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Posted 7/27/2009 2:58 PM (GMT -5)
Perhaps someone can clarify this for me.

I don't have the exact statistics, and maybe finding concrete numbers is difficult so I'm going to use ballpark numbers here.

Is it probable to conclude the overall success rate of surgery (I'll say at the 10 year mark, open or robotic for biochemical non recurrence) is somewhat better than radiation? Is using ballpark probability of success numbers .80 for surgery and .75 for brachy or external beam sound reasonable? And .50 for salvage radiation?

If so, then we apply parallel system of reliability math for surgery we get: 1-((1-.80)*(1-.5))=.90

So wouldn't the option of salvage radiation give surgery a fairly good advantage over radiation as a first choice of treatment? Or am I missing something?

Post Edited (Squirm) : 7/27/2009 2:03:21 PM (GMT-6)

Posted 7/27/2009 3:02 PM (GMT -5)
Others may quickly disagree with you, but I agree with your line of thinking, which is the major reason that I chose surgery. The options for a failed radiation as a primary treatment aren't as good as that of a failed surgery. Just my take.

David in Riley
Posted 7/27/2009 3:08 PM (GMT -5)
Hi David,

Even if we use a lower success probability rate for the salvage radiation of .35, it still gives surgery overall a .87 chance of success.
Posted 7/27/2009 3:28 PM (GMT -5)
An interesting question. Part of the problem is that radiation is used for cases which are too far advanced for surgery so one needs data broken down by various test results
Posted 7/27/2009 3:44 PM (GMT -5)

Hi Squirm:

Your math works fine but your assumptions are erroneous, therefore so is the conclusion. 

I can lead you to any number of studies showing the overall success rates for radiation, when normalized for patient diagnosis, are equal to or better than surgery.  But, why not just take it from surgery expert Dr. Patrick Walsh who states in his book Guide to Surviving Prostate Cancer, "...multiple studies have shown similar results for both brachytherapy and radical prostatectomy".

The second assumption about salvage radiation providing an advantage is potentially true, but not in the statistical sense that you postulated.  It does not provide a statistical advantage in terms of long term cure as there are also curative options for failed radiation patients, e.g. HT.  Therefore the advantage is not necessarily in cure rate but in the fact that it is an additional option that radiation patients generally do not have.

Now, you can find plenty of surgeons who will state that surgery is more curative and you will find radiation docs who will argue the opposite.  And, you can find studies that back either case...depending on the selected patient population.  But, I believe most real experts agree on the bottom line and that is -- for equally eligible patients, the cure rates for surgery and radiation are basically the same.

Given that, it leads to a whole other discussion re why different men pick different options...but that's for another debate...

Tudpock

Posted 7/27/2009 3:51 PM (GMT -5)
Too much math stuff for me. I had 1 cancerous prostate. Surgery equaled a minus 1 prostate. Net was zero. I had a definitive diagnosis that I then knew how to fight further if I needed to. Radiation was a little more fuzzy math for me.
Posted 7/27/2009 3:52 PM (GMT -5)
The real problem is that there are no good 10 year numbers for radiation because the state of the art has advanced a great deal in that time period.

My father had EBRT 10 years ago at the same facility where I'm considering treatment. That facility installed the latest Varian RT machine just 18 months ago. While my father is PCa free now, the machine he was treated with is light years behind the present. Couple that with the fact that patients with more advanced PCa are steered to radiation and its like comparing apples to oranges.

The biggest advances in RT treatment appear to be in the lack of serious side effects. While my father has problems with both incontinence and ED, my urologist told me that in the last 5 years he sees only minor side effects from radiation. If you read Walsh's book he does not list incontinence as a side effect of RT.

Each of us is a study of one and must reach our on conclusions. PCa seems to make it as difficult as possible to do so.

Good luck
Mike
Posted 7/27/2009 7:25 PM (GMT -5)
I did IMRT as primary treatment with adjuvant hormone due to the diagnosis indicating possible spread to the lymph nodes. My research led me to conclude that surgery and radiation (both external and brachy) had similar results for organ confined cases. In the case of spread to the nodes surgery was not as good. Mayo clinic begs to differ on that statement by the way. I knew, in my case, that radiation would follow the surgery immediately. My thought was this... If surgery and radiation were similar in results for organ confined then radiation would give the same results as if I had surgery in regards to the prostate gland.  There was an 18% chance of organ confined. In addition the radiation would be able to treat the suspect nodes (illiac and obturator) at the same time as the primary target. I also had a financial consideration as I am uninsured. At the end of the day I went with the IMRT and the concurrent hormone treatment. So far, so good. Very little in the way of radiation induced side effects but pretty much the full monty on the hormone with the exception of "man boobs". Doctor attributes that to my weight lifting. Who knew?!

I also recieved some positive feedback from others who elected the radiation treatment. In one case it was a friends father who had it done 28 years ago. He is 92 and no reoccurence. Technology has improved a bit since his time.

Side effects were another consideration but again they were similar with the exception that the likelihood of impotence was slightly higher with radiation. Personally, I cannot comment on that aspect as the hormones I take also can have this as a side effect although I did get some modest spontaneous erections in the mornings just after completing the radiation.

I suppose at the end of the day we each make out decision based on the available information and our own particular situation. But being an engineer I appreciate the mathematic application and probability.

Don

 

Posted 7/27/2009 7:40 PM (GMT -5)
The debate goes on. You can't evaluate radiation and surgery unless you have the exact same stats for patients going in. Basically any local treatment will cure a G6 tumor at a very high rate of probability. It's when you get into the higher grades and other factors such as margins, tumor location, size of tumor, node involvement ect. that it becomes difficult to compare. In some cases where the tumor is in an unfovorable location or has just penetrated the margin or where there is small lymph node involvement radiation is probably better. Radiation is also better on smaller size tumors than larger size. In the cases where the tumor is contained and not next to any major organs or structure, such as seminal vessels, urethea or rectum, then surgery is very efficient.
The biggest difference is the side affects and the time period in which they occur. Radiation generally has less adverse side affects.
Salvage radiation is effective in about 30% of procedures. This is mainly because if a patient has micro mets then salvage radiation won't work. Salvage only works when there is a local positive margin or when the surgeon has left some prostate tissue behind, you can never get it all and if that tissue contains PC cells it will grow. Initial radiation treatments would have generally taken care of these two issues. If there is a local reoccurrance in radiation it is because the dose was too small or the radiation wasn't delivered properly or the initial tumor was very large. There are few salvage procedures that work well in this case. The main failures in modern radiation and surgery is because the PC is already in the bloodstream by the time of treatment.
Killing PC in radiation is a matter of dose and accurracy, The new machines can delver a higher dose more accuratel to the prostate without affecting the surrounding tissues. An even higher dose can be obtained with a combination of seeds and IMRT.
When PC has escaped the capsul and is in the blood stream then niether radiation or surgery will cure it.
Some knowledgable experts believe that new PC can still grow years after radiation, because there is still prostate tissue and surgery may be sightly more favorable for younger patients
JT
Posted 7/28/2009 2:51 PM (GMT -5)
This debate can go on all day and night, with no winners and no losers.

Stats are stats...period. But truth be told if one is younger, has a low psa, reasonably low GS and no signs of extension, than surgery should be a no-brainer.

Its when you get into the other than "no brainer area" (higher psa, higher GS and less favorable staging) that radiation (or cryo) may be the better bet. 

However, to me the one real advantage to surgery, is that after surgery one has a clearer picture of what is truly going on (ie. post surgery biopsy and biopsy of selected lymph nodes). Compared to surgery, radiation and cryosurgery are shots in the dark...one never knows much beyond the needle biopsies and the other tests that may or may not show everything.

Therefore, if one gets salvage radiation following surgery, it is more likely that the salvage will work because more is known of what the problem is. If one gets salvage cryo for failed radiation or salvage cryo or salvage radiation following failed cryo, there is less known about where the disease is and more of a chance for re-failure. 

On the otherhand, I cannot think of anything which would be more defeating in the short-term than to find out after surgery that there is evidence of extension and that the surgery should be followed up in three months with radiation. However, this is a nasty beast and if thats what it takes to kill it than the heck with the short-term disappointment.

Just my opinion..... BTW: had I qualified for surgery I would have done it in a heartbeat. I did have a surgeon who said I did qualify but I didn't really have faith in his opinion. But then again, that surgeon did not tell me about doing an immediate salvage radiation, if he was wrong. Had I known that was an option (and covered by insurance) I would have had surgery.

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