prostate watchful waiting

[nkmiami]

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JAMA study
Why more low-risk prostate cancer patients are forgoing treatment - CNN


The researchers found that, among men with low-risk disease, the use of active surveillance increased while the use of radical prostatectomy -- or removing parts of the prostate gland -- decreased from 47.4% in 2010 to 31.3% in 2015. The use of radiotherapy also declined, falling from 38% in 2010 to 26.6% in 2015, the researchers found.
Among men with intermediate-risk disease, between 2010 and 2015, active surveillance increased from 5.8% to 9.6%; prostatectomy decreased from 51.8% to 50.6%; and radiotherapy went from 42.4% to 39.8%, the researchers found.
Among men with high-risk disease, active surveillance remained nearly unchanged, going from 1.9% to 2.2%; prostatectomy increased from 38% to 42.8%; and radiotherapy decreased from 60.1% to 55%, the researchers found.

 

[seper]

Active surveillance is not watchful waiting. Useful to highlight this distinction in consult notes, IMO

 

[RickyScott]

Active surveillance is not watchful waiting. Useful to highlight this distinction in consult notes, IMO

What is the difference- biopsies?

 

[seper]

watchful waiting = telling a 85 y/o patient with CHF and prostate Ca to go home and do nothing
surveillance = yearly DRE and PSA, re-biopsy prn

 

[Mandelin Rain]

If these numbers demonstrate anything, it's the need for more radiation oncologists.

*first to derail thread*

 

[medgator]

Among men with high-risk disease, active surveillance remained nearly unchanged, going from 1.9% to 2.2%; prostatectomy increased from 38% to 42.8%; and radiotherapy decreased from 60.1% to 55%, the researchers found.

Must be all that solid data supporting RP followed by Adjuvant/salvage xrt.








/s

 

[evilbooyaa]

Must be all that solid data supporting RP followed by Adjuvant/salvage xrt.








/s

Total number of prostatectomies done must remain the same. Justify increased use of RP without any evidence behind it because patients are informed about active surveillance now. Subject patients to trimodality treatment rather than bimodality for equivalent oncologic outcomes.

 

[MegaVoltagePhoton]

To make things more complicated for us, there's other SBRT data coming out or that just came out...

Oh well.

 

[Palex80]

The PROTECT trial clearly shows that Overall Survival is not compromised in selected patients opting for surveillance rather than active treatment.
"Surveillance" in PROTECT was not done as meticulously as usually done in standard active surveillance protocols (periodic rebiopsies were not mandatory/defined).
What PROTECT also showed is that after 10 years on surveillance half of the patients had undergone some kind of radical treatment.
https://www.nejm.org/doi/full/10.1056/NEJMoa1606220

Why more prostatectomies are performed is clear to me: it's the robot.
Patients are talked into it and misled sometimes that robotic surgery leads to less morbidity. It does, but only in terms of hospital stay and blood loss. It does not in terms of incontinence / sexual function. Yet I have heard urologists talk about how they "can see everything better" with the robot and "perform moves" they wouldn't be able to perform in open surgery or non-robotic laparoscopic surgery. Patients think then that if the surgeon can "see better and cut better" they are more likely to experience less side effects...

 

[Palex80]

watchful waiting = telling a 85 y/o patient with CHF and prostate Ca to go home and do nothing

Correction: ...until he gets back pain or starts urinating blood.

 

[Chartreuse Wombat]

The PROTECT trial is woefully underpowered. The primary endpoint is prostate cancer mortality and there were 17 events TOTAL in the more than 1500 patients. All PROTECT tells us is that RP has more sexual dysfunction and urinary incontinence than XRT.

 

[OTN]

5-fraction SBRT for low-risk prostate ca seems the easiest path and it's what I would choose, were I an elderly gentleman with the dx.

 

[xyz01]

Though more metastatic disease after 10 years with active surveillance, and as far as I remember about half in the active surveillance Group were treated anyway within 10 years...

 

[Radiator20]

"Surveillance" in PROTECT was not done as meticulously as usually done in standard active surveillance protocols

True. However, PROTECT was designed before active surveillance was a well established modality. Given that they were basically taking a first crack at defining how to do active surveillance, I think they did a pretty good job.

Though more metastatic disease after 10 years with active surveillance, and as far as I remember about half in the active surveillance Group were treated anyway within 10 years...

Yes on both. Thus, I think the implications of PROTECT are quite different depending on age/life expectancy. Also, the fact that active surveillance is now more intensive than was done on trial might decrease the first number by increasing the second, but of course that's just speculation.

All PROTECT tells us is that RP has more sexual dysfunction and urinary incontinence than XRT.

Those graphs are gold when discussing RP vs RT with patients. Of course, one has to see the patient in time to have that discussion...

 

[Palex80]

The PROTECT trial is woefully underpowered. The primary endpoint is prostate cancer mortality and there were 17 events TOTAL in the more than 1500 patients. All PROTECT tells us is that RP has more sexual dysfunction and urinary incontinence than XRT.

This is the POINT!
1% of all patients with factors as those entering PROTECT died from prostate cancer in the first 10 years! This has nothing to do with "underpowered", it shows once again that not-advanced and not-aggressive prostate cancer is not a problem within the first 10 years, irrelevant of what the patient chooses as primary treatment. What happens after these 10 years is another discussion. But if you see a 75 year old with a few comorbidities, who will probably be dead by 85 anyway, you don't have to push for active treatment after discussing it with him (if he fits PROTECT-criteria).

 

[Radiator20]

Well... I think Chartreuse is right from a statistical perspective. Their prespecified primary endpoint was PCSM at 10 y median f/u, comparing among AS vs RP vs RT. There were too few events to see differences between the arms, hence underpowered.

However, I think Palex is right from the larger perspective, that what this really means is that PCSM within 10y was very low regardless of treatment choice.

That said, as others have noted above, treatment was superior to AS with respect to freedom from distant mets at 10y. I bet that will eventually translate to PCSM benefit. There was also a trend towards improved PCSM with treatment in men <65y. So again, I think age and life expectancy are critical in applying these results.

 

[scarbrtj]

1% of all patients with factors as those entering PROTECT died from prostate cancer in the first 10 years!

In the WHI, after reporting an increased incidence of breast cancer of about 8 in 10,000 (this is a much less than 1% increased risk) by taking hormone replacement therapy, doctors (and the popular press) removed post-menopausal women off HRT. This was a possibly good intervention (prevent breast CA) that was not without bad consequences (cause more hip fractures, post-menopausal symptoms, etc.). And it may have not even been a good intervention because on further followup estrogen alone decreased breast CA risk substantially.

Anyhoo, for men with prostate cancer who HAVE a cancer and a ~1% risk of death from that cancer (over 5-10 years or so), we, and society, talk of not intervening and of countenancing that risk versus undergoing what can be argued to be a low-morbidity treatment (IG-IMRT, SBRT, etc.). Quite the opposite happened with breast cancer, hormone therapy, and women: due to a very mild increased risk of cancer, a good medical intervention was abandoned. A double standard. And a little sexist: for women, a therapeutic nihilism (flush your HRT pills) to prevent cancer, but for men a nihilism to accept their cancer ("Got prostate cancer? Live with it"). It's estimated that 20,000-90,000 women died over the 2002-12 time frame due to avoiding estrogen. Will there be an uptick in prostate cancer deaths (even though it's a low-mortality disease) by avoiding prostate cancer treatment? Every action has an equal and opposite reaction.

 

[xyz01]

This is the POINT!
1% of all patients with factors as those entering PROTECT died from prostate cancer in the first 10 years! This has nothing to do with "underpowered", it shows once again that not-advanced and not-aggressive prostate cancer is not a problem within the first 10 years, irrelevant of what the patient chooses as primary treatment. What happens after these 10 years is another discussion. But if you see a 75 year old with a few comorbidities, who will probably be dead by 85 anyway, you don't have to push for active treatment after discussing it with him (if he fits PROTECT-criteria).

Though I think we always forget, that active surveillance doesn't mean "no treatment for 10 years results in the same outcome than treatment" it just means they didn't recieve treatment at time of randomisation.

https://www.nejm.org/doi/full/10.1056/NEJMoa1606220 as shown in figure 2

Quite a few still recieved treatment which could be why toxicity profil is not really better in the AS-group...
So for some you "buy" some treatment free time with the need of a regular monitoring and a higher risk for metastases and disease progression and probabely have to treat him anyway....

 

[Palex80]

Though I think we always forget, that active surveillance doesn't mean "no treatment for 10 years results in the same outcome than treatment" it just means they didn't recieve treatment at time of randomisation.

https://www.nejm.org/doi/full/10.1056/NEJMoa1606220 as shown in figure 2

Quite a few still recieved treatment which could be why toxicity profil is not really better in the AS-group...
So for some you "buy" some treatment free time with the need of a regular monitoring and a higher risk for metastases and disease progression and probabely have to treat him anyway....

Absolutely correct and I stated that as well too in my first post #9:
What PROTECT also showed is that after 10 years on surveillance half of the patients had undergone some kind of radical treatment.

It also means that half of the patients did not undergo radical treatment (not necessary or their choice, we don't know).
Please also bear in mind that a sizable number of the patients in the surveillance arm of PROTECT that underwent radical treatment did that immediately after randomization. Those patients consented to the trial but were "surprised" when they landed in the surveillance group and opted for radical treatment immediately without signs of tumor progression. These are the shortcomings of transferring observations of a clinical trial to real life. Most of these patients would have probably sticked to active surveillance, had they actively opted for it and not havind been randomized to it. This does however also introduce a bias in the results of the surveillance group, since quite a few patients in that group received active treatment without having progression.

But I stand by what I said:
If a patient has a prognosis which is around 10 years regardless of his cancer, it seems that surveillance is quite a good option, bearing in mind that there is only 1% of him dying within these 10 years of prostate cancer.
Please bear in mind that we are talking about a 1% chance of dying of prostate cancer within 10 years for a patient we think there is a chance of 50% of him dying in the next 10 years due to other reasons (if we think his median survival irrespective of his prostate cancer is 10 years), right? This social security administration table says that life expectancy of US males at 75 is around 11 years, so that's not too far off 10 years.
Actuarial Life Table

Hello, Mr. Miller. You have prostate cancer. It's not aggressive. We think there's a 50% chance you will be dead in 10 years even if we radically treat your prostate cancer now.
If we do not operate or irradiate your prostate cancer immediately that chance is 51%. Do you want treatment for your prostate cancer now?

 

[scarbrtj]

In the Magic Bullet scenario, e.g. a single dose of a cancer-curing pill one could take with zero side effects, presenting a treatment/no-treatment equivalence to a patient seems wrong. Something like SBRT, as if IG-IMRT already wasn't, is getting closer to that Magic Bullet concept. The patient always has a choice to accept treatment or not. However getting off into the weeds with a crystal ball discussing competing death rates years or decades into the future I never do. I don't need any randomized data to know having prostate cancer increases your death risk. And we aren't talking about prophylactic gastrectomies here (or RP's!); we're asking men to come in and lie down on a table for a few minutes for a few days before their daily round of golf, or after mowing their lawn, for a painless X-ray with zero down-time, zero recovery time. If they don't wanna do it, fine. No big whoop. But I'm a no-hard-sale recommender.

 

[scarbrtj]

Please bear in mind that we are talking about a 1% chance of dying of prostate cancer within 10 years for a patient we think there is a chance of 50% of him dying in the next 10 years due to other reasons (if we think his median survival irrespective of his prostate cancer is 10 years), right? This social security administration table says that life expectancy of US males at 75 is around 11 years, so that's not too far off 10 years.
Actuarial Life Table

Hello, Mr. Miller. You have prostate cancer. It's not aggressive. We think there's a 50% chance you will be dead in 10 years even if we radically treat your prostate cancer now.
If we do not operate or irradiate your prostate cancer immediately that chance is 51%. Do you want treatment for your prostate cancer now?

If 65yo guy comes in, I assume you don't say:
Hello, Mr. Miller. You have prostate cancer. It's not aggressive. We think there's a 50% chance you will be dead in 20 years even if we radically treat your prostate cancer now.
If we do not operate or irradiate your prostate cancer immediately that chance is 52%. Do you want treatment for your prostate cancer now?
Although it would logically follow... it doesn't seem right to have that discussion. But it seems right for the 75yo guy. Ageism! (And in point of fact, healthy 75yo's have about a 15-20y average lifespan. This is not accounted for in the SS tables. Once you make it to 75 and aren't knocking on death's door, you have kind of proved you're a longer-liver I suppose.)

 

[xyz01]

Absolutely correct and I stated that as well too in my first post #9:
..........is that after 10 years on surveillance half of the patients had undergone some kind of radical treatment.

It also means that half of the patients did not undergo radical treatment (not necessary or their choice, we don't know).
Please also bear in mind that a sizable number of the patients in the surveillance arm of PROTECT that underwent radical treatment did that immediately after randomization. Those patients consented to the trial but were "surprised" when they landed in the surveillance group and opted for radical .......

Sorry, I may have overlooked your earlier post.

I get what you are saying, and I also think that active surveillance is a perfectly fine option for a patients if they are aware of the consequences.

Regarding your 75year old: so you put him on active surveillance, do regular PSA-checks, maybe Re-biospies and when he has PSA/Gleason Progression when he is 80 . Do you treat then as in the study arm? (to get the same OS) Or do you say "na.... your disease is more agressive now, but you may only life for 5 years now, come back if you have any pain"

 

[Palex80]

If 65yo guy comes in, I assume you don't say:
Hello, Mr. Miller. You have prostate cancer. It's not aggressive. We think there's a 50% chance you will be dead in 20 years even if we radically treat your prostate cancer now.
If we do not operate or irradiate your prostate cancer immediately that chance is 52%. Do you want treatment for your prostate cancer now?
Although it would logically follow... it doesn't seem right to have that discussion. But it seems right for the 75yo guy. Ageism! (And in point of fact, healthy 75yo's have about a 15-20y average lifespan. This is not accounted for in the SS tables. Once you make it to 75 and aren't knocking on death's door, you have kind of proved you're a longer-liver I suppose.)

We dont have data on how many patients die 10–20 years after starting surveillance from the Protect trial, thus your argument is wrong.
For all we know, there may be a lot of deaths at 15 years after starting surveillance. Follow up is short and 15 years down the road are relevant for a 65 year old patient. It‘s less relevant for a 75 year old.

 

[scarbrtj]

...thus your argument is wrong. For all we know, there may be a lot of deaths at 15 years after starting surveillance.

I'm a hypothesizer/extrapolator. Maybe the per annum death rates stay constant over time, even out to 20y. Either way, if you're going to try and predict the future 10 years from now with 75yo patients, why not try to predict the future 20 years from now with 65yo patients?

 

[Mandelin Rain]

It could also be pointed out that just because someone doesn't die of prostate cancer doesn't mean that progressive prostate cancer didn't severely impact their QOL.

 

[medgator]

Years of xgeva, Lupron and bone mets secondary to a lack of definitive tx is no way to live out retirement

 

[Mandelin Rain]

No, he didn't die of prostate cancer. He was on Lupron and it was working. He died of an acute MI/Stroke.

 

[DoctwoB]

In the Magic Bullet scenario, e.g. a single dose of a cancer-curing pill one could take with zero side effects, presenting a treatment/no-treatment equivalence to a patient seems wrong. Something like SBRT, as if IG-IMRT already wasn't, is getting closer to that Magic Bullet concept. The patient always has a choice to accept treatment or not. However getting off into the weeds with a crystal ball discussing competing death rates years or decades into the future I never do. I don't need any randomized data to know having prostate cancer increases your death risk. And we aren't talking about prophylactic gastrectomies here (or RP's!); we're asking men to come in and lie down on a table for a few minutes for a few days before their daily round of golf, or after mowing their lawn, for a painless X-ray with zero down-time, zero recovery time. If they don't wanna do it, fine. No big whoop. But I'm a no-hard-sale recommender.

This is the kind of talk that makes me hesitant as a urologist to send every patient to rad onc before operative intervention (note that i send a majority because I feel all options should be discussed by an appropriate expert in the field). Radiation is not a magic bullet. It's a valid treatment modality with a risk-benefit profile, much like radical prostatectomy. Many complications of radiation are never seen by you or any other radonc. There is a reason that many Urologists are anti-radiation, and its not only that we're biased (which of course we are), but because we see the consequences. I can't tell you how many patients i've seen in my office ruing the day they agreed to XRT, just as i'm sure you've seen many salvage patients ruing the day they had their prostatectomy. I'll be publishing data shortly from our center, detailing hundreds of operative interventions performed for post prostate XRT complications. I do this not even to claim that XRT is terrible and surgery is better, but that the view of XRT as a benign intervention is misguided. Your view is just as misguided as a Urologist saying that their patients can't have incontinence/impotence because of their advanced robotic reconstructive technique.

Furthermore, because XRT (or surgery) is not a benign intervention, we should not be even offering them to patients who will recieve no benefit, such as patients with low or very low risk prostate Ca on AS or almost anyone with a life expectancy < 10 years. Clearly both urologists and radoncs are at fault here. I do think that there are still areas of question in the data where treatment is reasonable, like what to do with the 50 year old with high volume gleason 6 disease, or the older patient with a <10 year life expectancy but with high risk disease, where you may not extend their life but may prevent mets related symptoms and morbidity.

 

[xyz01]

This is the kind of talk that makes me hesitant as a urologist to send every patient to rad onc before operative intervention (note that i send a majority because I feel all options should be discussed by an appropriate expert in the field). Radiation is not a magic bullet. It's a valid treatment modality with a risk-benefit profile, much like radical prostatectomy. Many complications of radiation are never seen by you or any other radonc. There is a reason that many Urologists are anti-radiation, and its not only that we're biased (which of course we are), but because we see the consequences. I can't tell you how many patients i've seen in my office ruing the day they agreed to XRT, just as i'm sure you've seen many salvage patients ruing the day they had their prostatectomy. I'll be publishing data shortly from our center, detailing hundreds of operative interventions performed for post prostate XRT complications. I do this not even to claim that XRT is terrible and surgery is better, but that the view of XRT as a benign intervention is misguided. Your view is just as misguided as a Urologist saying that their patients can't have incontinence/impotence because of their advanced robotic reconstructive technique.

Furthermore, because XRT (or surgery) is not a benign intervention, we should not be even offering them to patients who will recieve no benefit, such as patients with low or very low risk prostate Ca on AS or almost anyone with a life expectancy < 10 years. Clearly both urologists and radoncs are at fault here. I do think that there are still areas of question in the data where treatment is reasonable, like what to do with the 50 year old with high volume gleason 6 disease, or the older patient with a <10 year life expectancy but with high risk disease, where you may not extend their life but may prevent mets related symptoms and morbidity.

I am quite curious what intervention you are talking about. At our institution we have been following up the fast majority of our patients for 10 years after primary treatment and it never felt that the number for post treatment intervention is really high...
Active surveillance is also not completely benign as you have to do re-biopsies quite frequently in the first years and if Gleason/PSA Progression occurs you may have to deal with slightly more toxic treatment (at least with RTX e.g. short or long term ADT with radiation treatment vs radiation treatment /brachy alone...)
If a ptient is willing to compromise for this (and some higher chance for disease progression) AS is a perfectly fine option even for younger patients.
For patients with really limited life expectancy I think watchful waiting is the better option.

 

[Mandelin Rain]

My long-term prostate follow ups are usually the best part of my day.

 

[Palex80]

I believe that death rates will pick up the longer the follow up with active surveillance is. Do I have data to prove it? Not solid. But...

Concerning metastatic disease during active surveillance: 33/544 men on surveillance developed it; that is 6%.
In the active treatment groups it was rather half, around 3%. I presume that those 6% would probably die sonewhere between year 11-15 in PROTECT with longer follow up. Perhaps not all of them because of metastatic disease, but perhaps half (?). This would mean around 4% deaths by year 15 because of prostate cancer.

So...
Mr. Miller receiving a diagnosis at the age of 75 has 10 year later a chance to die from other causes of 50%, a chance to die of prostate cancer of 1% and a chance to develop metastasis of 6% if he opts for surveillance.

 

[OTN]

While I don't think anyone here would say radiation therapy is benign, the data on SBRT for low-risk prostate ca looks very good, with grade 3+ GI toxicity of 0% at 3 years and 3+ GU toxicity of 1.3-1.5% depending on the trial, with 98-100% biochemical control of low-risk disease.

 

[seper]

Are these toxicity data mature for > 10 years? Have not read the recent papers. That's what wold sway me to use SBRT for what is essentailly benign disease. BFS is not really important as active surveillance shows low death rates, anyway.

While I don't think anyone here would say radiation therapy is benign, the data on SBRT for low-risk prostate ca looks very good, with grade 3+ GI toxicity of 0% at 3 years and 3+ GU toxicity of 1.3-1.5% depending on the trial, with 98-100% biochemical control of low-risk disease.

 

[Radiator20]

I think urologists and rad oncs are prone to very different impressions of late RT toxicity based on whom we see.

Rad oncs should be following our patients and seeing more or less a representative cross-section of post-RT patients.

Urologists would in many cases be seeing them only if they have problems--late RT cystitis, etc. Rare, but maybe not from the perspective of the urologist who is involved with managing them.

The benefit of toxicity data from prospective trials is minimizing such bias.

 

[OTN]

Are these toxicity data mature for > 10 years? Have not read the recent papers. That's what wold sway me to use SBRT for what is essentailly benign disease. BFS is not really important as active surveillance shows low death rates, anyway.

The trial reporting the longest follow-up had a median f/u of 72 months- most others are in the 3-4 year range, so it's important to counsel patients about this when consulting.

 

[scarbrtj]

This is the kind of talk that makes me hesitant as a urologist to send every patient to rad onc before operative intervention (note that i send a majority because I feel all options should be discussed by an appropriate expert in the field). Radiation is not a magic bullet. It's a valid treatment modality with a risk-benefit profile, much like radical prostatectomy. Many complications of radiation are never seen by you or any other radonc. There is a reason that many Urologists are anti-radiation, and its not only that we're biased (which of course we are), but because we see the consequences. I can't tell you how many patients i've seen in my office ruing the day they agreed to XRT, just as i'm sure you've seen many salvage patients ruing the day they had their prostatectomy. I'll be publishing data shortly from our center, detailing hundreds of operative interventions performed for post prostate XRT complications. I do this not even to claim that XRT is terrible and surgery is better, but that the view of XRT as a benign intervention is misguided. Your view is just as misguided as a Urologist saying that their patients can't have incontinence/impotence because of their advanced robotic reconstructive technique.

Furthermore, because XRT (or surgery) is not a benign intervention, we should not be even offering them to patients who will recieve no benefit, such as patients with low or very low risk prostate Ca on AS or almost anyone with a life expectancy < 10 years. Clearly both urologists and radoncs are at fault here. I do think that there are still areas of question in the data where treatment is reasonable, like what to do with the 50 year old with high volume gleason 6 disease, or the older patient with a <10 year life expectancy but with high risk disease, where you may not extend their life but may prevent mets related symptoms and morbidity.

I never tell a patient radiation is benign. That’d be lying, or prophecy. What is benign treatment? It’s subjective. The Magic Bullet scenario is a gedankenexperiment. Don’t let it bother you. But let’s say you had an RP patient with zero long term side effects who was cured. And an SBRT prostate patient with zero long term side effects who was cured. (And not to mention no need for preop clearance, the need for catheter periop, SBRT is cheaper, etc). Which scenario is closer to the Magic Bullet? Urologists would have never countenanced HIFU or cryo without engaging in Magic Bullet thinking.

I'll be publishing data shortly from our center, detailing hundreds of operative interventions performed for post prostate XRT complications.

"Hundreds" is the numerator. Care to share the denominator?

 

[MegaVoltagePhoton]

The trial reporting the longest follow-up had a median f/u of 72 months- most others are in the 3-4 year range, so it's important to counsel patients about this when consulting.

There is also the recent update with median 7 year followup confirming the earlier toxicity reports

 

[scarbrtj]

Mr. Miller receiving a diagnosis at the age of 75 has 10 year later a chance to die from other causes of 50%, a chance to die of prostate cancer of 1% and a chance to develop metastasis of 6% if he opts for surveillance.

Why are you so pessimistic about Mr. Miller? He's my neighbor, I know him well. He is 75, married, 5'9"/150lbs, exercises, never drinks, never smokes, and doesn't have any health problems. He's got a less than 25% chance of dying in 10 years.

 

[Palex80]

Why are you so pessimistic about Mr. Miller? He's my neighbor, I know him well. He is 75, married, 5'9"/150lbs, exercises, never drinks, never smokes, and doesn't have any health problems. He's got a less than 25% chance of dying in 10 years.

Sure, if Mr. Miller is above-average healthy he is not going to die in 10 years. But I was refererring to the average patient.

 

[DoctwoB]

I never tell a patient radiation is benign. That’d be lying, or prophecy. What is benign treatment? It’s subjective. The Magic Bullet scenario is a gedankenexperiment. Don’t let it bother you. But let’s say you had an RP patient with zero long term side effects who was cured. And an SBRT prostate patient with zero long term side effects who was cured. (And not to mention no need for preop clearance, the need for catheter periop, SBRT is cheaper, etc). Which scenario is closer to the Magic Bullet? Urologists would have never countenanced HIFU or cryo without engaging in Magic Bullet thinking.

"Hundreds" is the numerator. Care to share the denominator?

Key limitation, don’t have the denominator. Will try to estimate from claims data but is obviously a flawed metric. Won’t be making claims on rates of complications or comparing to surgery. More just raising awareness about long term morbidity often not raised in fu duration of randomized trials.

 

[scarbrtj]

Sure, if Mr. Miller is above-average healthy he is not going to die in 10 years. But I was refererring to the average patient.

I hope every rad onc is doing some type of lifespan estimation analysis (preferably algorithmic versus a WAG, right?) on all prostate patients. We can assume no one is average, no matter his age.

 

[scarbrtj]

JAMA study
Why more low-risk prostate cancer patients are forgoing treatment - CNN


The researchers found that, among men with low-risk disease, the use of active surveillance increased while the use of radical prostatectomy -- or removing parts of the prostate gland -- decreased from 47.4% in 2010 to 31.3% in 2015. The use of radiotherapy also declined, falling from 38% in 2010 to 26.6% in 2015, the researchers found.
Among men with intermediate-risk disease, between 2010 and 2015, active surveillance increased from 5.8% to 9.6%; prostatectomy decreased from 51.8% to 50.6%; and radiotherapy went from 42.4% to 39.8%, the researchers found.
Among men with high-risk disease, active surveillance remained nearly unchanged, going from 1.9% to 2.2%; prostatectomy increased from 38% to 42.8%; and radiotherapy decreased from 60.1% to 55%, the researchers found.

If you never get a PSA, you really forgo treatment.
Prostate Cancer Mortality Progress Stalls, Prompting Questions About PSA Policies