Life – Terror. Ecstasy. Fight. Denial. Flight. Failure. PAIN. Forgiveness. Reconciliation. Hope. Love. Peace – Death.
Advanced Prostate Cancer, 6 years in – 7 consultants (never ever told I had a new consultant, I just had a new Doctors name on my appointments letters). I have never been advised about any ‘alternative’ cancer treatment options (available), never had any advice about trials. Rightly, or wrongly, all of my treatment choices have been 100% my own decision? Accountability? Thing is, I am not the expert in the room?
Have I made the right choices?
The most common treatment options for men with clinically localized prostate cancer include radical prostatectomy and radiation therapy. The choice between these options is often controversial. Selecting the optimal treatment poses a great challenge for patients and physicians.
Factors important to the decision include age and life expectancy of the patient, the natural history of the prostate cancer, how curable the disease is, and the morbidity of treatment. Use of these criteria to select treatment for a healthy, 70-year-old man presenting with a nonpalpable tumor, stage T1c disease, serum prostate-specific antigen of 12 ng/mL, and an adenocarcinoma with a Gleason score of 8 that is present in 2 of 12 biopsy cores would lead to the choice of radical prostatectomy over radiation therapy.
Data show that such a patient has a life expectancy of more than 12.3 years if the prostate cancer can be cured and a high probability of dying from the disease if it is not cured.
Data further show that radical prostatectomy in such a patient would confer a survival advantage over radiation therapy without resulting in greater complications or reduction in quality of life.
You want your prostate cancer treatment to be successful. But how does one measure prostate cancer treatment success?
Often, a successful prostate cancer treatment is measured by survival. If the patient does not die during treatment, was the treatment successful? Even if the cancer returns?
Measuring the Prostate Specific Antigen (PSA) level is still the most widely used method, the most common test to measure success of treatment (and occurrence/reoccurrence) of prostate cancer.
Regardless of the treatment you receive, it is the test you will have each time you have a medical consultation, it is the test you and your doctor will use to determine if your cancer is controlled or not.
If PSA levels become elevated, it will trigger further tests and very likely further treatment. The tests and subsequent procedures following an elevated PSA level after treatment can significantly worsen the quality of your life. Before deciding on an initial treatment, you need to understand how well that treatment does at controlling the cancer. What is the chance that you will need further treatment? PSA progression rates provide a framework, a model to compare different treatments.
Initially, PSA is used as a cancer screening tool. But after treatment, PSA is used to monitor for the recurrence (advancement) of cancer. Using survival as the measure for a successful prostate cancer treatment does not tell you whether the cancer is gone. Only PSA level can tell you that. Even if you fail the initial treatment, you can live with prostate cancer for many years.
However, one frontline treatment can have a prostate cancer control rate of 80%, but because patients can live with their cancer for a long time, the survival rate may be 90%. It is important to know the likelihood of requiring additional treatment and also the effects of additional treatment. Failure of primary prostate cancer treatment will have an impact on quality of life.
“Percent PSA Progression Free”, is an estimate, prior to treatment, of a particular treatment failure rate, and the likelihood of not requiring additional treatment. Survival measurement (alone) does not provide this important information.
If the survival rate of competing treatments are equal, this does not mean the cancer control rate, long term side effects, or the quality of life are equal. After initial treatment, a rising PSA level indicates treatment failure?
For this reason it is a strong indicator of a successful prostate cancer treatment. Survival reflects not only cancer treatment deaths but also all other reasons for death. For example, comparing a younger patient group receiving surgery with an older population receiving radiation can lead to very misleading results.
The members of the older group may have other medical problems, and their survival rate may not have anything to do with success of the prostate cancer treatment, because other factors were responsible for their deaths. Some research is misleading, for example – it might not tell you that their patients are 10-15 years younger, and in better health, than the comparison group. We are not trained experts, understanding interpreting specific data requires experience and expertise.
With additional treatment, survival can still be good. However cancer failure is accompanied by diagnostic tests and treatments that are ongoing for many years. While death can be often averted by secondary treatments, these treatments can come at a high cost to quality of life. Clearly, our best shot would be if we were able to choose the most effective, initial treatment.
Consider a patient whose PSA rises after surgery.
He will typically undergo 7 weeks of IMRT radiation, where the control rate is about 30%. Therefore, for a sample of 100 patients treated with surgery, if the failure rate from surgery is 30%, 30 patients will receive second treatment of radiation, and only 10 of those will have long term cancer control. The other 20, who fail the secondary treatment, will likely receive lifelong (10 years max), hormonal and or chemotherapy treatments. Typically they will (eventually) fail this therapy.
The future ‘Now’ – Artificial Intelligence (AI) is transforming clinical pathology. The full potential of AI can only be achieved by the seamless integration of AI in clinical workflows to support pathologists.
AI presents unparalleled solutions for clinical diagnostics in prostate cancer combining powerful AI-based image analytics and integrated image viewers with reporting tools to support pathologists’ decision making in the clinical workflow. There are private companies already offering, personalised treatment options analytic services.
There is movement within the NHS for such for ALL patients, as in the long-term it will save money, avoiding unnecessary, (expensive) ineffectual treatments, diverting treatments for maximum effect.
Thanks for Reading