One Man to Another
Where We Stand In Trying To Be “Cured”
(Is 98% rate of non-recurrence a realistic goal?)
by Jules Reichel
This is not a doctor’s column. I am a patient of Dr. Catalona and a member of the URF Board. This column attempts to provide a patient’s perspective on prostate cancer to the readers of QUEST.
To review my prior columns, please see Dr. Catalona’s Website, www.drcatalona.com. Click on the button on the front page to select my articles.
While the continuing reduction in suffering and death is obviously important in the treatment of prostate cancer, doctors are also beginning to produce a kind of roadmap for how reliable long-term remission, or “cure” can be achieved.
Those good results and the ideas about achieving long-term remission are not well understood by most men.
In articles by lay writers and in too many lectures by doctors, the impression is left that little progress has been made in treatment. These people argue that there are so many therapies and so many strains of prostate cancer that outcomes are as uncertain as a game of dice, so why not just wait and see? Maybe it’s better to opt for an unusual alternative?
Others add that it’s very likely that we will die with prostate cancer not from it, so why endure treatment? And others say that the disease is usually systemic so why use local therapies like surgery? And, they add, where is the scientific proof that local therapy works?
All these negative arguments are either false or misleading or both.
Unfortunately, though, these types of comments cause confusion and despair, and too often result in procrastination.
Men put off taking proper action. And it’s the proper action, taken in a timely fashion, which is going to produce the 98% non-recurrence rate.
All of the studies have not yet been done to make a reliable prediction, but it is my opinion that, within 5 to 10 years, a national leader like Dr. Catalona will be able to offer his patients a 98% probability of 10-year non-recurrence after surgery, with salvage radiation therapy when required.
Such treatments are not a cure because they all damage the prostate, but they do promise a full high-quality life after therapy—and that’s a wonderful result.
Best of all, many of these therapies are either available to us now, or will soon be available.
I will call this 10-year non-recurrence a “cure” even though some will object.
I became convinced that “cure” was possible when I studied the results in Catalona 1999.
All patients, from the lowest risk group to the highest, who were treated with PSA values in the range 2.6 to 4.0ng/ml, showed outcome patterns in which recurrence would primarily occur within the first two years after surgery.
In that data set no recurrences occurred during the 3rd through 6th year, although some recurrences do occur at even later times, as might be expected with men who start out with low PSA values.
This flatness of the recurrence curve suggests the possibility of a long term “cure” for most patients. Recurrence means that the PSA is rising and has exceeded some threshold value: usually 0.2 or 0.3ng/ml.
The last issue of QUEST describes the lowering of the threshold for screening to the range of 2.6 to 4.0ng/ml with the likely result of a “cure” rate of about 90% to 95%.
Best of all, there is now an explanation of why we get the improved “cure” rate. “Cure” is mostly achieved by treatment at small tumor volumes.
Dr. Catalona reported that when the volume of tumor was less than 10% of the volume of the prostate, and the disease was confined to the prostate (organ confined), then the “cure” rate for all of his 3500 patients was 88%.
“Cure” rate declines as the percentage of the prostate occupied by tumor increases. If the percent of tumor in the prostate exceeds 30%, then the “cure” rate declines to 59%. The merit of low PSA screening thresholds is that it permits the treatment of smaller tumors.
The “cure” rate at the lower screening threshold will be higher than 88%, as shown above. The 88% “cure” rate is pessimistic (that is, too low) because it combines both high-risk patients with the majority of men who will get much better results.
Dr. Walsh’s team published a corresponding study to Dr. Catalona’s work, and patients with small non-palpable tumors who had Gleason Scores less than 7, had a “cure” rate of 96%.
However, even this 96% result is pessimistic (too low) since they could have included patients with a wider range of Gleason Scores who had been screened at the lower PSA threshold of 2.6 and 4.0ng/ml.
Gleason pattern readings of 3+4 (a Score of 7), measured at the lower screening threshold, have about the same characteristics as a Gleason Score 6 measured up to a PSA reading of 10.0ng/ml as in Walsh’s data.
If we therefore extend Walsh’s result to include Gleason Score 3+4=7 by assuming that the doctors use the lower PSA screening thresholds, then the 96% “cure” rate should be available to over 90% of all of Dr. Catalona’s patients.
A few radiation oncologists who use high dosage rates claim a similar result of 96% “cure” rate for conditions comparable to those used by Dr. Walsh.
Some cases will recur and follow-up therapy is needed.
I’ve previously written that in my judgment, most options offered for recurrent prostate cancer are not very attractive and usually have very unpleasant side effects, but they are in widespread use.
If prostate cancer is not stopped during the period of local recurrence, then metastasis occurs, and although the medical options are greatly hyped by their developers, their benefit to the patient has so far been slight—with some surprisingly good exceptions for individual cases.
Salvage radiation in the event of recurrence after surgery has been the favored option, but study results have been variable and often poor over 10 years.
However, in a recent study by the Mayo Clinic, the salvage radiation dose was raised to exceed 64.8Gy (Gy is pronounced “Gray”).
At this high radiation dose level, and with patients who were treated before their PSA values exceeded 0.6ng/ml, Mayo had 77% rates of non-recurrence at 5 years (that’s potentially 77% of the 5% to 10% of patients who recur when using the lower screening and treatment threshold).
Their rule of less than 0.6ng/ml is consistent with Dr. Catalona’s rule of treating recurrence at a PSA value of 0.3ng/ml.
Startlingly, the Mayo team found that if the patient waited until his PSA exceeded 1.2ng/ml, then his 5-year non-recurrence rate was 0%! The window of opportunity, for excellent radiation salvage outcomes after a recurrence, is a small one.
However, a patient should be cautious when considering such a use of radiation. Some recent studies are now reporting negative outcomes from simple colonoscopy procedures taken after high levels of radiation have weakened the colon wall.
In this article, I have freely combined work from Drs Catalona and Walsh and from the Mayo Clinic. I don’t claim it as proof. It’s just my attempt to clarify approximately how much progress is being made.
Much work is left to do. Most importantly, doctors need to provide a major long-term data set that includes lower screening thresholds, early detection of more aggressive tumors, and coordinated use of effective salvage radiation. What we now have are piecemeal results that may have inconsistencies and have not been evaluated over a 10-year period.
Nevertheless, my estimate of 98% “cure” rate in 5 to 10 years under the guidance and treatment of national experts like Dr. Catalona seems like a very achievable goal. That excellent possibility should encourage men to actively screen for prostate cancer and, when appropriate, to consider the use of these latest therapies in a timely way.
You are encouraged to offer comments or ask questions about this column by contacting Dr. Catalona at his website: www.drcatalona.com (see "contact us"), or by sending me an e-mail at firstname.lastname@example.org. Please include the word "QUEST" in the subject line when sending me an e-mail.
Click here to read the next article, New Practices + Improved Techniques = Better Outcomes, in the One Man to Another series from Jules Reichel.