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Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Surviving Prostate Cancer: Good News for Radical Prostatectomy Patients

So you had radical prostatectomy and things have been going pretty well. You feel good, and your PSA remains undetectable. It's been several years now; are you out of the woods?

"Overall, men are highly unlikely to die from prostate cancer after surgery — even men with high-risk prostate cancer. If you do not experience recurrence for several years, your likelihood of survival for 10 more years is outstanding."

"After radical prostatectomy, about a third of men experience a return of PSA," says urologist Misop Han, M.D. the David Hall McConnell Professor in Urology. "However, only a very small number of men who have had surgery ultimately die from prostate cancer. So, men contemplating surgery or those who have already had surgery may wonder, What is my chance of surviving from prostate cancer if I have not had PSA recurrence for several years after surgery?"

Han and Brady epidemiologist Bruce Trock, Ph.D., recently set out to answer that question, using the Brady's massive database to track results from more than 14,000 men who had surgery at Johns Hopkins between 1984 and 2013. They divided men into three risk groups: low, intermediate, and high. Then they calculated what they call the Conditional Survival probability — the likelihood of survival for 10 additional years.

They found that men in the low- and intermediate-risk groups had a very high probability — at least 96 percent — of not dying from a return of prostate cancer at 10 years, "regardless of the time duration without recurrence," says Han. "In other words, these men are highly unlikely to die from prostate cancer, regardless of whether they experience recurrence or not." In the high-risk men, the probability of survival from prostate cancer at 10 years was 91 percent for those who experienced recurrence within one year. "However, if these high-risk men do not have recurrence for more than three years, their probability of survival from prostate cancer for 10 additional years is even higher — greater than than 99 percent.

"These results give much hope for men with prostate cancer," said Han. "Overall, men are highly unlikely to die from prostate cancer after surgery — even men with high-risk prostate cancer. If you do not experience recurrence for several years, your likelihood of survival for 10 more years is outstanding."

Re: Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Men considering a Radical Prostatectomy should read the results of the PIVOT trial.http://www.nejm.org/doi/full/10.1056/NEJMoa1113162

The conclusion from this trial is:

Among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up. Absolute differences were less than 3 percentage points. (Funded by the Department of Veterans Affairs Cooperative Studies Program and others.

Fred

Re: Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Fred-

Thank you for the information.

Digging deeper into the study numbers it suggests that while the total dying from prostate cancer is only 2.68% higher by waiting as opposed to operating. However, intermediate and high risk patients do much better having a prostatectomy than observation.

The risks of dying from prostate cancer have been calculated by me in the table below. Personally, I believe being in the high risk Gleason 8 category, I would want to be one of the 8, or so, patients out of a 100 that did not succumb to the disease.

Of course, if I were low risk I would take the observation route.

RISK OF DYING FROM PROSTATE CANCER - AS PER THE ABOVE STUDY
Risk Gleason
low int high Under 7 7 or above

OPERATE 5.77% 4.05% 4.65% 9.09% 4.33% 10.20%


WATCH 8.45% 2.70% 10.83% 17.50% 5.75% 17.44%
2.68% -1.35% 6.18% 8.41% 1.42% 7.24%

Sorry - the table became jumbled when I posted it -

In short - intermediate risk and high risk, 6% and 8.5% respectfully, better having surgery than watching. Gleason 7 or higher 7% better having surgery than observation.

Bobby Mac

Re: Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Hi Fred -

I did more research on the PIVOT Study - Just for full disclosure to someone relying on the study - please see below -


A PUBLICATION OF THE PATRICK C. WALSH PROSTATE CANCER RESEARCH FUND

Volume 9, Winter 2013


The PIVOT Study: No "Game-Changer”
Flawed Study Results in Misleading Advice for Men Considering Surgery



The PIVOT Study (Prostate Cancer Intervention Versus Observation Trial), whose results were recently published in the New England Journal of Medicine, began in 1994, early in the PSA era. It was originally designed to be a large study involving 2,000 men who were randomly assigned either to radical prostatectomy or observation. The study itself was severely flawed. For one thing, it was statistically underpowered; the scientists recruited only 731 men, instead of the 2,000. (An editorial that accompanied this article stated that it would require 1,200 patients to fulfill the statistical goal that the study's authors reported.) Also, although the study was designed to include only men with a life expectancy of at least 10 years, at the end of the study half of the participants had died of causes other than cancer, leaving only 171 men in the surgery group and 183 men in the observation group available for analysis at 10 years.



The men in this study were so sick
that 15 percent couldn't walk, and
within 10 years, half of them had died
of causes other than cancer.


But even worse was the fact that in onehalf of the men, cancer extended outside the prostate, making it difficult to cure. And, although the authors deny it, the follow-up of 10 to 12 years was far too short to be conclusive in making recommendations for men with low risk disease.

And yet, much of the news media took this story at face value. For example, the New York Times reported: "A new study shows that prostate cancer surgery, which often leaves men impotent or incontinent, does not appear to save the lives of men with early stage disease, who account for most of the cases, and many of these men would do just as well to choose no treatment at all."This study, the newspaper added, was "game-changing.”

If you have already undergone surgery, you might well have wondered, "what have I done?"Unfortunately, many young men with aggressive, curable disease will only remember this sound bite. Is this true? Sadly, no.

Does this Apply to My Cancer, and My Potential to Benefit from Treatment?
The study was carried out at Veterans Administration centers, where the surgery is often performed by inexperienced residents. The average age of the men in this study was 67; only 10 percent of the men were younger than 60. Today, cancer is diagnosed sooner than it was then, and the great majority of men at diagnosis have no symptoms and curable disease. The men in this study were so sick that 15 percent couldn't walk, and within 10 years, half of them had died of causes other than cancer.

The study's authors concluded that "among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate cancer mortality, as compared with observation."This study is a straw man; its authors wanted to mislead readers by suggesting that their findings apply to all men with prostate cancer – when in fact, their results only apply to men who are older or in poor health, and this finding is far from newsworthy. For three decades, we have said that men who have a life expectancy of 10 years or less should not undergo surgery.

The study's authors never conceded that their observations should not be applied to younger men. But an ever-growing volume of evidence shows that in men with low-volume cancer, progression continues for many years. For example, in a study from Sweden of men with very small cancers who were treated with observation alone, death rates from prostate cancer remained very low (15 per 100,000 persons) for the first 15 years – but beyond that point, they skyrocketed (to 44 per 100,000 persons), and nearly all these men eventually died from prostate cancer. The PIVOT authors did not admit this likelihood in their study. Because only 26 men who underwent surgery and 36 men in the observation group were alive at 14 years, this study will never have follow-up long enough to answer this question. With all of these shortcomings, it is surprising that they were able to demonstrate some significant benefits of surgery: There was an overall 60 percent decrease in the risk of metastases and a reduction in prostate cancer deaths in men who had a PSA greater than 10 ng/ml or who were in the high-risk category who underwent surgery.



All the PIVOT study tells us is
that for a man who has a life
expectancy of 10 years or less
and who has low-volume disease,
surgery is not an option.
This is old news.


All the PIVOT study tells us is that for a man who has a life expectancy of 10 years or less and who has low-volume disease, surgery is not an ideal option. This is old news, and is far from being a "game-changer."The information in this article is simply not good enough to be of help to an otherwise healthy man in his forties, fifties, or early sixties trying to figure out what he should do.

The Bottom Line

The PIVOT study provides no useful information for an otherwise healthy man in his forties, fifties, or early sixties who is contemplating whether he should undergo surgical therapy.

Bobby Mac

Re: Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Bobby,

I don't disagree with your criticism of this trial, however the average age of men diagnosed with PC is around 65. There is a real problem with over treatment with this disease. Only 10% of men that qualify for AS actually choose it. With the improvement in MP-MRI and fusion biopsy a man can safely choose this option and not worry that a more significant tumor was missed by the biopsy. UCSF has had an AS program for over 10 years and has not had 1 death in this group.

I just want men to understand that they can safely choose AS and avoid the nasty side effects associated with surgey/radiation.

Fred

Re: Good News for Radical Prostatectomy Patients - Johns Hopkins Article

Hi Fred. I don't think there are any PC victims who haven't wondered "what if" as to whether they should treat or just watch - and hope. Who hasn't wondered if they had just left things alone if their life might have been normal and unstressed by the devastating effects of treatment? It is difficult to feel certain of any decision one makes in this arena. There are very few consistencies to go by. One is always weighing the unknowns of the disease (which might kill you - or not) against the known facts of treatment which are almost always on the negative side. I too have wondered if I might have been better off not even knowing of the presence of the disease and yet I have seen what the disease does to you when it is allowed to kill you. Early detection and treatment seems to hold the best chance of beating the disease but early treatment also means you have more years of enduring treatment side effects, and still you never know if it was worth it. What a mess huh! Jon.

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