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Updated Nomogram for helping with SRT decision

User
Posted 19 Jun 2018 at 08:04

Useful update of the MKS Nomogram for post RP patients with a persistent PSA who are trying to decide when or if they should have Salvage Radio Therapy:


http://riskcalc.org/ProstateCancerAfterRadicalProstatectomyNew/


 

Edited by member 19 Jun 2018 at 23:43  | Reason: Not specified

User
Posted 19 Jun 2018 at 15:31

Originally Posted by: Online Community Member
Sorry to be flippant, but that’s just me.

Sometimes I wonder if I might get a more accurate prognosis from Gypsy Rose-Lee on the end of Blackpool Pier!


This is the nomogram you need at your stage but you will need to wait for your final pathology to stand a chance of a better prediction than gypsy rose:


https://www.mskcc.org/nomograms/prostate/post_op


πŸ˜†πŸ˜†

User
Posted 19 Jun 2018 at 22:45

You are not being thick at all. Those two individual men may end up with exactly the same outcome but when you take the wider population, British men don't do as well as they should.


In general:
- Americans tend to have a family MD who has known them for many years, and knows the familial history so is more likely to be on the ball re small changes in the man's health
- Many Americans have private health cover which includes annual check ups so small PSA rises are noticed & closely monitored
- Apparently, American men are much more interested in their inner workings than British men and less likely to put off seeing the doctor
- all of this means that American men tend to be diagnosed earlier than ours, and rates of advanced PCa diagnosis are much lower
- Americans are more likely to have open RP which has slightly lower rates of positive margins and salvage treatment is less often needed
- Americans are slightly more likely to have RP followed by adjuvant RT regardless of pathology; this is still a trial approach in England (although it makes sense since that is a common approach to breast cancer, obviously the side effects are more likely to put off a man than a woman)


So basically, those two men may appear to be in exactly the same situation but the data suggests that they probably aren't - that the English man is more likely to have a higher grade than expected, or more cancer than expected, or to have a recurrence. 


It is more interesting when you look at the adjustments for different parts of England. The regions where men are less likely to have a good outcome are more or less the same regions that have higher incidence of heart disease, obesity, diabetes, etc so outcomes are assumed to be linked to the same issues - poor diet, poor general health, poverty, reluctance to go to the GP, poor educational outcomes, lack of awareness of how your body works, and so on.


I don't think there is any data but I would guess that lack of confidence in challenging professionals / working class dis-empowerment may also affect outcomes. I would also guess that if you took out the middle-class and insurance-paying American population, the stats would show that poor Americans have much worse outcomes than any groups of British men. But that is only a guess.

Edited by member 19 Jun 2018 at 22:48  | Reason: typo

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 19 Jun 2018 at 23:48

Originally Posted by: Online Community Member


I am probably being very thick here but what I don't understand is ... if  a  Brits  pre op stats are exactly the same as an Americans and given they both have the same op ( usually robotic these days) done by an equally skilled surgeon. Following the op if all the margins etc are negative in both why should the American have a better chance of no recurrence?


 


I put this to my husband's Urologist as I had read on the Cancer Research UK site the chance of recurrence following prostatectomy is 1 in 3. He admitted this is correct but couldn't explain the difference.


Regards


Ann



I believe Anne and Lyn are both correct, given equal circumstance statistically outcomes will be the same. The USA has (until recently) routinely screened for PSA and this has lead to a lot of over treatment. So outcomes in the UK are worse because men are generally not identified until symtomatic which with PCA means advanced.


This nomogram however relates to specific values so give or take a few percent will be comparable because the methods, values for BCR , SRT procedure are thd same here and in the USA.


 

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User
Posted 19 Jun 2018 at 12:41

Thanks for adding this link.  It's great timing for me.


I finished salvage radiotherapy four days ago.  It took a lot of persuading, but my oncologist eventually agreed to put me on six months of bicalutimide as well.  Two months prior to starting salvage radiotherapy, two months whilst receiving SRT and now two months post SRT.


This nomogram says I have a 67% chance of no recurrence if I am on hormone therapy but only a 48% chance with SRT alone.


How long can I stay on bicalutimide for?  Apart from tiredness, I've tolerated it fine.  I want to ask my oncologist if I can stay on it for three years.  Any advice anyone has on this would be gratefully received.


My oncologist isn't a great fan of nomograms as she says they pay too much attention to the older data.  This seems to be an updated nomogram.  Is it?


Ulsterman

User
Posted 19 Jun 2018 at 15:13

the forum thread it came from is here:


https://www.cancerforums.net/threads/55295-Timing-of-SRT-increasing-evidence-for-starting-at-lower-PSA-values


Re nomograms they all usually say "outlook will have improved with current treatment".


I ran my figures through it with assumptions that I will hit .030 or above and for me it was very little difference waiting until 0.1 or starting at 0.03 or intrestingly adding Hormones, but this ties in with the other studies quoted on the thread and was reassuring for my current position (do nothing and wait for a year). the general gist is higher risk whack it with everything and do it early, lower risk wait and see but don' hang about once it gets to 0.1.

User
Posted 19 Jun 2018 at 15:17
Sorry to be flippant, but that’s just me.

Sometimes I wonder if I might get a more accurate prognosis from Gypsy Rose-Lee on the end of Blackpool Pier!
User
Posted 19 Jun 2018 at 15:31

Originally Posted by: Online Community Member
Sorry to be flippant, but that’s just me.

Sometimes I wonder if I might get a more accurate prognosis from Gypsy Rose-Lee on the end of Blackpool Pier!


This is the nomogram you need at your stage but you will need to wait for your final pathology to stand a chance of a better prediction than gypsy rose:


https://www.mskcc.org/nomograms/prostate/post_op


πŸ˜†πŸ˜†

User
Posted 19 Jun 2018 at 17:05
The thing to remember about the MSK nomograms is that most UK hospitals that use the nomograms make their own adjustments as British men tend to have worse outcomes than those in America generally and NY particularly, and men in West Yorks do worse than men in Surrey, etc, etc.

John had PSA 3.1 / G3+4 and a small benign prostate with clear MRI scan. The nomogram at St James' predicted a 55% chance of needing SRT within 5 years, which we first thought must be a typo but turned out to be reliable.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 19 Jun 2018 at 20:06

So, we need to develop a British nomogram for Ulstermen raised in Belfast and now living in Berkshire being treated by an NHS hospital in Slough!


Jonathan - very grateful to you for posting the whole thread.  It makes interesting reading.  Upon reading it, I'm very glad I fought for a combination of salvage radiotherapy and hormone therapy.


I've decided to continue the fight and will ask my oncologist to let me stay on bicalutimide a while longer.


Looking forward to seeing fellow members on Saturday at the Mill.


Ulsterman

User
Posted 19 Jun 2018 at 20:43
I'm told Nodal involvement means I can't get a reading? Why is that?
User
Posted 19 Jun 2018 at 20:58

I am probably being very thick here but what I don't understand is ... if  a  Brits  pre op stats are exactly the same as an Americans and given they both have the same op ( usually robotic these days) done by an equally skilled surgeon. Following the op if all the margins etc are negative in both why should the American have a better chance of no recurrence?


 


I put this to my husband's Urologist as I had read on the Cancer Research UK site the chance of recurrence following prostatectomy is 1 in 3. He admitted this is correct but couldn't explain the difference.


Regards


Ann

User
Posted 19 Jun 2018 at 22:45

You are not being thick at all. Those two individual men may end up with exactly the same outcome but when you take the wider population, British men don't do as well as they should.


In general:
- Americans tend to have a family MD who has known them for many years, and knows the familial history so is more likely to be on the ball re small changes in the man's health
- Many Americans have private health cover which includes annual check ups so small PSA rises are noticed & closely monitored
- Apparently, American men are much more interested in their inner workings than British men and less likely to put off seeing the doctor
- all of this means that American men tend to be diagnosed earlier than ours, and rates of advanced PCa diagnosis are much lower
- Americans are more likely to have open RP which has slightly lower rates of positive margins and salvage treatment is less often needed
- Americans are slightly more likely to have RP followed by adjuvant RT regardless of pathology; this is still a trial approach in England (although it makes sense since that is a common approach to breast cancer, obviously the side effects are more likely to put off a man than a woman)


So basically, those two men may appear to be in exactly the same situation but the data suggests that they probably aren't - that the English man is more likely to have a higher grade than expected, or more cancer than expected, or to have a recurrence. 


It is more interesting when you look at the adjustments for different parts of England. The regions where men are less likely to have a good outcome are more or less the same regions that have higher incidence of heart disease, obesity, diabetes, etc so outcomes are assumed to be linked to the same issues - poor diet, poor general health, poverty, reluctance to go to the GP, poor educational outcomes, lack of awareness of how your body works, and so on.


I don't think there is any data but I would guess that lack of confidence in challenging professionals / working class dis-empowerment may also affect outcomes. I would also guess that if you took out the middle-class and insurance-paying American population, the stats would show that poor Americans have much worse outcomes than any groups of British men. But that is only a guess.

Edited by member 19 Jun 2018 at 22:48  | Reason: typo

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 19 Jun 2018 at 23:48

Originally Posted by: Online Community Member


I am probably being very thick here but what I don't understand is ... if  a  Brits  pre op stats are exactly the same as an Americans and given they both have the same op ( usually robotic these days) done by an equally skilled surgeon. Following the op if all the margins etc are negative in both why should the American have a better chance of no recurrence?


 


I put this to my husband's Urologist as I had read on the Cancer Research UK site the chance of recurrence following prostatectomy is 1 in 3. He admitted this is correct but couldn't explain the difference.


Regards


Ann



I believe Anne and Lyn are both correct, given equal circumstance statistically outcomes will be the same. The USA has (until recently) routinely screened for PSA and this has lead to a lot of over treatment. So outcomes in the UK are worse because men are generally not identified until symtomatic which with PCA means advanced.


This nomogram however relates to specific values so give or take a few percent will be comparable because the methods, values for BCR , SRT procedure are thd same here and in the USA.


 

User
Posted 19 Jun 2018 at 23:55

Originally Posted by: Online Community Member
I'm told Nodal involvement means I can't get a reading? Why is that?


Hi Rich it's only applicable to guys who have had a prostatectomy and may then need radiotherapy not radiotherapy as the primary treatment. Salvage RT and Primary RT are different treatments so cannot be directly compared.


I suspect there will be a Radiotherapy nomogram somewhere but I haven' come across one yet..

User
Posted 20 Jun 2018 at 13:41

Had a look at the post op chart, Francij1.


What surprises me is that the chances of surviving 15yrs are so much higher than the chances of a recurrence even after 2 years.  Although it doesn't say how many will have died of other things and there are so many subtle differences between cases that a recurrence could be one of many types.

User
Posted 21 Jun 2018 at 07:20

Thanks Lyn and Jonathan.


I think one of Mark Twain's quotes sums it up. " Facts are stubborn but statistics are more pliable "


 


Best Regards


Ann

 
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