Treatment v do nothing?

[Terry Pinnell]

Here's an extract from a report I've just read by University College
Hospitals, London:

"The difference between surveillance and whole-gland treatment in terms of
reducing cancer-related deaths is very small. The difference in the number
of deaths from prostate cancer at 15 years between watchful waiting (a
type of surveillance) and treating the whole prostate is only 5%."

Does anyone here know if that surprisingly small difference in mortality
is the general consensus of the experts?

I'd assumed that whatever treatment I elect to suffer, with its varying
side effects, was to protect me against a significantly larger risk than
that!

PSA SEP 2010 3.9
PSA SEP 2011 5.7
PSA NOV 2011 6.8
Biopsy JAN 2012 3+4=7, T1c
PSA MAR 2012 7.3
Considered suitable for EBRT (IMRT)
Awaiting assessment for brachytherapy suitability 1stMay
Age now 71, otherwise fit

--
Terry, East Grinstead, UK

[Ed Friedman]

On 04/18/2012 02:04 PM, Terry Pinnell wrote:
> Here's an extract from a report I've just read by University College
> Hospitals, London:
>
> "The difference between surveillance and whole-gland treatment in terms of
> reducing cancer-related deaths is very small. The difference in the number
> of deaths from prostate cancer at 15 years between watchful waiting (a
> type of surveillance) and treating the whole prostate is only 5%."
>
> Does anyone here know if that surprisingly small difference in mortality
> is the general consensus of the experts?
>
> I'd assumed that whatever treatment I elect to suffer, with its varying
> side effects, was to protect me against a significantly larger risk than
> that!
>
> PSA SEP 2010 3.9
> PSA SEP 2011 5.7
> PSA NOV 2011 6.8
> Biopsy JAN 2012 3+4=7, T1c
> PSA MAR 2012 7.3
> Considered suitable for EBRT (IMRT)
> Awaiting assessment for brachytherapy suitability 1stMay
> Age now 71, otherwise fit
>

Terry,

This number is roughly correct
(see: http://www.medscape.com/viewarticle/742146 for surgery and
http://www.medscape.com/viewarticle/750994 for radiation)

However, deaths from prostate cancer are only part of the story. Overall
survival rates for men over 65 years of age whether they choose watchful
waiting or surgery seems to be the same. E.g., 1 in 200 men die within
30 days of having a prostatectomy.

Ed Friedman

[Alan Meyer]

On 04/18/2012 03:04 PM, Terry Pinnell wrote:
....
> "The difference between surveillance and whole-gland treatment in
terms of
> reducing cancer-related deaths is very small. The difference in the
number
> of deaths from prostate cancer at 15 years between watchful waiting (a
> type of surveillance) and treating the whole prostate is only 5%."
....

I think that statistics like the above are close to useless
because the results are so different for different subgroups. I
bet that the majority of men with high gleason score cancers that
go no treatment die of the disease in much less than 15 years.
Men who are older, or in poor health for other reasons, and
especially if they have low gleason score cancers, probably all
die of something else.

Now look at this strange paragraph in the article cited by Ed:

"The study stipulated that men treated with surgery who
progressed should receive hormonal therapy (as opposed to
observed men who progressed — they received surgery)."

It seems to indicate that men in BOTH groups got surgery but the
men in the treatment group got it earlier! If I'm reading that
right it says that this was NOT a study of treatment vs.
non-treatment. It was a study of early treatment vs later
treatment.

It is amazing to me that a study like this should be summarized
(in paragraph two of the article) as:

"The study shows that, at 15 years, the cumulative incidence
of death from prostate cancer was 14.6% among 347 men
randomized to prostatectomy and 20.7% among 348 men BEING
OBSERVED WITHOUT TREATMENT. [emphasis mine - AM]"

My conclusion is that no one should jump into treatment. Each
patient should find the very best specialist that he can and
discuss all of the options for HIS PARTICULAR DISEASE. Then he
should make the best choice he can considering his particular
goals.

Alan

[Terry Pinnell]

Alan Meyer <[email protected]> wrote:

>On 04/18/2012 03:04 PM, Terry Pinnell wrote:
>...
> > "The difference between surveillance and whole-gland treatment in
>terms of
> > reducing cancer-related deaths is very small. The difference in the
>number
> > of deaths from prostate cancer at 15 years between watchful waiting (a
> > type of surveillance) and treating the whole prostate is only 5%."
>...
>
>I think that statistics like the above are close to useless
>because the results are so different for different subgroups. I
>bet that the majority of men with high gleason score cancers that
>go no treatment die of the disease in much less than 15 years.
>Men who are older, or in poor health for other reasons, and
>especially if they have low gleason score cancers, probably all
>die of something else.
>
>Now look at this strange paragraph in the article cited by Ed:
>
> "The study stipulated that men treated with surgery who
> progressed should receive hormonal therapy (as opposed to
> observed men who progressed — they received surgery)."
>
>It seems to indicate that men in BOTH groups got surgery but the
>men in the treatment group got it earlier! If I'm reading that
>right it says that this was NOT a study of treatment vs.
>non-treatment. It was a study of early treatment vs later
>treatment.
>
>It is amazing to me that a study like this should be summarized
>(in paragraph two of the article) as:
>
> "The study shows that, at 15 years, the cumulative incidence
> of death from prostate cancer was 14.6% among 347 men
> randomized to prostatectomy and 20.7% among 348 men BEING
> OBSERVED WITHOUT TREATMENT. [emphasis mine - AM]"
>
>My conclusion is that no one should jump into treatment. Each
>patient should find the very best specialist that he can and
>discuss all of the options for HIS PARTICULAR DISEASE. Then he
>should make the best choice he can considering his particular
>goals.
>
> Alan

Thanks both.

I have to admit that I remain confused. It seems to me that on the
apparent evidence quoted it would be correct for me to say to my wife and
sons something like:
"I'm having treatment XYZ next month at age 71, with likely consequences
ABC, because it will increase my chances of being alive at 86 (when my
grandsons hopefully graduate) by about 5%".

--
Terry, East Grinstead, UK

[Terry Pinnell]

Terry Pinnell <[email protected]> wrote:

>Alan Meyer <[email protected]> wrote:
>
>>On 04/18/2012 03:04 PM, Terry Pinnell wrote:
>>...
>> > "The difference between surveillance and whole-gland treatment in
>>terms of
>> > reducing cancer-related deaths is very small. The difference in the
>>number
>> > of deaths from prostate cancer at 15 years between watchful waiting (a
>> > type of surveillance) and treating the whole prostate is only 5%."
>>...
>>
>>I think that statistics like the above are close to useless
>>because the results are so different for different subgroups. I
>>bet that the majority of men with high gleason score cancers that
>>go no treatment die of the disease in much less than 15 years.
>>Men who are older, or in poor health for other reasons, and
>>especially if they have low gleason score cancers, probably all
>>die of something else.
>>
>>Now look at this strange paragraph in the article cited by Ed:
>>
>> "The study stipulated that men treated with surgery who
>> progressed should receive hormonal therapy (as opposed to
>> observed men who progressed — they received surgery)."
>>
>>It seems to indicate that men in BOTH groups got surgery but the
>>men in the treatment group got it earlier! If I'm reading that
>>right it says that this was NOT a study of treatment vs.
>>non-treatment. It was a study of early treatment vs later
>>treatment.
>>
>>It is amazing to me that a study like this should be summarized
>>(in paragraph two of the article) as:
>>
>> "The study shows that, at 15 years, the cumulative incidence
>> of death from prostate cancer was 14.6% among 347 men
>> randomized to prostatectomy and 20.7% among 348 men BEING
>> OBSERVED WITHOUT TREATMENT. [emphasis mine - AM]"
>>
>>My conclusion is that no one should jump into treatment. Each
>>patient should find the very best specialist that he can and
>>discuss all of the options for HIS PARTICULAR DISEASE. Then he
>>should make the best choice he can considering his particular
>>goals.
>>
>> Alan
>
>Thanks both.
>
>I have to admit that I remain confused. It seems to me that on the
>apparent evidence quoted it would be correct for me to say to my wife and
>sons something like:
>"I'm having treatment XYZ next month at age 71, with likely consequences
>ABC, because it will increase my chances of being alive at 86 (when my
>grandsons hopefully graduate) by about 5%".

In fact, based on this para, which I hadn't spotted earlier,

"However, the survival benefit was confined to men younger than 65 years
of age, according to the study authors, led by Anna Bill-Axelson, MD PhD,
from the University Hospital in Uppsala, Sweden.

For men older than 65 years, survival was highly similar in the 2 groups."

it seems I could say:

"I'm having treatment XYZ next month at age 71, with likely consequences
ABC, even though studies show it won't increase my chances of being alive
at 86 (when my grandsons hopefully graduate)."

--
Terry, East Grinstead, UK

[I.P. Freely]

Terry Pinnell wrote:
>
> In fact, based on this para, which I hadn't spotted earlier,
>
> "However, the survival benefit was confined to men younger than 65 years
> of age
>
> it seems I could say:
>
> "I'm having treatment XYZ next month at age 71, with likely consequences
> ABC, even though studies show it won't increase my chances of being alive
> at 86 (when my grandsons hopefully graduate)."

It was caveats exactly like that, by the scores, pertaining to both
benefits and side effects, which led me to not only reject the strong
second-treatment advice (at two phases of my cancer history) of half a
dozen oncologists but also convince most of them I was right. They just
don't have the time to compare each patient to all the fine print in all
the relevant studies. Often one sentence such as yours above reverses
the entire tone of a study for the patient whom that glove fits.

I.P.

[frank curtis]

On Apr 19, 11:44*am, "I.P. Freely" <fuhgheddabou...@noway.nohow>
wrote:
> Terry Pinnell wrote:
>
> > In fact, based on this para, which I hadn't spotted earlier,
>
> > "However, the survival benefit was confined to men younger than 65 years
> > of age
>
> > it seems I could say:
>
> > "I'm having treatment XYZ next month at age 71, with likely consequences
> > ABC, even though studies show it won't increase my chances of being alive
> > at 86 (when my grandsons hopefully graduate)."
>
> It was caveats exactly like that, by the scores, pertaining to both
> benefits and side effects, which led me to not only reject the strong
> second-treatment advice (at two phases of my cancer history) of half a
> dozen oncologists but also convince most of them I was right. They just
> don't have the time to compare each patient to all the fine print in all
> the relevant studies. Often one sentence such as yours above reverses
> the entire tone of a study for the patient whom that glove fits.
>
> I.P.

I've often wondered what is meant by stating phrases like "will live 5
months longer" really mean.
Does that mean your life will be exactly the same but extended 5
months?.... then that is a reasonable goal.
If it means you live in pain and disabled 5 more months than
otherwise, then what good is that?
I think studies and trials should report and be focused on quality of
life as a benchmark, not longevity by itself.

[I.P. Freely]

frank curtis wrote:
>
> I've often wondered what is meant by stating phrases like "will live 5
> months longer" really means
> Does that mean your life will be exactly the same but extended 5
> months?.... then that is a reasonable goal.

Is it? I doubt that exchanging 5 years of blissful, symptom-free life
followed by 3 years of ever-increasing symptoms and death for 5 years
and five months of egregious -- often severe w/SRT -- SEs followed by
three years of ever-increasing symptoms and death is even desirable, let
alone a "reasonable goal". Even if those extra 5 months were
PC-symptom-free, what have we gained if that initial 5-year segment has
gone to hell ... very likely for many SRT candidates, for example. IOW,
which is better ... 60 months of bliss, travel, tennis, dancing, gym,
work, etc. or 65 months tethered to a toilet by a burning, busy, broken,
bloody butt? Each individual really needs to closely evaluate his own
case, the relevant research, and his priorities to make the choice. Our
doctors simply have too many patients to do that for every pt in their
120-hour work weeks.

> If it means you live in pain and disabled 5 more months than
> otherwise, then what good is that?

How about *65* more months, and still dying "on time"? A bird in the
hand comes to mind.

> I think studies and trials should report and be focused on quality of
> life as a benchmark, not longevity by itself.

Several studies are beginning to not just emphasize but focus on that
factor, especially regarding SRT.

I.P.

[Gourd Dancer]

IP, I am sure you are a nice guy and I enjoy reading your thoughts, but
quite frankly, if I followed only your writings 8 years ago, there is no
doubt that I would have preferred a bullet rather than treatment for
advanced prostate cancer.

You write of severe urinary and fecal incontinence as if it were common
place using terms as, "very likely for many SRT candidates." And, "tethered
to a toilet by a burning, busy, broken, bloody butt." Sure this could happen
as a result of treatment, however the incidence of severe urinary and fecal
incontinence is far, very far from common.

The Canadians put the percentage at 1.3% after five years. The British
publish 1-2% after five years and Americans publish a Grade 3 or 4 severe
bowel complication at 1.8% or 1.1% of all side effects.

I do not believe that this is your intent, however, it is what is
transmitted. Is it possible to draw a short straw, yes; but it is more
likely to draw a larger straw and live years with severe complications.

With respect to survival rates. One has to understand that median means half
of participants not average. Often the cohorts of groups are skewed as to
age and degree of disease. For example in one Phase II vaccine trial the
populace was skewed as such: 2 with Stage II, 12 with Stage 3A, 15 with
Stage 3B, and 46 with Stage 4 cancers. This would be compared to another
cohort receiving placebos only for the trial period comparing the median
(half of group) survival. The resulting positive number is then published as
a median survival of x number of months.

So of the 75 participants, half or 37 would live x months and the other half
would survival longer. Therefore, if I was a Stage 2 or even several Stage 4
in the trial and still alive when half died, I could expect to survival
greater than x number of months.

Gourd Dancer



"I.P. Freely" wrote in message news:rSekr.8144$[email protected]..

frank curtis wrote:
>
> I've often wondered what is meant by stating phrases like "will live 5
> months longer" really means
> Does that mean your life will be exactly the same but extended 5
> months?.... then that is a reasonable goal.

Is it? I doubt that exchanging 5 years of blissful, symptom-free life
followed by 3 years of ever-increasing symptoms and death for 5 years
and five months of egregious -- often severe w/SRT -- SEs followed by
three years of ever-increasing symptoms and death is even desirable, let
alone a "reasonable goal". Even if those extra 5 months were
PC-symptom-free, what have we gained if that initial 5-year segment has
gone to hell ... very likely for many SRT candidates, for example. IOW,
which is better ... 60 months of bliss, travel, tennis, dancing, gym,
work, etc. or 65 months tethered to a toilet by a burning, busy, broken,
bloody butt? Each individual really needs to closely evaluate his own
case, the relevant research, and his priorities to make the choice. Our
doctors simply have too many patients to do that for every pt in their
120-hour work weeks.

> If it means you live in pain and disabled 5 more months than
> otherwise, then what good is that?

How about *65* more months, and still dying "on time"? A bird in the
hand comes to mind.

> I think studies and trials should report and be focused on quality of
> life as a benchmark, not longevity by itself.

Several studies are beginning to not just emphasize but focus on that
factor, especially regarding SRT.

I.P.

[I.P. Freely]

Gourd Dancer wrote:
>
> You write of severe urinary and fecal incontinence as if it were common
> place using terms as, "very likely for many SRT candidates." And,
> "tethered to a toilet by a burning, busy, broken, bloody butt." Sure
> this could happen as a result of treatment, however the incidence of
> severe urinary and fecal incontinence is far, very far from common.

You apparently missed the many long discussions I presented last Fall
after researching something like 300 modern SRT studies. If I were to
condense those thousands of pages of studies, my hundreds of
single-spaced pages of notes based on those studies, and my 15-25 --
maybe dozens of -- pages of recent posts into one short sentence about
the benefits and SEs of SRT, it would go something like this: SRT
demonstrates virtually no survival benefit and a 0.4 to 0.65 likelihood
of permanent debilitating side effects. For a reality check I consulted
with one of the West Coast's preeminent rad oncs; he generally concurred.

YMMV.

> The Canadians put the percentage at 1.3% after five years. The British
> publish 1-2% after five years and Americans publish a Grade 3 or 4
> severe bowel complication at 1.8% or 1.1% of all side effects.

That's largely because modern targeting systems drive the RTOG Grade 3
and 4 SE clusters into the Grade 2 cluster, which the vast majority of
studies dismiss as "inconsequential". i.e.; they're sweeping severe SEs
under the rug ... declaring being tethered to a toilet for the rest of
one's life "inconsequential".

I ... and that towering rad onc ... do not consider Grade 2 urinary or
bowel morbidity "inconsequential" even if it's happening to a total
stranger. Just because a toilet tether doesn't quite demand additional
surgery doesn't make it the non-event most studies declare it to be.

> With respect to survival rates. One has to understand that median means
> half of participants not average.

It's been many years now, but I did very well in my very advanced
graduate courses in Bayesian statistics. The problem with SRT survival
statistics is not the distinction between average and mean, rather the
pressure to publish or perish. Researchers haven't the patience,
motivation, or grant funds to wait 10, 12, or 15 years for ultimate
results; they typically publish SRT results at 36 to 48 months, with
claims like "86 percent of pts remain met-free at 48 months". This
sounds great, until two other facts emerge:
1. 86% of SRT pts who did nothing *also* remained met-free at 48 months.
2. Both the SRT and the observation-only cohorts die side by side 8-12
years later.

I hate it when that happens.

So what did all those SRT pts get from their treatments? More than half
got nasty SEs I consider severe, while a large minority skate by with
lesser degrees of radiation proctitis. I'm sure some get nothing more
than moderate occasional itching, burning, bloody, and/or leaky anus
and/or bladder incontinence or blockage, but those are a lucky smallish
minority. Now compound that by the fact that SRT becomes almost useless
by any measure if we let our recurring PSA sneak past very low single
digits. The useful SRT PSA window ranges from about 0.2 to 1.5 ... long
before any current technology has much chance of locating a target to zap.

I.P.

[Gourd Dancer]

Damn IP, I apologize. I forgot that you have a hard on for SRT. Quite
frankly, I am not a proponent for SRT and I do not know anyone who is
tethered to a toilet as well. SRT has never been an option in my mind for
me. Seems to me that if PSA rises after a prostrate is removed, then cancer
is still around; most likely floating around in the blood stream or
lymphatic system just waiting to attach to a remote spot to grow and
metastasize. Early ART seems a better option while the tumor is minimal and
still local to the prostate bed. If someone wants to try SRT, then I support
their decision. No one should be made to fear their decision because they
might fall into the category of less than 2% with severe complications. It's
all a risk. Some want to delay, some do not.

I thought this thread was about "treatment or do nothing" ............ and,
not particularly about SRT. To me additional treatment includes hormone
therapy, chemotherapy, and new frontier drugs dealing with immunization etc.
depending on age, PSA, and metastatic formations.

The only thing that I know is my personal experiences with brachytherapy and
adjunctive external radiation as a primary treatment for prostate cancer and
early chemotherapy (14 months after seed implantation) when I drew the black
bean with metastases.

I think most in this group know that I am a proponent for early chemotherapy
to kick the bastard hard.

I promise to refrain from writing about SRT, if you can refrain from using
terms as "very likely for many SRT candidates." It would be preferable to
write that it is a small risk that one can spend their life tethered to a
toilet and that it is debatable among researchers whether SRT is a valid
treatment option as compared to doing nothing.....

Peace,

GD

"I.P. Freely" wrote in message news:crkkr.15551$[email protected]..

Gourd Dancer wrote:
>
> You write of severe urinary and fecal incontinence as if it were common
> place using terms as, "very likely for many SRT candidates." And,
> "tethered to a toilet by a burning, busy, broken, bloody butt." Sure
> this could happen as a result of treatment, however the incidence of
> severe urinary and fecal incontinence is far, very far from common.

You apparently missed the many long discussions I presented last Fall
after researching something like 300 modern SRT studies. If I were to
condense those thousands of pages of studies, my hundreds of
single-spaced pages of notes based on those studies, and my 15-25 --
maybe dozens of -- pages of recent posts into one short sentence about
the benefits and SEs of SRT, it would go something like this: SRT
demonstrates virtually no survival benefit and a 0.4 to 0.65 likelihood
of permanent debilitating side effects. For a reality check I consulted
with one of the West Coast's preeminent rad oncs; he generally concurred.

YMMV.

> The Canadians put the percentage at 1.3% after five years. The British
> publish 1-2% after five years and Americans publish a Grade 3 or 4
> severe bowel complication at 1.8% or 1.1% of all side effects.

That's largely because modern targeting systems drive the RTOG Grade 3
and 4 SE clusters into the Grade 2 cluster, which the vast majority of
studies dismiss as "inconsequential". i.e.; they're sweeping severe SEs
under the rug ... declaring being tethered to a toilet for the rest of
one's life "inconsequential".

I ... and that towering rad onc ... do not consider Grade 2 urinary or
bowel morbidity "inconsequential" even if it's happening to a total
stranger. Just because a toilet tether doesn't quite demand additional
surgery doesn't make it the non-event most studies declare it to be.

> With respect to survival rates. One has to understand that median means
> half of participants not average.

It's been many years now, but I did very well in my very advanced
graduate courses in Bayesian statistics. The problem with SRT survival
statistics is not the distinction between average and mean, rather the
pressure to publish or perish. Researchers haven't the patience,
motivation, or grant funds to wait 10, 12, or 15 years for ultimate
results; they typically publish SRT results at 36 to 48 months, with
claims like "86 percent of pts remain met-free at 48 months". This
sounds great, until two other facts emerge:
1. 86% of SRT pts who did nothing *also* remained met-free at 48 months.
2. Both the SRT and the observation-only cohorts die side by side 8-12
years later.

I hate it when that happens.

So what did all those SRT pts get from their treatments? More than half
got nasty SEs I consider severe, while a large minority skate by with
lesser degrees of radiation proctitis. I'm sure some get nothing more
than moderate occasional itching, burning, bloody, and/or leaky anus
and/or bladder incontinence or blockage, but those are a lucky smallish
minority. Now compound that by the fact that SRT becomes almost useless
by any measure if we let our recurring PSA sneak past very low single
digits. The useful SRT PSA window ranges from about 0.2 to 1.5 ... long
before any current technology has much chance of locating a target to zap.

I.P.

[Terry Pinnell]

"I.P. Freely" <[email protected]> wrote:

>Gourd Dancer wrote:
>>
>> You write of severe urinary and fecal incontinence as if it were common
>> place using terms as, "very likely for many SRT candidates." And,
>> "tethered to a toilet by a burning, busy, broken, bloody butt." Sure
>> this could happen as a result of treatment, however the incidence of
>> severe urinary and fecal incontinence is far, very far from common.
>
>You apparently missed the many long discussions I presented last Fall
>after researching something like 300 modern SRT studies. If I were to
>condense those thousands of pages of studies, my hundreds of
>single-spaced pages of notes based on those studies, and my 15-25 --
>maybe dozens of -- pages of recent posts into one short sentence about
>the benefits and SEs of SRT, it would go something like this: SRT
>demonstrates virtually no survival benefit and a 0.4 to 0.65 likelihood
>of permanent debilitating side effects. For a reality check I consulted
>with one of the West Coast's preeminent rad oncs; he generally concurred.

I for one would dearly like to see such a summary by you! A short book
perhaps? Paper or online. In relatively lay terms that the likes of me
could understand and use as a decision tool. And for discussions with the
UK NHS specialists with whom I get to spend so little time with.

PSA SEP 2010 3.9
PSA SEP 2011 5.7
PSA NOV 2011 6.8
Biopsy JAN 2012 3+4=7, T1c
PSA MAR 2012 7.3
Considered suitable for EBRT (IMRT)
Awaiting assessment for brachytherapy suitability 1stMay
Considering HIFU, but...

--
Terry, East Grinstead, UK

[Terry Pinnell]

"Gourd Dancer" <!!!noreply!!!@gmail.com> wrote:

>Damn IP, I apologize. I forgot that you have a hard on for SRT.

Meant to ask in my reply to IP earlier, but am I right that SRT = Salvage
RT? (I have a growing lost of abbreviations, but that wasn't on it.)

>Quite
>frankly, I am not a proponent for SRT and I do not know anyone who is
>tethered to a toilet as well. SRT has never been an option in my mind for
>me. Seems to me that if PSA rises after a prostrate is removed, then cancer
>is still around; most likely floating around in the blood stream or
>lymphatic system just waiting to attach to a remote spot to grow and
>metastasize. Early ART seems a better option while the tumor is minimal and
>still local to the prostate bed. If someone wants to try SRT, then I support
>their decision. No one should be made to fear their decision because they
>might fall into the category of less than 2% with severe complications. It's
>all a risk. Some want to delay, some do not.
>
>I thought this thread was about "treatment or do nothing" ............ and,
>not particularly about SRT.

Yes, that was my intention, because I am at the post-diagnostic,
pre-treatment stage for "early, localised PC."

--
Terry, East Grinstead, UK

[I.P. Freely]

Gourd Dancer wrote:
> I do not know anyone who is tethered to a toilet.

IMO, that doesn't negate the overwhelming statistics.

> No one should be made to fear their decision

So you think we should hide facts from decision-makers to protect them
from any risk of fear? Then why bother with PSA tests or biopsies at all?

> because they might fall into the category of less than 2% with severe
> complications.

We've been over that. You say "severe" begins at SEs so severe they
require recurrent surgeries to *try to* correct them. I -- and the head
of the Seattle Cancer Care Alliance -- say "severe" begins with rectal
blood and pain and leakage and urgency sufficient to tether us to a
toilet (his words), in the sense that we must be near a toilet at all
times if the day and night. It's vital that patients making decisions
understand the difference and decide for themselves what level of
morbidity they wish to consider acceptable or severe. Just being
confined to the vicinity of a toilet, all by itself, would ruin my QOL.
Add to that the pain, bleeding, urinary and/or fecal leakage, urgency,
failure to reach the toilet in time, etc. which occur to some degree in
at least half of SRT pts, and QOL is shot to hell in my book.

> I thought this thread was about "treatment or do nothing" ............
> and, not particularly about SRT.

I brought up SRT as a classic, and I doubt rare, example of the BS we're
being fed by physicians regarding PC tx, especially salvage. That senior
rad onc agrees with some of the newer studies that show that SRT SEs and
benefits are vastly understated and overstated, respectively, and ADT is
emerging into the same light. Ditto lap and robotic and most other
panaceas to varying degrees.

> I promise to refrain from writing about SRT, if you can refrain from
> using terms as "very likely for many SRT candidates."

No. Anything less would be a lie.

> It would be
> preferable to write that it is a small risk that one can spend their
> life tethered to a toilet

Sorry. I don't do lies.

> and that it is debatable among researchers
> whether SRT is a valid treatment option as compared to doing
> nothing.....

That would imply little is know about the subject, so a pt may as well
toss a coin, refuse, or go for broke based on whim or psychological
makeup. On the contrary, there's a lot of knowledge available from
PubMed with which each pt can compare his own numbers to emerge with
some reasonably defined odds of benefit vs harm *in his case*. I
consider that encouraging and enabling, not fear-mongering.

I.P.

[I.P. Freely]

Terry Pinnell wrote:
> "I.P. Freely" wrote:

>> the many long discussions I presented last Fall
>> after researching something like 300 modern SRT studies. If I were to
>> condense those thousands of pages of studies, my hundreds of
>> single-spaced pages of notes based on those studies, and my 15-25 --
>> maybe dozens of -- pages of recent posts into one short sentence about
>> the benefits and SEs of SRT, it would go something like this: SRT
>> demonstrates virtually no survival benefit and a 0.4 to 0.65 likelihood
>> of permanent debilitating side effects. For a reality check I consulted
>> with one of the West Coast's preeminent rad oncs; he generally concurred.
>
> I for one would dearly like to see such a summary by you! A short book
> perhaps? Paper or online. In relatively lay terms that the likes of me
> could understand and use as a decision tool. And for discussions with the
> UK NHS specialists with whom I get to spend so little time with.

Therein lie a few problems.
• My notes are long ... probably >150 pages.
• They're deliberately dense, because at first I printed them out so I
could review them as my wife drove us to the doctors 220 miles away.
After that I just bought a cheap laptop largely for that purpose.
• They are not only highly condensed, but are often condensed from
condensations (abstracts) if not from entire studies.
• As my notes progress with time, they get ever more cryptic because I
didn't want to keep typing or clipping and pasting oft-repeated phrases.
But for the same reasons, a new reader thereof would probably learn the
jargon and assumptions at the same rate I began to rely on them ... if
that makes sense.
• I've gotten used to the jargon, at least the parts I understand. If I
didn't understand some new obscure comment adequately, I didn't copy it
into my notes.

A few examples (when your eyes glaze over, skip to the bottom paragraph):

Boorjian, 2009, RT after RP: impact on mets and survival.
PURPOSE: Although secondary RT decreases the risk of BCR after RP, its
impact on metastasis and survival is less well established. We evaluated
the impact of adjuvant and salvage RT on clinical progression and mortality.
MATERIALS AND METHODS: 361 adjuvant RT pts were matched based on
clinicopathological features to patients who did not receive adjuvant
radiation in a 2:1 case-control ratio. ... second cohort of 2,657 men
w/BCR after RP was separately evaluated.
RESULTS: Adjuvant RT was associated with significantly improved 10-year
BCR-free survival (63% vs 45%, p <0.001), local recurrence-free survival
(97% vs 82%, p <0.001) and a decreased need for late hormone therapy
(17% vs 28%, p = 0.002) but did not impact systemic progression and
overall survival (p = 0.94 and 0.27, respectively). Of the 2,657
patients who experienced BCR after surgery 856 (32.3%) received SRT. On
multivariate analysis SRT decreased the risk of local recurrence (HR
0.13, 95% CI 0.06-0.28, p <0.0001) and delayed hormonal therapy (HR
0.81, 95% CI 0.71-0.93, p = 0.003) and systemic progression (HR 0.24,
95% CI 0.13-0.45, p <0.0001) but did not significantly impact mortality
(p = 0.48).
CONCLUSIONS: Adjuvant and salvage radiation provide long-term local
control and decrease the need for delayed hormonal therapy but neither
improves survival. These results must be weighed against the potential
morbidity of SRT when counseling patients.


Trock, Han, Freedland, Humphreys, DeWeese, Partin, and Walsh that
salvage radiation offers a survival benefit in a subgroup of patients:
"Radiotherapy vs Observation in Men With Biochemical Recurrence After
Radical Prostatectomy." JAMA. 2008;299(23):2760-2769. (Full text
available for free.)[6]

This one is extensive, profound, and highly condensed here.
SRT alone => 3-fold increase in prostate cancer–specific survival
relative to those who received no salvage treatment (HR = .32 says
otherwise to me). Adding ADT was not associated with any additional
increase in prostate cancer–specific survival. The increase in prostate
cancer–specific survival associated with salvage radiotherapy was
limited to men with a prostate-specific antigen doubling time of less
than 6 months and remained after adjustment for (i.e., was independent
of) pathological stage and other established prognostic factors. Salvage
radiotherapy initiated more than 2 years after recurrence provided no
significant increase in prostate cancer–specific survival. Salvage
radiotherapy also was associated with a significant increase in overall
survival.

IOW, SRT within 2 years of recurrence improves survival only for PSADT <
6 months, independent of other prognostic features such as pathological
stage or Gleason score
It is currently difficult to determine whether increasing serum PSA
level after surgery represents an isolated recurrence at the surgical
site or occult metastases that cannot be detected by imaging. For such
men it is unknown whether salvage radiotherapy confers a survival
benefit compared with observation. Furthermore, it is unknown whether
the likelihood of benefit differs for immediate vs delayed salvage
radiotherapy, or among subgroups of men defined by pathological
attributes. These are critical questions because 65% of men with
biochemical or local recurrence will develop overt metastases if left
untreated and the majority of these will die from their disease.4 No
studies to date (2010) have evaluated the association of salvage
radiotherapy with prostate cancer–specific survival.

Recently, the need to determine the impact of salvage therapy on
survival has been given a sharper focus by publication of 2 large
randomized controlled trials of adjuvant radiotherapy in men with
pathologically advanced (stage pT3) prostate cancer. Both trials
demonstrated that adjuvant radiotherapy provides significant improvement
in biochemical relapse–free survival and clinical recurrence–free
survival, but no significant improvement in metastasis-free or overall
survival.


Swanson, 2011, Long-term FU and risk of cancer death after SRT for
post-RP BCR.
PURPOSE: SRT for BCR after RP appears favorable, but short FU clouds
ultimate outcome of most studies.
METHODS AND MATERIALS: 1990 - 1995, 92 pts BCR post-RP. PSA ranged from
0.1 to 30.5. The median time from surgery to radiation was 2.1 years,
fossa only w/median dose 65 Gy.
RESULTS: 85 pts responded to SRT, as predicted by Gleason score and PSA
level at the start of radiation. Five- and 10-year biochemical failure
free survival (BFFS) was 35% and 26% [that’s pitiful; is that really a
response?], respectively, and overall survival was 86% and 67%,
respectively. Median survival was 12.0 years, and median BFF was 2.3
years. G8-9 had a significantly higher post-SRT progression rate than
≤7. No significant differences in outcomes based on pathology findings
(margins or SVI). Overall, 22 (24%) patients died directly from prostate
cancer, resulting in a 10-year cancer-specific survival rate of 82%.
Multivariate analysis risk factors for dying of cancer were Gleason's
score (8 to 9) and PSA at the start of radiation therapy (>1.0), [and
that’‘s with SRT].
CONCLUSIONS: In those for whom therapy fails, radiation delays the need
for other salvage therapy, indicating at least a transient benefit to
most patients. Yet zero mention of toxicity! BFD; what has it REALLY
accomplished for those not cured?


EORTC-22911 preliminary reports 2006-2007, by Bolla and others’ ; consensus
After a median follow-up of 5-years, BCR free survival was significantly
improved in the irradiated group (74%, 98% CI: 68.7-79.3 vs 52.6%, 98%
CI: 46.6-58.5; P<0.0001) Clinical progression free survival was also
significantly improved (P<0.0009). The cumulative rate of loco-regional
failure was also significantly improved (P<0.0009). Grade 2 or 3 late
effects were significantly more frequent in the postoperative
irradiation group (P=0.0005), but severe toxicity (grade 3 or higher)
were rare with a 5-year rate of 2.6% in the wait-and-see group and 4.2%
in the postoperative irradiation group (P=0.07). Van der Kwast concluded
that margin status was the strongest predictor of prolonged BCR-free
survival with immediate postoperative radiotherapy (heterogeneity, P <
..01): by year 5, immediate postoperative irradiation could prevent 291
events/1,000 patients with positive margins versus 88 events/1,000
patients with negative margins. The hazard ratio for immediate
irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to
1.46) in the groups with positive and negative margins, respectively.
Immediate post-op RT might not be recommended for PC pts w/negative
surgical margins. Gomella concluded: Patients with negative surgical
margins had no benefit from postoperative radiotherapy.


Choo, 2010, Mayo, SRT for pts w/PSA Relapse Following RP: Issues and
Challenges
A progressively rising PSA after RP invariably indicates the recurrence
of PC, but optimal management thereof has remained uncertain due to a
wide variability in the natural course of post-RP PSA relapse, the
inability to separate local R from distant metastasis, and the lack of
phase III clinical studies demonstrating which therapeutic approach may
prolong life with no significant morbidity. Radiotherapy has been the
main therapeutic modality with a curative potential for patients with
post-RP PSA relapse. This review presents the literature data for the
efficacy of SRT, alone or w/ADT. Ultrasensitive assays are useful for
monitoring, but premature for decision making. Consensus advice trends
strongly towards 0.4, but my case is so clear that acting before 0.2 may
be warranted. … Likelihoods of finding mets via scans w/PSA below 10 or
PSAV < 0.5/month is essentially zero; PSADT <6 mo may bump up scan
results. Nagda reported that the positive predictive value of
ProstaScint in detecting recurrent disease outside the prostatic bed was
only 27%. In his study of 58 patients who underwent SRT for BCR, bNED
rates at 4 years were not different among patients with negative scan
(53%) vs. those with positive uptake in the prostate bed alone (45%) vs.
those with positive uptake outside the prostate bed (74%). Koontz and
Thomas similarly reported that a positive vs. negative result of
ProstaScint did not predict the treatment outcome after salvage RT
(48,49). As of 2010, there is no reliable radiological tool to
accurately identify the site of tumor recurrence for patients with
post-RP PSA relapse; PSA sensitivity is far ahead of any means of
determining tumor site location w/BCR after RP. Optimal management for
patients with post-RP BCR remains unclear because a) we still can’t
distinguish between prostate bed BCT and occult metastasis and b) the
wide variation in the natural course of post-RP PSA relapse. STILL no
published phase III study addressing the efficacy of salvage therapeutic
modalities.

Trock, 2009, Hopkins, PCSS following SRT vs observation w/BCR after RP.
CONTEXT: BCR after RP often => SRT, but STILL no studies have had
sufficient # pts or FU to determine whether RT improves survival, and if
so, the subgroup of men most likely to benefit.
OBJECTIVES: To quantify the relative improvement in PCSS of SRT vs no
therapy after BCR following RP, and to identify subgroups for whom
salvage treatment is most beneficial.
DESIGN, SETTING, AND PATIENTS: Retrospective analysis of a cohort of 635
US men undergoing RP from 1982-2004, FU through December 28, 2007, who
experienced BCR and/or local recurrence and received no salvage
treatment (n = 397), SRT alone (n = 160), or SRT + HT (n = 78).
MAIN OUTCOME MEASURE: PCSS defined from time of recurrence until death
from disease.
RESULTS: Median FU of 6 years after recurrence and 9 years after RP, 116
men (18%) died from PC, including 89 (22%) who received no salvage
treatment, 18 (11%) who received SRT alone, and 9 (12%) who received SRT
+ HT. SRT alone was associated with a significant 3-fold increase in
PCSS relative to those who received no salvage treatment (hazard ratio
[HR], 0.32 [95% confidence interval {CI}, 0.19-0.54]; P<.001). Addition
of HT to SRT was not associated with any additional increase in PCSS
(HR, 0.34 [95% CI, 0.17-0.69]; P = .003). The increase in PCSS
associated with SRT was limited to men with a PSADT < 6 months and
remained after adjustment for pathological stage and other established
prognostic factors.


And on and on and on it goes, for 150 pages in small type. Trying to
rewrite this in plain English would take me months full time; just
cut'n'pasting it took me many hundreds of hours. You're probably better
off Googling the archives from roughly August through November for the
comments I posted here regarding SRT. On top of that, my computer and my
external hard drive backup have apparently lost some lengthy,
particularly meaty, culls from these documents; some of those may now be
preserved ONLY in the archives of this forum. Ditto the two seasons of
recorded television which accrued while I was doing all that research --
maybe 500 hours' worth -- disappeared this morning when my DVR hard
drive failed .... again. I'm in no mood to try to restore or re-create
lost documents.

[I.P. Freely]

Terry Pinnell wrote:
> "Gourd Dancer"wrote:
>
>> I thought this thread was about "treatment or do nothing" ............ and,
>> not particularly about SRT.
>
> Yes, that was my intention, because I am at the post-diagnostic,
> pre-treatment stage for "early, localised PC."

Yes, but Terry also wrote
> In fact, based on this para, which I hadn't spotted earlier,
> "However, the survival benefit was confined to men younger than 65 years
> of age

which led me to caution him that
"It was caveats exactly like that, by the scores, pertaining to both
benefits and side effects ... [doctors] just don't have the time to
compare each patient to all the fine print in all the relevant studies.
Often one sentence such as yours above reverses the entire tone of a
study for the patient whom that glove fits"
then support that with SRT therapeutic ratio research results as a
classic example.

Now add to that today's Wall Street Journal's front page expose that a
very significant amount of the last 40 years' cancer research,
especially but not limited to breast cancer, may have been in vain due
to rampant clerical error concealed by the medical profession. An example:
"Dr. Tarin has spent 25 years working with that cell line—or so he
thinks. A body of research suggests that MDA-MB-435 isn't breast cancer;
many scientists now believe the cells growing in labs and used in
decades of research are melanoma.

<snip>

Increasingly, medical journals won't accept research on breast cancer
involving the MDA-MB-435 cell line, throwing into question decades of
experiments and innumerable published papers based on the line."

Other decades of BC research accidentally used mislabeled cervical
cancer cells.

Don't ya hate it when that haoppens?

Support your jaw with both hands and see
http://tinyurl.com/7bv4jzx .

And you guys criticize me for not worshiping doctors?

I.P.

[Terry Pinnell]

"I.P. Freely" <[email protected]> wrote:

>Terry Pinnell wrote:
>> "I.P. Freely" wrote:
>
>>> the many long discussions I presented last Fall
>>> after researching something like 300 modern SRT studies. If I were to
>>> condense those thousands of pages of studies, my hundreds of
>>> single-spaced pages of notes based on those studies, and my 15-25 --
>>> maybe dozens of -- pages of recent posts into one short sentence about
>>> the benefits and SEs of SRT, it would go something like this: SRT
>>> demonstrates virtually no survival benefit and a 0.4 to 0.65 likelihood
>>> of permanent debilitating side effects. For a reality check I consulted
>>> with one of the West Coast's preeminent rad oncs; he generally concurred.
>>
>> I for one would dearly like to see such a summary by you! A short book
>> perhaps? Paper or online. In relatively lay terms that the likes of me
>> could understand and use as a decision tool. And for discussions with the
>> UK NHS specialists with whom I get to spend so little time with.
>
>Therein lie a few problems.
>• My notes are long ... probably >150 pages.
>• They're deliberately dense, because at first I printed them out so I
>could review them as my wife drove us to the doctors 220 miles away.
>After that I just bought a cheap laptop largely for that purpose.
>• They are not only highly condensed, but are often condensed from
>condensations (abstracts) if not from entire studies.
>• As my notes progress with time, they get ever more cryptic because I
>didn't want to keep typing or clipping and pasting oft-repeated phrases.
>But for the same reasons, a new reader thereof would probably learn the
>jargon and assumptions at the same rate I began to rely on them ... if
>that makes sense.
>• I've gotten used to the jargon, at least the parts I understand. If I
>didn't understand some new obscure comment adequately, I didn't copy it
>into my notes.
>
>A few examples (when your eyes glaze over, skip to the bottom paragraph):
>
>Boorjian, 2009, RT after RP: impact on mets and survival.
>PURPOSE: Although secondary RT decreases the risk of BCR after RP, its
>impact on metastasis and survival is less well established. We evaluated
>the impact of adjuvant and salvage RT on clinical progression and mortality.
>MATERIALS AND METHODS: 361 adjuvant RT pts were matched based on
>clinicopathological features to patients who did not receive adjuvant
>radiation in a 2:1 case-control ratio. ... second cohort of 2,657 men
>w/BCR after RP was separately evaluated.
>RESULTS: Adjuvant RT was associated with significantly improved 10-year
>BCR-free survival (63% vs 45%, p <0.001), local recurrence-free survival
>(97% vs 82%, p <0.001) and a decreased need for late hormone therapy
>(17% vs 28%, p = 0.002) but did not impact systemic progression and
>overall survival (p = 0.94 and 0.27, respectively). Of the 2,657
>patients who experienced BCR after surgery 856 (32.3%) received SRT. On
>multivariate analysis SRT decreased the risk of local recurrence (HR
>0.13, 95% CI 0.06-0.28, p <0.0001) and delayed hormonal therapy (HR
>0.81, 95% CI 0.71-0.93, p = 0.003) and systemic progression (HR 0.24,
>95% CI 0.13-0.45, p <0.0001) but did not significantly impact mortality
>(p = 0.48).
>CONCLUSIONS: Adjuvant and salvage radiation provide long-term local
>control and decrease the need for delayed hormonal therapy but neither
>improves survival. These results must be weighed against the potential
>morbidity of SRT when counseling patients.
>
>
>Trock, Han, Freedland, Humphreys, DeWeese, Partin, and Walsh that
>salvage radiation offers a survival benefit in a subgroup of patients:
>"Radiotherapy vs Observation in Men With Biochemical Recurrence After
>Radical Prostatectomy." JAMA. 2008;299(23):2760-2769. (Full text
>available for free.)[6]
>
>This one is extensive, profound, and highly condensed here.
>SRT alone => 3-fold increase in prostate cancer–specific survival
>relative to those who received no salvage treatment (HR = .32 says
>otherwise to me). Adding ADT was not associated with any additional
>increase in prostate cancer–specific survival. The increase in prostate
>cancer–specific survival associated with salvage radiotherapy was
>limited to men with a prostate-specific antigen doubling time of less
>than 6 months and remained after adjustment for (i.e., was independent
>of) pathological stage and other established prognostic factors. Salvage
>radiotherapy initiated more than 2 years after recurrence provided no
>significant increase in prostate cancer–specific survival. Salvage
>radiotherapy also was associated with a significant increase in overall
>survival.
>
>IOW, SRT within 2 years of recurrence improves survival only for PSADT <
>6 months, independent of other prognostic features such as pathological
>stage or Gleason score
> It is currently difficult to determine whether increasing serum PSA
>level after surgery represents an isolated recurrence at the surgical
>site or occult metastases that cannot be detected by imaging. For such
>men it is unknown whether salvage radiotherapy confers a survival
>benefit compared with observation. Furthermore, it is unknown whether
>the likelihood of benefit differs for immediate vs delayed salvage
>radiotherapy, or among subgroups of men defined by pathological
>attributes. These are critical questions because 65% of men with
>biochemical or local recurrence will develop overt metastases if left
>untreated and the majority of these will die from their disease.4 No
>studies to date (2010) have evaluated the association of salvage
>radiotherapy with prostate cancer–specific survival.
>
>Recently, the need to determine the impact of salvage therapy on
>survival has been given a sharper focus by publication of 2 large
>randomized controlled trials of adjuvant radiotherapy in men with
>pathologically advanced (stage pT3) prostate cancer. Both trials
>demonstrated that adjuvant radiotherapy provides significant improvement
>in biochemical relapse–free survival and clinical recurrence–free
>survival, but no significant improvement in metastasis-free or overall
>survival.
>
>
>Swanson, 2011, Long-term FU and risk of cancer death after SRT for
>post-RP BCR.
>PURPOSE: SRT for BCR after RP appears favorable, but short FU clouds
>ultimate outcome of most studies.
>METHODS AND MATERIALS: 1990 - 1995, 92 pts BCR post-RP. PSA ranged from
>0.1 to 30.5. The median time from surgery to radiation was 2.1 years,
>fossa only w/median dose 65 Gy.
>RESULTS: 85 pts responded to SRT, as predicted by Gleason score and PSA
>level at the start of radiation. Five- and 10-year biochemical failure
>free survival (BFFS) was 35% and 26% [that’s pitiful; is that really a
>response?], respectively, and overall survival was 86% and 67%,
>respectively. Median survival was 12.0 years, and median BFF was 2.3
>years. G8-9 had a significantly higher post-SRT progression rate than
>?7. No significant differences in outcomes based on pathology findings
>(margins or SVI). Overall, 22 (24%) patients died directly from prostate
>cancer, resulting in a 10-year cancer-specific survival rate of 82%.
>Multivariate analysis risk factors for dying of cancer were Gleason's
>score (8 to 9) and PSA at the start of radiation therapy (>1.0), [and
>that’‘s with SRT].
>CONCLUSIONS: In those for whom therapy fails, radiation delays the need
>for other salvage therapy, indicating at least a transient benefit to
>most patients. Yet zero mention of toxicity! BFD; what has it REALLY
>accomplished for those not cured?
>
>
>EORTC-22911 preliminary reports 2006-2007, by Bolla and others’ ; consensus
>After a median follow-up of 5-years, BCR free survival was significantly
>improved in the irradiated group (74%, 98% CI: 68.7-79.3 vs 52.6%, 98%
>CI: 46.6-58.5; P<0.0001) Clinical progression free survival was also
>significantly improved (P<0.0009). The cumulative rate of loco-regional
>failure was also significantly improved (P<0.0009). Grade 2 or 3 late
>effects were significantly more frequent in the postoperative
>irradiation group (P=0.0005), but severe toxicity (grade 3 or higher)
>were rare with a 5-year rate of 2.6% in the wait-and-see group and 4.2%
>in the postoperative irradiation group (P=0.07). Van der Kwast concluded
>that margin status was the strongest predictor of prolonged BCR-free
>survival with immediate postoperative radiotherapy (heterogeneity, P <
>.01): by year 5, immediate postoperative irradiation could prevent 291
>events/1,000 patients with positive margins versus 88 events/1,000
>patients with negative margins. The hazard ratio for immediate
>irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to
>1.46) in the groups with positive and negative margins, respectively.
>Immediate post-op RT might not be recommended for PC pts w/negative
>surgical margins. Gomella concluded: Patients with negative surgical
>margins had no benefit from postoperative radiotherapy.
>
>
>Choo, 2010, Mayo, SRT for pts w/PSA Relapse Following RP: Issues and
>Challenges
>A progressively rising PSA after RP invariably indicates the recurrence
>of PC, but optimal management thereof has remained uncertain due to a
>wide variability in the natural course of post-RP PSA relapse, the
>inability to separate local R from distant metastasis, and the lack of
>phase III clinical studies demonstrating which therapeutic approach may
>prolong life with no significant morbidity. Radiotherapy has been the
>main therapeutic modality with a curative potential for patients with
>post-RP PSA relapse. This review presents the literature data for the
>efficacy of SRT, alone or w/ADT. Ultrasensitive assays are useful for
>monitoring, but premature for decision making. Consensus advice trends
>strongly towards 0.4, but my case is so clear that acting before 0.2 may
>be warranted. … Likelihoods of finding mets via scans w/PSA below 10 or
>PSAV < 0.5/month is essentially zero; PSADT <6 mo may bump up scan
>results. Nagda reported that the positive predictive value of
>ProstaScint in detecting recurrent disease outside the prostatic bed was
>only 27%. In his study of 58 patients who underwent SRT for BCR, bNED
>rates at 4 years were not different among patients with negative scan
>(53%) vs. those with positive uptake in the prostate bed alone (45%) vs.
>those with positive uptake outside the prostate bed (74%). Koontz and
>Thomas similarly reported that a positive vs. negative result of
>ProstaScint did not predict the treatment outcome after salvage RT
>(48,49). As of 2010, there is no reliable radiological tool to
>accurately identify the site of tumor recurrence for patients with
>post-RP PSA relapse; PSA sensitivity is far ahead of any means of
>determining tumor site location w/BCR after RP. Optimal management for
>patients with post-RP BCR remains unclear because a) we still can’t
>distinguish between prostate bed BCT and occult metastasis and b) the
>wide variation in the natural course of post-RP PSA relapse. STILL no
>published phase III study addressing the efficacy of salvage therapeutic
>modalities.
>
>Trock, 2009, Hopkins, PCSS following SRT vs observation w/BCR after RP.
>CONTEXT: BCR after RP often => SRT, but STILL no studies have had
>sufficient # pts or FU to determine whether RT improves survival, and if
>so, the subgroup of men most likely to benefit.
>OBJECTIVES: To quantify the relative improvement in PCSS of SRT vs no
>therapy after BCR following RP, and to identify subgroups for whom
>salvage treatment is most beneficial.
>DESIGN, SETTING, AND PATIENTS: Retrospective analysis of a cohort of 635
>US men undergoing RP from 1982-2004, FU through December 28, 2007, who
>experienced BCR and/or local recurrence and received no salvage
>treatment (n = 397), SRT alone (n = 160), or SRT + HT (n = 78).
>MAIN OUTCOME MEASURE: PCSS defined from time of recurrence until death
>from disease.
>RESULTS: Median FU of 6 years after recurrence and 9 years after RP, 116
>men (18%) died from PC, including 89 (22%) who received no salvage
>treatment, 18 (11%) who received SRT alone, and 9 (12%) who received SRT
>+ HT. SRT alone was associated with a significant 3-fold increase in
>PCSS relative to those who received no salvage treatment (hazard ratio
>[HR], 0.32 [95% confidence interval {CI}, 0.19-0.54]; P<.001). Addition
>of HT to SRT was not associated with any additional increase in PCSS
>(HR, 0.34 [95% CI, 0.17-0.69]; P = .003). The increase in PCSS
>associated with SRT was limited to men with a PSADT < 6 months and
>remained after adjustment for pathological stage and other established
>prognostic factors.
>
>
>And on and on and on it goes, for 150 pages in small type. Trying to
>rewrite this in plain English would take me months full time; just
>cut'n'pasting it took me many hundreds of hours. You're probably better
>off Googling the archives from roughly August through November for the
>comments I posted here regarding SRT. On top of that, my computer and my
>external hard drive backup have apparently lost some lengthy,
>particularly meaty, culls from these documents; some of those may now be
>preserved ONLY in the archives of this forum. Ditto the two seasons of
>recorded television which accrued while I was doing all that research --
>maybe 500 hours' worth -- disappeared this morning when my DVR hard
>drive failed .... again. I'm in no mood to try to restore or re-create
>lost documents.

Thanks - I see your point! Even if you covered only the area of immediate
interest to recently diagnosed early stage patients (like me), turning
your notes into a layman-readable document would plainly be a major
project.

Mind you, I sort of assumed that when I made the suggestion! I also had
the vague and probably naive idea that it would be publishable and
commercially attractive, although guessing they would at best be secondary
motives - with simple sharing and wider publicity as the primary ones.

Sorry to hear about the DVR disaster. Mine is a Sky+ with no user access
to its HD so I never touch it and therefore have zero expertise to offer
in the 'DVR' area. Presumably you are or will soon be sloughing through
google 'hits' like these?
http://tinyurl.com/7febnkw

--
Terry, East Grinstead, UK

[I.P. Freely]

Terry Pinnell wrote:
> Thanks - I see your point! Even if you covered only the area of immediate
> interest to recently diagnosed early stage patients (like me), turning
> your notes into a layman-readable document would plainly be a major
> project.

I'm an engineer, a total layman regarding medicine. Much of what I read
in these studies zings right over my head. I was frustrated when,
despite my advanced education in statistics, some of these terms and
numbers seemed Greek. (I felt redeemed when Googling the commonly used
but confusing "hazard ratio" revealed that it is extensively
misunderstood and misapplied throughout the medical research field. From
pages of advanced mathematics to brief verbal explanations,
interpretations by study leaders and teams are all over the map.)

However, through sheer exposure forced by widespread medical
controversies, doctors' practical time limitations, and the realization
that making our own informed decisions provides strong insurance against
hand-wringing second-guessing when the beast returns, I managed to learn
to get the gist, and often the whole message, from abstracts and many
whole studies. The more focused a study is on my particular case
history, the harder I dig to understand it and the harder I try to find
the entire study and not just the abstract. (Many studies PubMed wants
$30-$100 for can be Googled up free of charge.)

> Mind you, I sort of assumed that when I made the suggestion! I also had
> the vague and probably naive idea that it would be publishable and
> commercially attractive, although guessing they would at best be secondary
> motives - with simple sharing and wider publicity as the primary ones.

Unfortunately, I'm not that altruistic. I barely fill my own squares and
still make time for sufficient sleep. Much more important, my literature
researches initially and at recurrence focused on my own particular case
of prostate cancer ... my Gleason grade, my SVI, PSA, PSADT, margins,
time to recurrence, recurrent PSA dynamics, etc. ... and on my personal
QOL priorities. My research and the leading oncologists I consulted
agreed that the two most likely scenarios I face are seven healthy and
vigorous years followed by three years of dying to 10 years tethered to
a toilet (or much worse) ending in dying at that same 10 year point.
That's a no-brainer choice for me, but other patients with exactly my
"numbers" may legitimately choose to pursue even the slight (<0.2)
chance of longer remission with its attendant high (well above 0.8)
chance of decimating my QOL from now until I die. And a guy with just
slightly different numbers, such as positive margins or a lower PSADT or
no SEs from his initial treatment, would face entirely different outcome
likelihoods. i.e., "my book"
would be of little use to him. Now compound that by the number
(thousands!) of different cases presented by the number of variables
involved.

> Sorry to hear about the DVR disaster. Mine is a Sky+ with no user access
> to its HD so I never touch it and therefore have zero expertise to offer
> in the 'DVR' area. Presumably you are or will soon be sloughing through
> google 'hits' like these?
> http://tinyurl.com/7febnkw

I've been both routes: the erasure your link addresses and this total
hard drive crash. Dish Network tech gurus declare both unrecoverable. My
plan is to write off the lesser shows, catch what I can from my wife's
DVR, watch what I can online, and find out Monday if a HD data recovery
service can recover the contents. If they can, I'll have that done and
take Dish Network to small claims court for the 4-digit data recovery
cost. Meantime I'm raking Dish over the coals on the internet. I resent
the hell out of getting screwed with no chance of an orgasm, and have a
29:1 win/loss record with corporations that try it. I have yet to meet
the attorney I cannot beat with facts and logic, from consumer squabbles
to federal court to 9-figure Pentagon research programs. Just my first
call to Dish Network Accounting got me lifetime discounts running into
four figures beginning today, and I haven't even started my internet and
snail mail barrage yet.

Jeez, but I love being retired! It does my heart, head, and bank acount
good to get a letter of apology, a problem correction, and in two cases
my HOME back from foreclosures due to bank errors, due just to diligent,
informed persistence and having proof of my claims. (My wife chewed up
and spit out the largest mortgage institution in the world in 43 long
phone calls in one of those cases, after which we got a written apology
from the CEO and they changed their global accounting procedures to make
damned sure they never made either mistake -- wrongfully accusing
customers in general or my wife in particular with not paying their
bills -- again.)

$#!+, now I'm getting worked up. Dish Network had better be glad I'm
switching gears and seasons from winter recluse to summer windsurf bum;
my priorities are changing rapidly.

Soap Box Off. Sorry about that.

[Gourd Dancer]

IP, can we agree on the following definitions with respect to radiation
induced damage to the bowel - colon and rectum damage for prostate cancer
patients who radiotherapy:

Grade 1 - Slight Radiation Damage (mild inflammation, symptoms do not affect
lifestyle.)
Grade 2 - Mild Radiation Damage (more significant inflammation, responds
well with outpatient treatment, symptoms do not affect lifestyle.)
Grade 3 - Moderate Radiation Damage (must have prominent loss of epithelium
with varying degrees of inflammation, symptoms do affect lifestyle and may
require surgery to correct.)
Grade 4 - Severe Radiation Damage (ulcer, necrosis, symptoms do affect
lifestyle and requires surgery to correct.)

GD



"I.P. Freely" wrote in message news:xeBkr.162028$[email protected]..

Gourd Dancer wrote:
> I do not know anyone who is tethered to a toilet.

IMO, that doesn't negate the overwhelming statistics.

> No one should be made to fear their decision

So you think we should hide facts from decision-makers to protect them
from any risk of fear? Then why bother with PSA tests or biopsies at all?

> because they might fall into the category of less than 2% with severe
> complications.

We've been over that. You say "severe" begins at SEs so severe they
require recurrent surgeries to *try to* correct them. I -- and the head
of the Seattle Cancer Care Alliance -- say "severe" begins with rectal
blood and pain and leakage and urgency sufficient to tether us to a
toilet (his words), in the sense that we must be near a toilet at all
times if the day and night. It's vital that patients making decisions
understand the difference and decide for themselves what level of
morbidity they wish to consider acceptable or severe. Just being
confined to the vicinity of a toilet, all by itself, would ruin my QOL.
Add to that the pain, bleeding, urinary and/or fecal leakage, urgency,
failure to reach the toilet in time, etc. which occur to some degree in
at least half of SRT pts, and QOL is shot to hell in my book.

> I thought this thread was about "treatment or do nothing" ............
> and, not particularly about SRT.

I brought up SRT as a classic, and I doubt rare, example of the BS we're
being fed by physicians regarding PC tx, especially salvage. That senior
rad onc agrees with some of the newer studies that show that SRT SEs and
benefits are vastly understated and overstated, respectively, and ADT is
emerging into the same light. Ditto lap and robotic and most other
panaceas to varying degrees.

> I promise to refrain from writing about SRT, if you can refrain from
> using terms as "very likely for many SRT candidates."

No. Anything less would be a lie.

> It would be
> preferable to write that it is a small risk that one can spend their
> life tethered to a toilet

Sorry. I don't do lies.

> and that it is debatable among researchers
> whether SRT is a valid treatment option as compared to doing
> nothing.....

That would imply little is know about the subject, so a pt may as well
toss a coin, refuse, or go for broke based on whim or psychological
makeup. On the contrary, there's a lot of knowledge available from
PubMed with which each pt can compare his own numbers to emerge with
some reasonably defined odds of benefit vs harm *in his case*. I
consider that encouraging and enabling, not fear-mongering.

I.P.