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ART paper - interesting information

User
Posted 17 Mar 2019 at 16:21

Hi


Paper regarding ART with high risk patients. Long term / old but encouraging that ART makes things much better.


http://ascopubs.org/doi/full/10.1200/JCO.2006.09.6495?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed


Highlights:


Failure is more often localised rather than distant, which is encouraging.


ART appears to have really good impact on outcomes (adjuvant HT not included in this as study started a long time ago) - I suspect HT will make it even better


Immediate post RP PSA levels play a major part <0.2 best, > 2.0 worst. Correlation with Gleason as well. No reference to PSADT.


What I find annoying is that SRT outcomes are truly rubbish in comparison to ART (sort of "why bother" levels). Should we not press for ART in all cases if SRT is so crap? If someone can read this and see if I have that wrong I would be grateful.


PP

User
Posted 17 Mar 2019 at 19:49
Practice has changed a lot in recent years, partly due to research like this. Adjuvant RT is offered much more widely than it used to be, for cases of positive margins, first post-op PSA of more than 0.1 or significant Gleason upgrade and when we 9ccasionally get a member here posting that their pathology / first PSA wasn’t great but the uro advised a wait & see approach, you will note a number of us virtually screaming ‘get a referral to an onco ... don’t wait”. Research like this one also influenced the trial that outer hospital was involved in where all men were offered ART regardless of their pathology.

The reasons that we still have SRT are:-
- for some men the post op pathology is great and the need for further treatment only emerges months or years down the line
- some men would prefer to wait and see if they actually need further treatment
- some urologists might delay referral for further treatment because it affects their reportable outcomes
- some men would rather recover from the side effects of surgery before risking any new side effects
- I don’t know for sure but perhaps some CCGs might prefer to only pay for follow up RT where it is demonstrably necessary?
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 17 Mar 2019 at 21:50

PP


I had a poor histology and remember having a conversation with my consultant about ART when it was raised on this site about three years ago. His answer was that if all men were given ART post surgery many would be over treated, if no one was given ART many would be under treated. As Lyn says practice has changed. 


Thanks Chris

User
Posted 18 Mar 2019 at 00:59

Originally Posted by: Online Community Member


What I find annoying is that SRT outcomes are truly rubbish in comparison to ART (sort of "why bother" levels). Should we not press for ART in all cases if SRT is so crap? If someone can read this and see if I have that wrong I would be grateful.


PP



Don't know where you are getting your SRT figures from? The MSK Nomogram says better than 70% chance of remission after 6 years for SRT with your figures. Is that not good?


If all cases of RP received ART more than 50% of the patients would be overtreated. 


 

User
Posted 18 Mar 2019 at 07:37
It's worth noting that RT is not risk free. For many men the damage caused by the radiation will outweigh its benefits.

Chris
User
Posted 18 Mar 2019 at 08:47

Originally Posted by: Online Community Member


Originally Posted by: Online Community Member


What I find annoying is that SRT outcomes are truly rubbish in comparison to ART (sort of "why bother" levels). Should we not press for ART in all cases if SRT is so crap? If someone can read this and see if I have that wrong I would be grateful.


PP



Don't know where you are getting your SRT figures from? The MSK Nomogram says better than 70% chance of remission after 6 years for SRT with your figures. Is that not good?



He is getting the figures from the research that he has shared above :-/ 


 

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 18 Mar 2019 at 11:33

@Chris * 2 - yes, on reflection, I think that is the issue particularly as I was not recorded as being high risk, I assume over treatment was more of an issue than BCR risk


@Francij / Lynn - yes, the information was from the paper. Re-reading it and thinking about it, I think these numbers were from people on the dummy arm of the trial who later received SRT due to BCR but (and this is the difference) they were classed as high risk so it does seem logical after thought that ART would work better than SRT. I ran the MSK nomogram and got 74% with my numbers. Better than a lot of folk!


What was interesting was that they seemed to emphasise that there was far more prevalence of localised rather than distant spread which as with the trial Lynn mentioned gives possibilities for abroader range of earlier more aggressive treatment.


 


Also interesting that MSK are very conservative in their phrasing talking about controlling / undetectable rather than cure.



EDIT - I ran the progression free likelihood nomogram but I did not run the 5/10/15 chance of death one. Does that make me a wuss?

Edited by member 18 Mar 2019 at 13:28  | Reason: Not specified

User
Posted 18 Mar 2019 at 14:58
Yes it makes you a wuss!
User
Posted 18 Mar 2019 at 15:27

I'd cry if I thought you were serious tongue-out


Joking aside, I feel really uncomfortable doing this check and my onco never did it. It is funny how we would rather be ignorant of the worst case sometimes.

Edited by member 18 Mar 2019 at 17:25  | Reason: Not specified

User
Posted 19 Mar 2019 at 11:08
I eventually put the numbers in - could be worse. Could be a lot better - 5 / 18 / 34 :(
User
Posted 19 Mar 2019 at 23:39

Presumably there are historic cases that would indicate the no treatment people so only the new treatment method needed testing.  Can't say I'm over impressed by this type of testing, especially if I was selected to have the worst treatment.

 
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