgery outcomes, the aggregated percent of BCR over the very wide spectrum of RISK categories—and it is a very wide spectrum—is meaningless. I described this thoroughly and accurately earlier, but anyone in the high-risk category should basically expect BCR after surgery for primary treatments…but there are reasons why it might be advantageous for a subset of high risk patients to undergo surgery first. The percent of BCR for high-risk patients is high….considerably higher than 35%. On the other hand, BCR for low-risk patients is considerably lower than 35%. (If you are unaware of these fact, go to the MSKCC prostate cancer nomogram page and enter various sample cases yourself…the differences are huge.)

So, the overall statistic of BCR for ALL prostate cancer cases is irrelevant and completely meaningless…unless you are studying health policy. If you actually have PC, go to a nomogram instead to individualize your risk of BCR.

trailguy said...
Those G3 cancer stem cells can and do further mutate into G4's and those will cheerfully mutate into G5's.

It doesn’t work that way. You may grow some new cancer cells which include Gleason pattern 4, but G3 does not “mutate” into G4.

Post Edited (NKinney) : 9/25/2015 1:24:55 PM (GMT-6)

Michael:

I agree with you that surgery has been termed the "gold standard." That term should be eliminated as there are so many tx. options, each with its own set of advantages/disadvantages.

You gave 3 reasons why men choose surgery. I agree that #1 and #3 are very specious reasons and patients should be aware of that. #2 is actually a VERY VALID reason. For me personally, there were many more reasons that I chose surgery.
They include the fact that I was in good condition and I preferred to have the SE up-front.
More importantly, I wanted to know the total pathology (not some biopsy estimate). Also, in my particular case, I had some major BPH issues. One of the largest benefits of the surgery in my case was that it eliminated those very severe symptoms (on a few occassions, I was very close to going to the ER to get catheterized). Additionally, in my case, I did have a world class surgeon (Dr. Menon) not too far away.

Also, I did have the "get it out" mentality. That psychology is significant (forget what your relatives tell you -- what do YOU think!)

Anyway, the bottom line was that based on my biopsy, I had a real chance for a total cure. Sadly, it didn't come out that way, no pun intended.

Mel

I have the impression that for Urologists surgery is the default option, and is more often recommended by Uros when their patients are dx'd. I give my Uro credit for honestly describing all options to me. And then I chose an option he wouldn't have expected me to choose.

Every case is different, and everyone's psyche is different. Hard medical issues aside, there are some who psychologically are better suited for surgery with the thought they have "gotten everything out". I was ok without that.

Would be an easier choice for many if there weren't really a choice. To know that given your conditions (whatever they were) that you clearly needed this therapy, and not another. Nature of this condition is that often any one of several different therapies will work for you.

In my case, parsing literature and stats the best I could, I decided on HDR BT as being roughly equivalent to surgery in efficacy and better for SE's. But there seems to be enough conflicting information that there's no way to know for sure. And 5 or 10 years in if things are going well I could be convinced the path I chose was the right one - though I might've had the same outcome with another path. And if things aren't going well, the outcome might've been the same if I had chosen a different path.

Wish the people here who did not get the results they would've liked had gotten better results - but try not to kick yourself - no guaranty that things would've necessarily been better with a different path.