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Just wondered...

User
Posted 20 Dec 2019 at 23:51

So I'm Gleason 8 (4+4), T3aN? (see other posts).  In short I'm now faced with the choice between surgery and RT that most (ie those without APC) here face.  Just purely by casual observation of the posts here it seems to me (and I may be wrong) that most go for surgery.  Am I right?  I can certainly understand if that is the case because that was my immediate reaction.  Get rid of it, no prostate = no prostate cancer, right?  Just wondered if there were any stats showing the balance in terms of choice made between the two options.  How many men go for one over the other.  Personally my surgical team and my oncologist confirm the info in the toolkit - i.e. both equally successful.  Was just curious.

User
Posted 21 Dec 2019 at 02:17
Generally speaking, if all things are equal (T1 or T2 N0 M0) the younger men go for surgery and older men go for RT. As soon as you get into the realms of T3 or N?M? it is dictated more by the approach of the surgeons in that region - if they don't believe they can get it all out, most will be reluctant to put the man through the side effects for possibly no gain. There are a small number of surgeons now who are more minded to remove the prostate knowing that adjuvant RT will be needed but many men would be reluctant to go through two treatments if RT alone is likely to have a better outcome than surgery alone.

What you see on this forum is not necessarily a reliable indicator. The men / families who post most frequently tend to be those who either had RP that failed, or are struggling with the side effects of RP, or have advanced disease, need chemo, etc. There are many who join us for a while, have a successful op & quietly stop posting because they don't need the support OR join us, have successful RT or brachy and quietly stop posting for the same reason. Not everyone who posts has problems but there is a definite bias.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 21 Dec 2019 at 02:21

"Get rid of it, no prostate = no prostate cancer......"


Not necessarily the case unfortunately.  Sometimes when surgery is done cancer is revealed beyond where surgery can go.  There is also the possibility that some micro cancer cells may have escaped the Prostate.  RT can be directed at a wider area but no guarantee there either.  If required RT can usually be given after surgery but is much more difficult after RT and few surgeons will do it. (The operation is an intricate one and operating on a Prostate damaged by radiation makes it even more difficult).  Side effects have to be considered too and having both of these forms of treatment can increase the degree and extent of combining these two forms of treatment.   Younger men tend to have surgery whereas order men more often have RT.  There are several reasons for this but perhaps the main one is that many years on there is a small risk that RT can initiate a further cancer and a younger person would normally have more years for this to be a risk.


You could ask whether if you have surgery you will also be given RT or whether this is a strong possibility in your case.


HT is usually started prior to RT and may continue for anything up to 3 years thereafter.  You should also consider the possible side effects of HT which could affect your treatment decision.  (Potential side effects are detailed in the Tool Kit).

Barry
User
Posted 21 Dec 2019 at 12:22
In many cases there's a clear recommendation for one treatment over the other, of course. A youngish man with clearly localised PCa will probably be recommended to have surgery. In my own case, both my urologist and oncologist recommended RT/HT, so that's what I opted for.

Cheers,

Chris


User
Posted 21 Dec 2019 at 14:09

There's a research paper I read (but don't seem to have saved) that looks at success of prostatectomies (in terms of length of time before biochemical recurrence) verses diagnosis before treatment. They used the three high risk ratings as the markers to check against, i.e.


Presenting PSA >= 20;


Gleason >= 8;


T3 or above.


Basically, your chance of biochemical recurrence is quite low if you are not high risk in any of these 3 catagories, but increases if 1 or 2 of these apply, and if I recall correctly is around 50% if all 3 apply.


Of course, these are general stats, and there may be reasons why they don't apply to you. It's good to put the assumptions you are making to your consultants, so they can tell you if any are invalid, of if there's something about your case which means you should be considering other factors.


Of course, what risk you chose to accept is up to you, but I would suggest that most people would probably not go through a prostatectomy if they thought it had only a 50% chance of success, and failure meant having to do RT and HT too. The probability of things like ED and urinary incontinence if you have both radical procedures is very significantly higher than with just either one alone.

Edited by member 21 Dec 2019 at 14:12  | Reason: Not specified

User
Posted 21 Dec 2019 at 14:44

The Memorial Sloan Kettering nomograms are really useful as long as you keep in mind that outcomes tend to be slightly worse in the UK than in New York, and that outcomes in some regions of the UK are worse than others. Many NHS hospitals have developed their own nomograms based on local data and it may be that your MDT used these to make the recommendation that you are best going for RT/HT.


My husband was 50 at diagnosis, with a PSA of 3.1, G7(3+4) T1a N0Mx and no discernible tumour on his scans. However, the urologist predicted a 55% chance of recurrence based on the Leeds version of the MSK nomogram and he was right - it was upgraded to T3 and had spread to his bladder. J needed salvage RT 2 years post-op.

Edited by member 21 Dec 2019 at 14:46  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 21 Dec 2019 at 14:56

I've often wondered about this apparent bias in favour of surgery myself Bean121 because it is quite noticeable on these forums. You could be forgiven for thinking that RT and/or brachytherapy were only undertaken by a minority. I think Lyn's first response to this thread almost certainly nails it. Given that younger men have a tendency to opt for surgery and might be a bit more comfortable with on-line forums that could be another explanation for the apparent greater number of posts relating to surgery.

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User
Posted 21 Dec 2019 at 02:17
Generally speaking, if all things are equal (T1 or T2 N0 M0) the younger men go for surgery and older men go for RT. As soon as you get into the realms of T3 or N?M? it is dictated more by the approach of the surgeons in that region - if they don't believe they can get it all out, most will be reluctant to put the man through the side effects for possibly no gain. There are a small number of surgeons now who are more minded to remove the prostate knowing that adjuvant RT will be needed but many men would be reluctant to go through two treatments if RT alone is likely to have a better outcome than surgery alone.

What you see on this forum is not necessarily a reliable indicator. The men / families who post most frequently tend to be those who either had RP that failed, or are struggling with the side effects of RP, or have advanced disease, need chemo, etc. There are many who join us for a while, have a successful op & quietly stop posting because they don't need the support OR join us, have successful RT or brachy and quietly stop posting for the same reason. Not everyone who posts has problems but there is a definite bias.
"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 21 Dec 2019 at 02:21

"Get rid of it, no prostate = no prostate cancer......"


Not necessarily the case unfortunately.  Sometimes when surgery is done cancer is revealed beyond where surgery can go.  There is also the possibility that some micro cancer cells may have escaped the Prostate.  RT can be directed at a wider area but no guarantee there either.  If required RT can usually be given after surgery but is much more difficult after RT and few surgeons will do it. (The operation is an intricate one and operating on a Prostate damaged by radiation makes it even more difficult).  Side effects have to be considered too and having both of these forms of treatment can increase the degree and extent of combining these two forms of treatment.   Younger men tend to have surgery whereas order men more often have RT.  There are several reasons for this but perhaps the main one is that many years on there is a small risk that RT can initiate a further cancer and a younger person would normally have more years for this to be a risk.


You could ask whether if you have surgery you will also be given RT or whether this is a strong possibility in your case.


HT is usually started prior to RT and may continue for anything up to 3 years thereafter.  You should also consider the possible side effects of HT which could affect your treatment decision.  (Potential side effects are detailed in the Tool Kit).

Barry
User
Posted 21 Dec 2019 at 12:22
In many cases there's a clear recommendation for one treatment over the other, of course. A youngish man with clearly localised PCa will probably be recommended to have surgery. In my own case, both my urologist and oncologist recommended RT/HT, so that's what I opted for.

Cheers,

Chris


User
Posted 21 Dec 2019 at 14:09

There's a research paper I read (but don't seem to have saved) that looks at success of prostatectomies (in terms of length of time before biochemical recurrence) verses diagnosis before treatment. They used the three high risk ratings as the markers to check against, i.e.


Presenting PSA >= 20;


Gleason >= 8;


T3 or above.


Basically, your chance of biochemical recurrence is quite low if you are not high risk in any of these 3 catagories, but increases if 1 or 2 of these apply, and if I recall correctly is around 50% if all 3 apply.


Of course, these are general stats, and there may be reasons why they don't apply to you. It's good to put the assumptions you are making to your consultants, so they can tell you if any are invalid, of if there's something about your case which means you should be considering other factors.


Of course, what risk you chose to accept is up to you, but I would suggest that most people would probably not go through a prostatectomy if they thought it had only a 50% chance of success, and failure meant having to do RT and HT too. The probability of things like ED and urinary incontinence if you have both radical procedures is very significantly higher than with just either one alone.

Edited by member 21 Dec 2019 at 14:12  | Reason: Not specified

User
Posted 21 Dec 2019 at 14:44

The Memorial Sloan Kettering nomograms are really useful as long as you keep in mind that outcomes tend to be slightly worse in the UK than in New York, and that outcomes in some regions of the UK are worse than others. Many NHS hospitals have developed their own nomograms based on local data and it may be that your MDT used these to make the recommendation that you are best going for RT/HT.


My husband was 50 at diagnosis, with a PSA of 3.1, G7(3+4) T1a N0Mx and no discernible tumour on his scans. However, the urologist predicted a 55% chance of recurrence based on the Leeds version of the MSK nomogram and he was right - it was upgraded to T3 and had spread to his bladder. J needed salvage RT 2 years post-op.

Edited by member 21 Dec 2019 at 14:46  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard
User
Posted 21 Dec 2019 at 14:56

I've often wondered about this apparent bias in favour of surgery myself Bean121 because it is quite noticeable on these forums. You could be forgiven for thinking that RT and/or brachytherapy were only undertaken by a minority. I think Lyn's first response to this thread almost certainly nails it. Given that younger men have a tendency to opt for surgery and might be a bit more comfortable with on-line forums that could be another explanation for the apparent greater number of posts relating to surgery.

 
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