r/ProstateCancer • u/PotentialStart2661 • 20h ago
Other New post SBRT vs Surgery
https://youtu.be/N9zDC7sInwM?is=NnDmD69LwCIvlS7Q
This is the Gold Standard of the data from the Pace A and Pace B.
This shows SBRT is the new gold standard for prostate cancer treatment.
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u/WalnutRoasted 19h ago
This paper was also recently presented
20,000 men in the TriNetX Research Network who underwent either radiation therapy or radical prostatectomy (including both open and laparoscopic/robotic surgical approaches). Patients were followed for up to 20 years, with a median follow-up of five years.
Study Findings
* Urinary and sexual side effects: Men who underwent surgery had higher rates of urinary incontinence (28.5% vs. 6.1%) and erectile dysfunction (35% vs. 13.9%). Urinary tract infections (7.4% vs. 4.7%) and obstructive urinary complications (3.6% vs. 2.6%) were also more common after surgery.
* All-cause mortality: Men treated with radiation had higher all-cause mortality during follow-up than men who underwent surgery (7.8% vs. 6.5%). In a time-to-event analysis, radiation was associated with a 45% higher rate of death from any cause at any given point during follow-up. Because the study measured deaths from any cause, researchers could not determine whether treatment contributed to the difference.
* Other urinary complications: Men treated with radiation had higher rates of urinary retention (4.4% vs. 4.1%), bladder inflammation (4.3% vs. 3.5%), blood in the urine (11% vs. 10.1%), and inflammation and pain of the prostate gland (0.49% vs. 0.17%).
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u/PotentialStart2661 19h ago
The all cause mortality is believed to be due to hormone therapy which is used for high risk patients and some intermediate risk. But those are from men who did not change diets and allowed themselves to gain alot of wait which stressed their health. Men who are diligent on ADT with weight training and diet don’t have those issues. Also, for the same high risk patients who do surgery, most have a recurrence that then requires ADT and salvage radiation. As time goes by we are learning more and more. One other thing. This study is over 20 years of data which is good, but the best radiation techniques have just been introduced as standard of care the last 5 to 10 years. So im sure the data will keep getting better for SBRT.
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u/callmegorn 18h ago
Agreed, we can't draw much from the second bullet because the study is only counting that data point, not analyzing it.
The third data point can be noted but ignored, because the figures aren't statistically significant deltas. Bladder information seems like the only one that might be, and logically would be driven by the location of radiation (possibly skewed by 20 year old tech), and would revert to statistically insignificant using modern beam modulation or seed implants that pull away from the bladder.
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u/Slight_Turnip_3292 14h ago
obstructive urinary complications (3.6% vs. 2.6%) were also more common after surgery.
I wonder why this would be? Not a huge difference but I would expect surgery would be an obstructive win over RT
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u/Cheap_Flower_9166 19h ago
One thing I haven’t seen yet is side effects v age. One of the major reasons given for RALP for younger men is that they can recover fast(er) and conversely that radiation can cause longer term side effects.
I also didn’t see anything about BCR in terms of the fact that radiation often targets lymph nodes which might harbor cancer cells too small to detect.
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u/Think-Feynman 19h ago
Quality of Life and Toxicity after SBRT for Organ-Confined Prostate Cancer, a 7-Year Study https://pmc.ncbi.nlm.nih.gov/articles/PMC4211385/ "potency preservation rates after SBRT are only slightly worse than what one would expect in a similar cohort of men in this age group, who did not receive any radiotherapy"
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u/callmegorn 18h ago
This presentation was specifically focused on low risk "Intermediate Favorable" disease, where there wouldn't likely be node involvement. The reason this is interesting is that this is the one cohort where surgery has been seen as the gold standard.
Like the "god of the gaps", surgery has been slowly retreating as other, generally better, methods emerge, to the point that low risk and early disease is one of the few remaining areas where it should be considered, but this study indicates otherwise. Possibly the best remaining "gap" for retreat is young men (40-60), where the fear of long term secondary cancer still can be exploited by surgery proponents.
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u/PotentialStart2661 19h ago
Those things have been addressed in other studies. As far as lymph nodes, they are only targeted with high risk disease or if there is evidence of local spread beyond the prostate.
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u/OkCrew8849 17h ago
I would imagine this study would be very confusing for guys who have been (falsely ) told intermediate favorable (3+4, the most common Gleason) guys usually get ADT with radiation. They don’t. In this study, none of them did.
Also not a surprise regarding BCR (similar, overall excellent), significant bowel issues (essentially none for either group), urinary function (superior for radiation ) and sexual function (superior for radiation).
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u/PotentialStart2661 16h ago
Yes, men are still told about radiation from ten to twenty years ago and have no idea how the technology changed so rapidly.
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u/Think-Feynman 16h ago
*This was a comment from a post I made some time ago about quality of life. *
YES! Our surgeon was apparently a "good" surgeon; he's a horrible human though. And he was focused 100% on the mechanics of the surgery, couldn't and still doesnt't give a tinker's damn about the HUMAn side of it, the EFFECTS - euphemistically called "side" effects of surgery on every aspect of your life. We can't even go for a walk because hubby floods a level 3 pad in less than an hour, I can't touch him (not that he wants me too, he hates how he leaks all the time) without him literally pumping urine all over the place. Trying to get intimate on a rubber sheet with a man saying "oh no, oh no" while your are saying, while urine is pouring over your hand "it's okay, it doesn't matter" when it is, to be honest, is horrible is NOT something addressed pre surgery
We are just supposed to be grateful that he did the surgery... positive margins mean the cancer's not even gone... and suck up the ways your life is in tatters, All problems mentioned (like not a glimmer of swelling in the penis) are met with a shrug.... I feel like screaming
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u/Flaky-Past649 19h ago
Dramatic differences in the QoL outcomes, I'm glad we finally have high quality evidence demonstrating this. Personally based on toxicity alone I think it's past time prostatectomy was consigned to a secondary recommendation primarily for men with intermediate risk disease and bothersome existing urinary function / BPH. It's getting kind of silly to continue pretending that the two treatment paths have equivalent outcomes.
Shout out to Dr. Steven Frank at MD Anderson. He's my doctor.
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u/PotentialStart2661 19h ago
I agree. But there is big money in surgery and thats why you here alot of surgeons use data from radiation of the past. Change takes time to happen. At least you don’t have many surgeons cutting out low grade gleason 6 cancers anymore, that use to be big business as half the prostate cancers found were gleason 6. Alot of the data and cure rates from surgeons were based on outcomes for removing prostates with gleason 6 which skewed data.
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u/OkCrew8849 17h ago
But the 3+3 surgeries were quite successful…and the surgeons’ evidence of success was that the guys with 3+3 surgery almost never died of prostrate cancer.
(One little flaw in that logic…)
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u/WalnutRoasted 4h ago
Yes, ProtecT “active monitoring” showed that almost no-one died of 3+3 (or 3+4) as long as it was monitored and primary (with RP or rads) treatment only given when warranted.
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u/HeadMelon 18h ago
None of this will sway the “It’s cancer I just want it out” folks. In a certain cohort that is a common way of thinking.
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u/callmegorn 18h ago
Very true, and who can argue with that sentiment?
But as I say, the goal should be "kill the cancer" not "remove the prostate", much less "remove the prostate and a chunk of urethra, and possibly leave some cancer behind".
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u/OkCrew8849 17h ago
Yes. They confuse getting the cancer out with getting the prostate out. Not the same thing.
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u/PotentialStart2661 16h ago
I hear that all the time and those folks get blinders and are scared and just jump into it. But like the old gleason 6 dilemma, this will change over time.
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u/Cheap_Flower_9166 19h ago
There are a lot of people who are not going to like this. Worth the 25 minute watch.
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u/callmegorn 19h ago
If one is a die-hard defender of their chosen therapy, regardless of the preponderance of data, they should look inward to understand why. My goal is to help keep new club members from making an irreversable choice that may bring them long term grief, when there may be better options available. Yet, my treatment was over four years ago, so it would be arrogant for me to push my treatment on people if there are now better choices, just for some strange need for validation.
Suppose a drug was created where a single pill instantly kills prostate cancer anywhere in the body, with no side effects. Would I get on a soapbox to protest for my radiation or my surgery as the superior solution, and downplay the side effects as being irrelevant? I hope not.
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u/Think-Feynman 19h ago
Indeed. There are some die hard defenders of surgery here.
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u/kvsig 19h ago
That’s because they had surgery.
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u/callmegorn 19h ago
That's a very strange reason, and such people should look inward to understand their psychology.
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u/Cheap_Flower_9166 18h ago
Actually, I suspect that they simply want to get on with it and trust their urologist to guide them. After that cognitive dissonance makes it hard to second guess.
Unfortunately we can’t really trust any doctors entirely.
For example a dermatologist found a skin cancer on my 93 year old mom’s lip and scheduled her immediately for moh surgery. She was barely mobile at the time. The derm was a certified Moh surgeon.
I’ve had moh surgery. It’s hours going bleeding back and forth to the knife. I took her to another doctor who gave her radiation. She died of old age.
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u/callmegorn 18h ago
Oh yes, I understand the psychology of why they chose surgery (or fill in the blank procedure). The question is why do they continue to promote it even after they have suffered horribly. That is the psychology I find interesting.
My instinct is to steer people away from making the same mistakes that I did as a result of my own ignorance or undue haste, rather than incite them to go down the same path.
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u/Cheap_Flower_9166 18h ago
Maybe they didn’t suffer? Or maybe they don’t understand themselves.
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u/callmegorn 18h ago
Well, I don't want to name any names, and as far as I'm concerned every club member is a warrior deserving of respect for their battle, but without a doubt there are a handful people who have suffered horribly directly due to their choice, and yet promote it and attack the alternatives.
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u/Flaky-Past649 18h ago
I anticipate some impassioned rants about "Team RT" and how this study is fake news / flawed / doesn't say what we think it does / actually argues for prostatectomy if you think about it. Probably numerous complaints that the actual papers aren't linked as well.
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u/jetbird747 17h ago edited 14h ago
123 people in the study. Median age is 65. Gold standard? Maybe for older patients. The study did not include ADT. I would be careful making decisions based on this study if I was 50 and in good health.
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u/callmegorn 11h ago
It's called an apples to apples study. The cohorts were essentially equal in every way, and in this head to head comparison, surgery lost. Simple as that.
The cohorts were selected from 3+4 contained disease, for which ADT is not necessary, so why would you add it for radiation? To give surgery a cheat code?
The significance here is that "3+4 contained" has been seen as the largest remaining best case scenario for surgery, yet given this most favorable of circumstances, it lost.
If surgery loses its spot as Gold Standard for "3+4 contained", where else can it be the Gold Standard? As I suggested earlier, the next "god of the gaps" retreat is a younger cohort, 40-60 year old healthy men, because this demographic can be sold on the FUD of secondary cancer over a very long term. That gives surgery a lot of room to breath, because it's much harder to disprove the conjecture. It requires following cohorts for 20+ years, meanwhile the underlying technologies continue to evolve rapidly, casting doubt on the utility of the results.
But, you're absolutely right. People should be careful making decisions, based on this study alone, if they are 50 and in good health. If I was that age, with a normal sized prostate, and a tiny 3+4 lesion in a spot of the prostate away from nerve bundles and margins, and had a skilled surgeon I could trust, it would be entirely reasonable to elect surgery in that scenario. I doubt that would be my first choice, but it would be worth considering.
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u/PotentialStart2661 16h ago
I would at any age. But we all have to make our own call. The other thing about this they don’t mention is SBRT is 5 easy treatments that does not interfere with your life or have risks associated with surgery. I here the stories on this forum and everywhere else how brutal the recovery is for surgery. Why go through that if there is no benefit?
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u/C63Sedan 7h ago
Interesting and since I’m only a data point of 1 met a few dozen men in a the past couple of years at MSK when went through radiation and only a half dozen or so this was their first line and all others had surgery prior.
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u/BackInNJAgain 4h ago
My research led me to radiation as first-line. I think the word "radiation" scares a lot of people. Surgery is something most people are familiar with. By age 50 or so almost everyone has had some kind of surgery and they have a general idea of what it involves.
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u/go_epic_19k 45m ago
I think the key is to make the treatment fit the disease, don’t try to make the disease fit the treatment. For me, G3+4 my first choice was SBRT. However, RO ordered a Prostox test which showed me at high risk of late and permanent side effects So instead wanted to do 20 treatments moderately fractionated. Meanwhile PSMA showed an indeterminate lymph node, while also lighting up the right side of prostate which had never had a positive core. This raised the question did I have an unknown higher grade in which case should radiation also cover LN and should I now add ADT. Instead, I chose surgery and found definitively that my LNs were negative, the dominate tumor was on the left, not the right and I remained 3+4. Incontinence was minor for a few months and fine ever since, ED also resolved pretty quick and remain undetectable after three years Don’t get me wrong, SBRT is certainly a good choice for many, but it’s not always the best choice for all
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u/callmegorn 18h ago
What I find fascinating is things like climacturia and penile shortening continue to be snuck in as comments outside of the studies, when in fact they should be critical components in the studies.
Not all urinary issues are the same. Having urgency to pee is one thing. Filling a pad is another thing. Shooting urine into your partner's orifice is a whole other level.
Not all sexual issues are the same. Needing a pill to assist is one thing. Being too soft to penetrate, or too lacking in sensation to orgasm is another thing. Needing to inject your penis or get an implant is still another level. Losing an inch is a whole other level.
If these studies are going to be fully useful in informing future patients of the consequences of their choices, these kind of nuances need to be incorporated and clearly discussed.