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3 Myths about radiation vs surgery shattered by the ProtecT trial

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Posted 9/17/2016 9:13 PM (GMT -5)
Here are three biggies that went down:

Myth #1: The side effects end up about the same for surgery or radiation

Myth #2: With surgery, you get the side effects all at once and steadily recover; with radiation, the side effects come on steadily and may hit you many years later.

Myth #3: Over time, erectile function is about the same for surgery and radiation.

All of these are now demonstrably untrue. Anyone caught propagating any of them will be paddled and made to wear a dunce cap (I've been reading way too many Victorian novels).

You can read about it here:

Patient-reported outcomes from ProtecT - the first randomized trial comparing surgery, radiation, and active surveillance
Posted 9/17/2016 9:29 PM (GMT -5)
Well, maybe incontinence with radiation doesn't get worse, but it sure is a hell of a lot better than with RP. So , yeah radiation doesn't seem to get worse with time..but I'll bet the incontinence you get with RP sure seems like you get it all at once..like the day after surgery.
Posted 9/18/2016 11:16 AM (GMT -5)
My number one SE has been ED. I had nerve sparing RP ,SRT to prostate bed and RT to pelvic lymph nodes. I'm coming off HT and hope ED improves now that my libido is coming back. What are my chances of regaining potency?
Bob
Posted 9/18/2016 11:54 AM (GMT -5)
Allen -

Having surgery at 69 years of age and looking at those incontinence percentages, I feel lucky my incontinence only lasted 2 or so months.

However, my luck was not so good with the cancer being contained in the capsule. I'd trade the incontinence for it being contained any day of the week!

I have seen other incontinence study results, some retrospective, and those percentages vary widely with the different studies. Some better, some worse, then your referenced study.

Bobby Mac
Posted 9/18/2016 12:11 PM (GMT -5)
Bob,

as Allen wrote in his blog mentioned above, only 21% will regain potency after nerve sparing RP. If you add SRT, RT and HT to that it will be a lower percentage.

You can try sildenafil plus a vaccum pump. Alternatives are intracavernous injections or a penile implant.

It will take about half a year or longer for testosterone to return.

George
Posted 9/18/2016 12:44 PM (GMT -5)
George and TA
I really was steered in the wrong direction with RP!
Bob
Posted 9/18/2016 12:46 PM (GMT -5)
Hi George -

Yes, thanks, but I had large volume disease with no nerve sparing.

My surgeon said injections will work after HT. That may be like "the checks in the mail" kind of thing!

Maybe an implant if injections will not work?

Bobby Mac
Posted 9/18/2016 1:29 PM (GMT -5)
I would take any such data with a grain of salt as I've seen other studies with very different results - particularly showing more chance of bowel damage with radiation. Like everything, it depends to some extent the potential biases of whoever is conducting the study. Just anecdotally, many men in the prostate group I attend who've had radiation appear to have experienced more significant problems than this study would indicate but perhaps those without problems are less likely to remain in such groups. I also note that the study is on men with open surgery. While early studies indicate that there is little difference between outcomes with robotic and open, I believe that early data was skewed due to this being a new technology and the learning curve involved. I think as time goes by we are going to be getting better significantly better results from robotic over open surgeries. I've had minimal side-effects from my robotic surgery with no requirement for pads and no ED, although I do use the low dose cialis.

That being said, I wouldn't discourage anyone from seeking radiation if they felt that was the right choice for them.
Posted 9/18/2016 1:47 PM (GMT -5)
Well I must say, based on recent surgeries for people on this site, certainly not scientific, the incontinence percentages on Allen's mentioned study do seem inflated.

I had Da vinci surgery in April and a handful of other had surgeries after me, and to my knowledge all were continent withing 2 months, or so.

Dreamerboy, you may have something with the open surgery theory?

Bobby Mac
Posted 9/18/2016 2:49 PM (GMT -5)
This was probably one of the least biased studies ever done. It was large, long term, and precisely laid out from the start. This was a UK study and I can't imagine it ever being replicated in the US. I found many flaws that I noted, and that the authors are well aware of too. Mostly the flaws occurred because (1) it began in 1999 and (2) they analyzed it exactly the way they said they would from the start, and treated men with the same protocols. Unlike all previous studies, this was a large randomized trial - the men in each treatment cohort are exactly the same.

That said, the RP part of it came closest to contemporary standards. The article has a link to a very recent (just published about a month ago) study of men treated 2010-2014 showing that open and robotic surgery have identical outcomes. It is entirely possible that some doctors have better outcomes than those in the UK; some have worse, too. These are population statistics, not individual anecdotes.

It's easy to throw stones and say "Well, it's not my experience, so it can't be true." I think as empowered patients, we are much better off when we don't chuck out data that does not conform to our biases. That's called "confirmation bias," and is a huge source of cognitive error.
Posted 9/18/2016 3:19 PM (GMT -5)
The patient and physician focus on fighting cancer. The side effect of ED is not in focus.

However, if you would start early practicing with sildenafil and a vacuum pump, more patients will regain potency than is the case today.

The problem is if the erectile tissue is not being used, it turns to collagen – a scar. This is a permanent structural damage. Also the erectile muscle will degenerate if not used. So even if the nerves recover at some point in time the damage to the erectile tissue may already have occured.

A penile implant including surgery adds up to about $ 25,000. You should discuss this with your wife. I read a post in a different forum that the partner refused to have sex with the patient after the penile implant was put in.

George
Posted 9/18/2016 3:59 PM (GMT -5)
My experience may not be typical, my case sure is not.

Radiation has given me essentially zero side effects 3 years out. I had one brief bout of urinary bleeding, but it hasn't recurred. HT was no fun, but it was intended to help the radiation do its job.

I have usable sexual functionality, and it keeps improving since I got off of HT. I have no trouble whatsoever with incontinence. No bowel issues at all. Other than persistent hot flashes, and some ongoing fatigue, both of which I attribute to 3 years of HT, I really have no issues from the treatment at all.

As opposed to my initial discussion with my urologist back then, when he said he would do surgery for me, but it would have to be a "very wide excision" with no "luxury things" like nerve sparing. His whole proposal sounded like significant incontinence risk, and guaranteed permanent ED. Oh, and not likely curative. So, no, I didn't choose surgery.

My radiation choice has proven to be very successful regarding any side effects or complications from it. Whether it proves to provide durable remission remains to be seen, but it was quite unlikely that surgery would have done so for me. And the quality of life I'm enjoying right now certainly would not have been possible with the surgery choice with which I was presented.

Just my personal experience, worth no more nor less than that.
Posted 9/18/2016 5:51 PM (GMT -5)

Dreamerboy said...
I would take any such data with a grain of salt as I've seen other studies with very different results.

Dreamerboy, perhaps you would be kind enough to share these differing studies especially if they are recent. Most of the recent studies that have been posted here on HW are supportive of the study that Allen shared. In fact you can go back to the QOL study published in the NEJM in 2008 that showed a considerable advantage to radiation over surgery when it came to less onerous side effects. This has been validated over and over again since then...

Jim
Posted 9/18/2016 6:55 PM (GMT -5)
This trials comes with data that debunks the myths that TA refers to but it also comes with concerns about AS.

I don't think that it is possible to ignore what it says about AS while listening to what it says about radiation vs surgery side effects.

Radiation, surgery and AS standards have changed since this trial started. This trial is valuable because it is randomised but clearly it's outcomes can be used to support a variety of positions.

An
Posted 9/18/2016 7:16 PM (GMT -5)
21% potency is hogwash period...I'll give y'all one thing when the deliverer comes y'all goose step sharply... Escape from Freedom...
Posted 9/18/2016 7:42 PM (GMT -5)
An -

I suppose you are talking about their other oncological analysis discussed in the link below. There is a section on AS you might find interesting.

The first randomized clinical trial comparing active surveillance, surgery and external beam radiation tells us little :-(


If you are talking about toxicity concerns for AS, remember that the AS cohort here includes men who were treated (some within the first 6 months), primarily with surgery. They promise a purified analysis of the data eventually
Posted 9/18/2016 8:10 PM (GMT -5)

Tudpock18 said...

Dreamerboy said...
I would take any such data with a grain of salt as I've seen other studies with very different results.

Dreamerboy, perhaps you would be kind enough to share these differing studies especially if they are recent. Most of the recent studies that have been posted here on HW are supportive of the study that Allen shared. In fact you can go back to the QOL study published in the NEJM in 2008 that showed a considerable advantage to radiation over surgery when it came to less onerous side effects. This has been validated over and over again since then...

Jim

I had a pamphlet comparing the side-effects but I was just digging through my stuff and couldn't find it. But here is one such study, although admittedly, like many of these studies, it may be somewhat biased.

www.itnonline.com/article/new-study-shows-prostate-cancer-surgery-has-fewer-side-effects-radiation

The robotic technology is becoming more advanced every year and the image that the surgeon sees can be magnified to many multiples and the sensitivity of the surgery tools can be adjusted so a hand movement only moves the instrument fractions of a millimeter.

I do know that in my prostate cancer group, radiation burns or irritation to the bladder seem somewhat common. In fact, that was one of my main reasons for choosing surgery - I already had a urinary frequency problem before surgery and given that, even the radiologist recommended surgery as the best option.

I'm not saying that other factors may not make radiation the best option for others. Basically what I'm saying is depending on your condition, physiology and personal preferences one or the other may be the best option.
Posted 9/18/2016 8:35 PM (GMT -5)
Individual experiences reported on health forums are useful in several ways, but randomized studies with hundreds of patients in each group trump those individual reports.
PS: I am trying to say in simple words what Tall Allen wrote earlier in this thread.
Posted 9/18/2016 8:41 PM (GMT -5)
Dreamerboy - one critically important factor to avoid bladder issues is the practice of having it comfortably full at the planning CT session, and then that full every time during the treatments. This puts it out of the treatment field as best as possible. Along with the alignment fiducials for my IGRT, this gave the best possibility of safely administering 79.2 Gy.

I've talked to other radiation recipients, and find quite a variety of knowledge and opinion about that. No big deal according to some. More or less useful according to some. Very important according to some. I read Purgatory's disastrous outcome from radiation with an empty bladder, and I was highly motivated to avoid that. The full bladder at treatment time was the most uncomfortable aspect of my RT sessions.

Of course that isn't the reason for all folks who may have problems from RT, but it is a known factor that can help. I practiced for about two weeks before my RT started to get the timing right.

Same thing with empty rectum. I scrupulously followed the diet guidelines and, well, trained my system to get elimination on a predictable schedule daily about 2 hours before my appointment.
Posted 9/18/2016 8:45 PM (GMT -5)
That's a perfect illustration why we should never rely on information from random sites on the net. When I write an article, I provide links to peer-reviewed professional journals. I'd be thrilled if patients checked the sources.

The ProtecT trial was published in the New England Journal of Medicine, arguably the most prestigious professional journal in the world. It was peer-reviewed by some of the top urologists and radiation oncologists in the world. This study was in planning for 7 years before it began recruiting. It was executed with attention to detail. about 50 or so (I didn't count) researchers from various fields and places collaborated on planning, monitoring, and analyzing the data. Following up on this large a group of men for 10 years is a formidable undertaking, requiring substantial resources. It was conducted at 9 institutions around the UK. It would be hard to find a higher quality long-term study anywhere. And I doubt we will ever see its like again, especially not in the US.

As Tony Crispino rightly points out, data analyses (Level 2 evidence) may turn out to be wrong and is suitable for hypothesis generation until such time (if ever) that we get higher quality data. But Level 1 evidence like this is seldom wrong (although people may draw erroneous iinferences from even the highest quality data).
Posted 9/18/2016 8:59 PM (GMT -5)

Sr Sailor said...
Individual experiences reported on health forums are useful in several ways, but randomized studies with hundreds of patients in each group trump those individual reports.
PS: I am trying to say in simple words what Tall Allen wrote earlier in this thread.

I agree. But as I said there are different studies showing different results. And we are dealing with a variety of variables - age of the patient, health of the patient, patient's weight, existing conditions, aggressiveness of the cancer, improving technology in regards to both surgery and radiation. My opinion is that surgery is best for some patients and radiology is better for others. Not an easy choice for a person to make.
Posted 9/19/2016 6:09 AM (GMT -5)
As they further churn the data, it will be even more interesting to see what they turn up. For example, they have the data to look at actual outcomes for the various treatments, and to break it down further for variables like age, initial staging, etc.

An extremely valuable study, flaws and all.
Posted 9/19/2016 7:29 AM (GMT -5)
Allen -

I can't logically accept the RP 46% incontinence percentage at the 6 month time point, based upon what I have seen on this site, books I have read, and other sites.

I believe there may be questionnaire risk involved?

You may tell me again that I can't base my doubt of trial results on my own experiences, but that's what I am doing!! :)

The other incontinence time points more reasonable.

Bobby Mac
Posted 9/19/2016 8:42 AM (GMT -5)
Allen said " I think as empowered patients, we are much better off when we don't chuck out data that does not conform to our biases. That's called "confirmation bias," and is a huge source of cognitive error."

True, but as a practical matter such data has no real value to a man who has had differing results. "Cognitive error"? Probably but the cognition on the part of the patient is already different so it in itself is a kind of "error".
If we are talking about simply discussing different treatments as google doctors or advocates for other PCa patients the studies do have some value in terms of course of action, but if the horse has left the barn it's hard to look at the studies objectively if you've had differing results.
Posted 9/19/2016 9:09 AM (GMT -5)
all the replies seem pretty logical ...what more can be said on this ??? we NEED the large controlled group stats....and the individual stats.....they are ALL so important for us to make our decisions.........David
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