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Conversations With Prostate Cancer Experts


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Exercise Programs For Prostate Cancer

Professor Rob Newton is the Associate Dean of Medical and Exercise Sciences and the Co-Director of the Exercise Medicine Research Institute, School of Medical and Health Sciences at Edith Cowan University in Perth, Australia.

Prostatepedia spoke to Dr. Newton about his exercise recommendations for men with prostate cancer.

Not a member? Join us to read our December issue on diet, lifestyle, and prostate cancer.

What specific exercise plans do you recommend for prostate cancer patients?

Dr. Newton: At the moment, we have a very generic recommendation from the American Cancer Society: complete 75 to 150 minutes per week of moderate to vigorous aerobic exercise and two or more resistance training sessions per week. That’s the same recommendation that the American College of Sports Medicine gives for any healthy adult, whether he or she has cancer or not. That recommendation needs to be more tailored to the stage of prostate cancer and the treatments the patient is undergoing.

I’m writing a letter to the Journal of Clinical Oncology in response to a paper by a group in Perth that they published in the last edition. The paper recommends that the way forward with the management of cancer will be home-based exercise programs prescribed by physicians, and most likely, walking programs. This is a tragic step backward in terms of the management of cancer with exercise medicine. It’s ineffective.

Compliance in home-based programs is woeful. It’s the wrong medicine. Depending on the problem the patient is experiencing, walking may be the wrong medicine. It’s like giving antibiotics as contraception. This is not the direction in which oncology should go.

For men on active surveillance, we have two principal targets. First, we try to reduce the risk of other chronic diseases. At this stage, the prostate cancer is not progressing that fast, so chances are the patients are going to die of something else.

If they’re overweight, obese, or their blood glucose is out of control, for example, metabolic syndrome will kill them long before their prostate cancer will. You’ve got to say, “Why are you worried about your prostate cancer? You won’t live long enough to get it.” If a man is overweight, physically inactive, or has a poor diet, then the focus should be on controlling that, not on the prostate cancer.

The other target for patients on active surveillance is to stimulate the mechanisms that might inhibit the tumor from developing further. We’re starting to get a good understanding of this. The key is to maintain or increase the amount of muscle in the patient’s body.

Muscle produces strong antitumor drugs. It’s natural, internal medicine, but it produces a range of substances that have an antitumor effect. We need to increase the size of the muscle and then activate that muscle regularly to get it to dispense these chemicals.

We’re unsure at the moment of what specific types of exercise drive the greatest quantity and which specific endogenous medicine will suppress tumor growth. At this stage, that’s why we recommend a combination of resistance exercise and aerobic exercise. That should help to slow the tumor progression.

Join us to read the remainder of Dr. Newton’s comments.


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The Moustache: A Fun Approach To A Serious Problem

Sandy Goodman is one of Movember’s top fundraisers. Prostatepedia spoke to him about their annual moustache-growing campaign.

Goodman

What is Movember?

Sandy Goodman: Movember is a fun approach to a serious problem. A bunch of guys sat down over some beers and dreamed up this way to follow the lead of breast cancer awareness advocates, who had been doing such a great job talking to women about early detection. These guys talked about what could be done for men. It’s grown into something much larger. The bottom line: guys don’t talk and men are dying too young (6 years earlier than women, on average).

Men are dying too young, and, for Movember, the simple solution is the moustache. The moustache is just our ribbon—it’s our banner. I don’t grow a moustache normally. Because I do it once a year, everyone asks why I’m growing one. It sparks the conversation.

Movember has been very innovative. They’ve made all the fundraising and gift-giving tools available online to everybody. An incredible amount of partnership and research has been funded through Movember. The back end—what the money is going towards—has real outcomes.

I’m happy to be a part of something that’s fun, and I’m proud to be part of something that’s truly making a difference.

image003Sounds like the annual campaign isn’t just about fundraising, but is also a way to start talking about some of these issues.

Sandy Goodman: Yeah, that’s right. It’s definitely all about sparking conversation. Men are terrible at making doctor appointments. Men are terrible at following up on doctor appointments. Men are terrible about checking themselves and being aware of what’s going on. To the extent that we can just spark conversation is a big impact.

Movember used to say that one moustache reaches an average of 100 people in a month. The number of emails you send out and share, Facebook posts, blog posts, the pictures—the reach is large and it just multiplies.

I’d be surprised to find anyone on the globe now who doesn’t understand what a moustache during the month of November means.

For me, it’s just about being involved with something. We all need to give back. I’m a huge believer in lifting with your pinkies as a group. It’s such a powerful thing when we all just lift together.

How did you get involved with Movember?

Sandy Goodman: I got involved 10 years ago because my father-in-law was diagnosed with prostate cancer. He had been doing all the right things. He went to his doctor for PSA and DRE exams every year. When his doctor saw something he didn’t like, he said, “You have an elevated PSA score and need to come back.”

At the time, he was getting remarried. His brother had had some complications after a prostatectomy, so my father-in-law was afraid to go back. He didn’t go back until a year later when he was doubled over in pain and they said it was too late. He was terminally ill with prostate cancer. It had spread. They gave him three years to live; he made it eight years, but it was not a very good eight years.

Early detection is so important, but beyond early detection is early action. My father-in-law did the right things, but then didn’t follow through… he didn’t take action. It was sad to watch this whole process. It was especially terrible, because it was completely avoidable.

At the time, I knew nothing about my prostate. I didn’t know what it did. I didn’t really know where it was and I never checked it. I was 45 years old. None of my friends knew anything about their prostates, either. We never checked our testicles or any of that stuff.

At the same time, a work friend’s dad had cancer. He was getting involved with Movember. He started a team and I joined him. Movember had only been in the United States for a year at the time.

It was a fun approach to a serious problem, which was right up my alley. I grew a moustache, got hooked, and I’ve been growing for 10 years now. I’ve been talking to everyone I can, all my bros.

Movember has had the viral social media aspect going for it.

Sandy Goodman: Completely. I started a golf tournament for our team 5 years ago. It’s grown. My goal was to bring the Movember message to my local community. I was walking around the South Bay and people would recognize that I had grown a moustache, but I think they saw me as a novelty. I wanted to do more. The golf tournament brings in local businesses. They set up on every other hole, so it’s an interactive experience. It’s a fun day. One of them sponsors the team photos of everyone holding up the tournament banner.

This year, instead of having a professional photographer there to take the picture, we’re asking the players to take the pictures with their own cameras and phones, so they’ll have it immediately. Then they can share and post their photos with hash tags. It’s just another way to keep the message growing virally.

There are new ideas every year.

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What has been your own approach to Movember?

Sandy Goodman: It’s changed over the years. At first, it was about getting people on the team. We’ve had as many as 80 people on a team and we’ve had as few as 20. I haven’t even really started building a team yet for this year. I used to start up on September 15, the day the website goes up, but it was a bit early. I just sent my first email for recruiting.

Originally, we just had a get-together with the guys. Then, we connected with some local bars and existing local events. Now we help promote. Bars and restaurants are happy for us to bring our crew, so we’ve had a lot of success with that. If there’s too much happening on the calendar, though, people can get burnt out, so we take that into consideration.

Movember has made it easier to host an event. Once you’re signed up, you can send invites to your friends or you can post events publicly. It’s fantastic. You could post a keg party if you wanted and ask for donations as admission.

When they were in college, I helped my sons set up their own team, The Buffalo Mo Bros. I encouraged them to use those tools to set up keg parties and things like that. It was super easy. It’s about getting together, having fun, and raising awareness and some money.

How do you motivate people to donate to a cause like this?

Sandy Goodman: In the beginning, I fundraised almost exclusively through email. I would send out about eight emails throughout the campaign. I started with the kickoff, maybe something for Halloween, then Veterans Day, and halfway there’s the golf tournament and then the wrap-up.

I would always attach a personal message. I would cut my group into subgroups, such as work friends or high school friends, and then cater the messages to them. Movember allows you to upload pictures to the site, so I do that, and they can see my progress.

Now, I focus exclusively on the golf tournament, because it’s just a big event. It raises about $50,000. I organize everything.

For whatever reason, I am fortunate to have some very generous friends. Everyone understood that I was passionate about it and that resonated. I was passionate because of my father-in-law. I was passionate because I have three sons who have a history to be concerned with because they’re two and a half times more likely to get it than I am.

What works for my fundraising is email campaigns and being thoughtful about how I word the emails and who I send them to.

I’ve been doing this for 10 years. I’ve been the top United States fundraiser for the past 8 years. The individual who has raised the MOst MOney is called the MoMo. It’s a title I love. I would love to retain it.

I imagine if you’ve been doing this for eight years, you must have a core group of people who campaign with you every year?

Sandy Goodman: I do, but people come in and out. It’s hard to maintain the passion. There are many charities that compete for our attention and our dollars. People have other things in their lives. Sometimes life throws you a curve ball, and your focus and priorities just change.

For example, one of the guys who has been with me all these years just told me: “My mother-in-law has breast cancer. So I’ve decided to focus on the breast cancer walk this year.” I think that’s great. There’s nothing wrong with that. I miss him, but he’s still doing great things.

For me, it’s just about being involved with something. It’s such a powerful thing when we all lift together. It’s about numbers.

It’s about having a clear message and a clear path for success. You have to make it frictionless for people so that they can just click and be done. If people don’t see a hyperlink and they don’t understand your methods, you’re not going to win. Movember has been fantastic at that. They get that need for ease. That’s why they were trailblazers and why they were able to have such success and to grow so quickly.

They made it frictionless. They made it easy for people to understand the message, to follow somebody who’s passionate and having fun and to see your progress. Pictures and emails are template-driven, so they allow you to spin to your group, update, and customize your message. “Just click here.” It’s that simple.

What are your tips for men who want to start their own group?

Sandy Goodman: Have fun. Be passionate. And do the work. There’s a full spectrum of Mo Bros and Mo Sisters. There are people out there who sign up and they’ve raised zero dollars, but they have fun and they have an excuse to spark conversations. That’s great. They’re doing something and making a difference. If one moustache saves one life, even if you haven’t raised any dollars, that’s fantastic.

On the other end of the spectrum, some people just get really into it. They get passionate, organized, do the hard work, and they raise a lot of money and awareness. It’s a balance between both.

Do you have any advice for patients or their loved ones who want to participate?

Sandy Goodman: I watched my father-in-law suffer. It was a very difficult experience for everybody—obviously for him—but also for all his family members. Once he had prostate cancer, we learned that it was so confusing to find and understand the resources available, the best course of action, or the best treatments.

Movember had resources that were really comforting and helpful and focused on care (LIVESTRONG at the time). Knowing that they’re doing the research and the work is comforting also.

Under “About Us,” they have information on the work that they’re doing. There are over 1,200 projects funded by Movember in all areas of men’s health: prostate cancer, testicular cancer, and mental health and suicide prevention.

They also provide links to other resources. They have hotlines for people to call for more information and support.

Resources for mental health have really grown in prominence at Movember over the past few years, mostly in response to the mental anguish that you go through when faced with any cancer and not knowing who to talk to. When you consider that three out of four suicides are men, it’s a huge issue at all ages.

I never want to get a message from someone saying they’re glad I’m doing this because they’ve just been diagnosed with prostate cancer. That’s terrible. But the fact that they were diagnosed and they’re taking action is fantastic, because they’re reaching out. They’ve seen me, my passion, and they’ve seen my moustache every year.

I always pick up the phone. I try to help however I can. If I can provide a resource through Movember, I always do that, but it’s a tough journey.

Most people with prostate cancer will die of something else.

Sandy Goodman: That’s true. For those who already have prostate cancer, it’s the treatment and it’s the side effects that are difficult.

I have several friends that have gone through complete prostatectomies and several going through active surveillance. It’s not an easy journey, even if it’s super successful. It just takes time.

Do you still feel men don’t want to talk about prostate cancer?

Sandy Goodman: That’s changing a little. I have two good friends who have had prostatectomies and they’ve had some very serious side effects. They are extremely open about wearing diapers and the other issues. That conversation wouldn’t have happened 10 years ago. I would have waived them off like: “I don’t want to hear that.” Now, I’m open to it, everyone around me is open to it, and it’s not taboo anymore. It’s more about being there for them than anything else. The message is being heard.

Do you think that this change is due to efforts like Movember’s annual campaign, or do you think society is evolving?

Sandy Goodman: I think it’s a combination. It’s not one or the other. People are coming of age in a more communicative era. We have Facebook and social media and charities out there are promoting and discussing these issues.

We’re more accustomed to sharing our emotions as a culture?

Sandy Goodman: Yes. We share a lot. We share everything on the worldwide web. There it’s frictionless, and the messages are bouncing around at hyper speed all the time. Sometimes more than you want. But that’s for the best when you’re talking about things that in the past were not discussed and should be.

Depression and suicide?

Sandy Goodman: One hundred percent. People suffer on their own for many reasons, including cancer. That’s the main message of Movember: talk, listen, and be there. I’ve picked up the phone to check on people many times over the last couple years, and we just have a conversation. Other times people have reached out to me when I wasn’t feeling great about things. I would just be honest and say: “I just need to talk to someone right now.”

For me, that support is completely thanks to Movember and their message. I try to practice what they preach, but it’s not always easy. We’re guys. We still grew up being guys. We don’t cry. We say, put a Band-Aid on it, you’ll be fine. But that’s not as powerful as reaching out.

Join Prostatepedia to learn more about prostate cancer and its treatments.


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Focal Therapy + Imaging

Dr. Mark Emberton is a Professor of Interventional Oncology at University College London.

Prostatepedia spoke with him about focal therapy for prostate cancer.

What is focal therapy for prostate cancer?

IMG_0571Dr. Emberton: Focal therapy is an attempt to improve the therapeutic ratio. It addresses the harms and benefits of treatment. In prostate cancer treatment, the harms are too great for the benefit to accrue.

We can’t improve the benefit very much, but we can certainly reduce the harms that we inflict on our patients. Nearly every patient who has been treated for prostate cancer will experience a reduction in quality of life because of the impact on his sexual function, continence, or rectal function.

Focal therapy attempts to address that by preserving tissue. We’ve managed to preserve tissue in all other cancer management: breast through lumpectomy, kidney through partial nephrectomy, liver through partial hepatectomy, and penile cancer through partial penectomy. Prostate is the last bastion. Until recently, all men had the prostatic equivalent of bilateral mastectomy. In other words, their whole prostate tissue was removed irrespective of tumor volume, location, or number. Everyone was treated the same. With focal therapy, we attempt to preserve tissue, which preserves function.

How do doctors determine if focal therapy is appropriate for a man?

Dr. Emberton: It’s not for everybody. At the moment, we do surveillance so that men with very low-risk disease have no treatment. We offer surgery to men with high-risk disease who’ve got extensive, high-burden tumors in the same way we manage, say, breast cancer. We might choose to watch an elderly woman with a small breast lump. We might choose to do a mastectomy on a young woman with very aggressive breast cancer. But the majority of women—currently 80%—can get away with a lumpectomy. This is enabled by the ability to identify tumors and determine location and volume.

That’s a very recent development in prostate cancer. Until very recently, we were treating all men blindly. Since Hugh Hampton Young did his first prostatectomy at Johns Hopkins about 100 years ago, we’ve been treating prostate cancer without knowledge of tumor location.

What is the role of imaging?

Dr. Emberton: The new trick in town is that we can see the prostate cancer with MRI. If we can see it, we can direct needles at it. If we can direct needles at it, we can direct energy at it. We can zap the tumor rather than having to remove the whole prostate. We can have a much more nuanced approach now. Instead of treating all men the same, we can now stratify men by risk with great precision by biopsying them differently depending on where the tumor is and then allocating treatment depending on the risk stratification that has been assessed. If a man has one millimeter of Gleason 4+3, most of us would not treat. I certainly wouldn’t. If he has extensive bilateral disease, I would offer whole-gland treatment in the form of surgery or radiation therapy. If he has got a 0.5 cc tumor in the right peripheral zone of the prostate, I see no reason why we shouldn’t offer a selective destruction of that tumor that preserves erections, ejaculation, and continence. We’re doing that today. We’re having conversations with men today that we couldn’t have had three to four years ago because we didn’t have the tools.

What about other advances in imaging?

Dr. Emberton: PSMA is very useful in staging men. It’s concordant with MRI and the prostate, but it doesn’t give us the spatial resolution that we would require to decide which part of the prostate to treat. The PSMA PET/CT will be positive on the left or the right side of the prostate, but will not give us any more information. It’s really useful in the high-risk man with whom you’re trying to rule out metastatic disease.

There are a variety of forms of focal therapy, correct?

Dr. Emberton: I think conceptually, it’s very clear. We offer men focal therapy when we can treat the tumor plus a margin and we think we can do so faithfully. But there are lots of ways to do it. Just like surgery, you can have an open, transperineal, laparoscopic, or robotic prostatectomy. In brachytherapy, high-dose rate (HDR), low-dose rate (LDR), CyberKnife, TrueBeam, protons, external beam, the principle is the same.

Yes, we have a few options with focal therapy, though not as many as surgeons and radiation therapists. We’re often accused of having a cornucopia of ways of treating. Actually, we don’t. We have heat (hot or cold) and we have electricity in the form of radio frequency or electroporation.


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Is There A Consensus On Focal Therapy?

David Crawford, the distinguished Professor of Surgery, Urology, and Radiation Oncology, and Head of the Section of Urologic Oncology, at the University of Colorado Anschutz Medical Campus frames Prostatepedia’s November discussions on focal therapy for prostate cancer.

There is a lot of interest in focal therapy right now. Years ago, when I used to recommend radical prostatectomy and radiation to patients, they would ask why I couldn’t just take out a part of their prostate and not the whole thing. I would chuckle and say, “You can’t do that.” I’d say that prostate cancers tend to be multifocal. We can’t just operate on part of your prostate. We have to treat the whole thing.

That resonated with many urologists for years. Then Drs. Gary Onik and Winston Barzell started using cryotherapy to ablate prostate tumors and mapping biopsies to localize the cancer. Like a lot of things in medicine, there was a backlash of people who felt focal therapy was inappropriate because prostate cancer is multifocal.

Dr. Onik persisted. When somebody came in with a low-grade or even intermediate-grade prostate cancer on the left side of the prostate gland, he would biopsy the right side of the prostate extensively. If there wasn’t any cancer, he would do an ablation and treat the whole left side. That was the beginning of focal therapy.

I became interested in what I call targeted focal therapy about 15 years ago. Of course, focal therapy hinges on our ability to effectively biopsy patients so that you know you’re not missing other, more aggressive tumors. Focal therapy means focally treating a lesion, but I like the term targeted focal therapy because we’re targeting exactly where the tumor is with our mapping biopsies.

There are many ways to do focal therapy. We can use lasers, cryotherapy, or high-intensity focused ultrasound (HIFU). We’re working on using immunotherapy to target lesions. We can even put alcohol into the lesion and get rid of the cancer that way. Ablating the tumor isn’t the hard part. The hard part is knowing where the lesion is and targeting it.

Fifteen years ago, we had several hundred radical prostatectomy specimens; a researcher from Japan named Dasako Hirano, who had been with us for two years, outlined the tumors on acetate paper and then we put them into a 3D system so that we could simulate where these tumors were using different biopsying techniques. We showed that if you use the transperineal approach to place a needle into the prostate every five millimeters, you could sample the whole prostate without missing many significant cancers. I felt that it was safe to go forward with targeted focal therapy.

We knew we would not do any harm with 3D mapping biopsies.

We also talk about MRI in relation to focal therapy. MRI has been around for a long time. We’ve gone from 1 Tesla to 3 Tesla and now 5 Tesla MRI units. We’re getting better at reading the MRI results. There has been a lot of discussion about how accurate MRI is and what it misses. MRIs still can miss aggressive cancers. Depending on which expert you believe, MRI misses anywhere from 7-10% up to 30% of aggressive cancers. MRI is a lot simpler than our painstaking 3D mapping biopsy, though, so it’s caught on.

Dr. Mark Emberton was the first to champion MRI in the United Kingdom. Dr. Emberton and his team now have a lot of experience in using MRI in focal therapy, primarily cryotherapy.

But to me, the gold standard remains the mapping biopsies. MRI is good, but not perfect. Perhaps we can use molecular markers along with MRI to rule out more aggressive cancers.

Focal therapy is a response to overtreatment and it does have a place, but with prostate cancer, we’ve got to follow people a long time before we come to a consensus.

Subscribe to read about focal therapy on November 1.


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Focal Therapy + Prostate Cancer

Dr. Charles “Snuffy” Myers offers his comments on our November issue on focal therapy for prostate cancer:

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Last month we reviewed the impact of new tools like imaging on treatment choices for newly diagnosed men. We discussed how improved imaging impacts planning of both radiation therapy and surgery, as well as the role imaging plays in active surveillance in terms of patient selection and monitoring. .

This issue is a logical extension of those conversations as we look at focal therapy treatment options based on those imaging tools. The renaissance of focal therapy is due to MRI, which has the ability to visualize cancer within the prostate gland with much greater precision than older techniques.

Focal treatment makes sense when the cancer is of limited extent, usually limited to a single major lesion on one side of the prostate. If the cancer is truly limited to only part of the gland, it may not be necessary to destroy the whole prostate. The hope is that focal therapy will have less impact on sexual function and urination than radical prostatectomy or radiation therapy to the whole gland. A frequently used analogy is a lumpectomy versus mastectomy for breast cancer.

As you read the interviews, there are a number of issues to keep in mind. With radical prostatectomy and radiation therapy, we know in detail the odds of long-term cancer control. This information is lacking for the various forms of focal therapy. One reason that cancer control might be less complete after focal therapy is that focal therapies largely depend on the ability of the MRI to identify patients with cancer limited to one area of the prostate gland. But, as we learned last month, the MRI is not a perfect tool and can miss small, aggressive cancers. Also, first-rate MRI facilities with well-trained radiologists are limited in number.

As a medical oncologist, I have recently had to deal with a particularly difficult situation. With the arrival of new, highly sensitive imaging for metastatic disease, such as the C-11 Acetate, fluciclovine F 18, and PSMA PET/CT scans, I am seeing a growing number of patients who have had radiation therapy and the only detectable recurrent cancer is in the prostate gland. Focal therapy in this setting is difficult because of radiation damage to surrounding normal tissue as well as dense scar formation within the gland. Several interviews touch on treatment options for this situation, but those options are far from ideal. It is unclear what the right path is for these men.

Subscribe! Don’t miss our focal therapy issue when it debuts next Wednesday.


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Prostate Cancer Diagnosis + Risk Stratification

Dr. Leonard Gomella spoke at the 18th Future Directions in Urology Symposium in Colorado Springs in August 2017. In this video interview, he offers a short summary of the talks he gave at that conference.

He focuses on two factors for prostate cancer diagnosis and risk stratification that he is researching and interested in improving. The first factor is the role of genetic testing for prostate cancer risk. He reviewed our preliminary consensus data from a big meeting in Philadelphia back in March to talk about what are the indications to sending a patient on to genetic counseling for further potential screening for inherited prostate cancer risk. He talked about things that will be coming out in his paper at the end of the year.

The second topic he addressed is what he calls Beyond MRI. He spoke about the new evolving next generation imaging involving PET scanning. He talked about the fact that there are 20-30 different PET scan technologies out there, but in reality only about 5-6 are getting attention right now. He believes that these new PET imaging will allow us to move beyond standard MRI and standard CAT scans and get much more information about disease status in individual patients.

 


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Prostate Cancer Mortality Rates?

john_davis.jpg.resize.810.1150.highAt a presentation he gave at the18th Annual Future Directions in Urology Symposium, Dr. John W. Davis of the University of Texas M.D. Anderson Cancer Center, talks about prostate cancer mortality statistics:

One of the common things we rally around is the efficacy of PSA screening and what guidelines panels have shown. The US Task Force panel in 2012 gave PSA screening a poor rating and downstream this impacted biopsy and other effects to treating prostate cancer.

Their study quoted a 1990s study that said 1 in 200 men undergoing prostate surgery died within 30 days…the problem was that it lost data when the patient was discharged…the data set is now better, it is called premier perspective, and now it does capture discharged data so you can get a clear 30 day rate.

There has been a dramatic shift, when we first looked at the database from 2004-10, so the predominant technique was open surgery. Now, looking at the 2008-16 data, and the shift is heavily robotic.

Over the decades, the mortality rate for surgery is significantly improved over what the Task Force quoted in their evidence review, and we need to continue this trend. If you look at how many people screening saves in prostate cancer mortality, if you create a new treatment-related mortality that is non-prostate that has undone your effort. In the future direction of prostate cancer we need to also pay attention to non-prostate mortality.

Dr. John W. Davis talks about mortality statistics after both prostatectomy and radiation.