‘Primary vs Definitive’ or ‘Radical vs Total’ which denotes correct Terminology in P Ca

• 19 Aug 2020 10:23:30 AM
• |Onco Urology

Dear All,

We use terminologies frequently which are not clear. It adds to the confusion which could be avoided where possible. Many could ask what is wrong in this. Mark Soloway has written 2 Editorials, one in 2010 and the other 10 years later, wherein he has suggested that the word ‘Definitive’ should not be used but the word ‘Primary’ should be used for treatment offered especially in the context of P Ca. He has explained the reasons behind this succinctly. I tend to agree with the observations made by Soloway. More often we use terminologies to suit our convenience and it does not reflect what we really offer.

Today many oncological surgeons believe that the age old wide excision surrounding the cancer has no evidence and as mentioned by some of our own that the need is excision is to be as close to the cancer as possible and it is a safe oncological principle. This has been exemplified more than Prostatectomy in Partial (nephron sparing) Nephrectomy where some mention that the excision could be very close to the lesion leaving a margin of even an mm. I somehow do not have the will to purchase this. PSM is considered as an important cause for probable recurrence and studies have shown that PSM increases the closer we are to the cancer that we are excising. There are many articles addressing this issue and claim that that Local recurrence is a problem when performing NSS for complex Lesions. But do the present day Uro-oncologists take this into consideration.

On a similar vein, Soloway has in 2008 mentioned that we should not use the word ‘Radical’ for prostatectomy as we are not implementing what the word ‘radical’ Implies. As we dissect the prostate closer to the prostate in our pursuit for nerve preservation ‘Intrafascial’, Soloway opines that the correct terminology is ‘Total’. Studies have demonstrated that more closely our dissection to the prostate more is the likelihood for PSM. Are we compromising on our dissection for better outcomes for Incontinence and ED?

https://www.europeanurology.com/article/S0302-2838(08)00401-6/pdf

How many of us will think that such usages have no real meaning  and presume ‘word is a word’ as long as it conveys some meaning, it is right to use wrong words and we should not over emphasize on Semantics.

With warm Regards,

Venu

Comments(1)

• 

  Venugopal P

  26 Aug 2020 09:53:27 AM

  Dear All,

  I had requested Makarand to Comment on this. I am placing his comments for all to read and understand

  Venu

  Thanks for twinkling by brain and thinking process and also stimulating me to write my views on three papers /editorials . It is not that I am semi-retired from medical writing  , I do publish regularly , but not as frequently as in the past , this is mainly due to my editorial work for BJUI as a consulting editor , reviewer for other journals and of course the clinical work . Anyway , this pandemic gave me more time to publish many articles which were in the wings , so you will not be disappointed.

  My comments are as follows:

  1.       ‘‘Definitive Therapy’’ for Cancer: Is Our Message clear? Mark Soloway 2010

  I entirely agree with Mark. I think we should use a terminology that has a precise meaning and should convey the right message and the intent as well. The management of prostate cancer has moved from single modality to multimodality even in case of organ confined disease. This is farthest the best example of how clinicians have adapted to the evidence based treatments rather than sticking to 'norms' and 'whims' of the so called Experts.

  On the same lines of what my dear friend Mark Soloway has said ,  Gleason scoring system ( though had many updates and revisions through ISUP meetings ), till recently confused the clinicians and the patients greatly . On top of that there was this issue of interobserver variability too. When the patients (and the non urological doctors) used to read the report of Gleason score  of 6 , they used to think  that it is a worse disease on the scale of 6 out of 10. It is only when the international group came together for a consensus meeting and designed Grade Groups; there was simplicity and clarity on what the pathology report meant and what its implications. I am glad that I was involved in this vigorous process closely and wrote a commentary on Current Urology reports in 2016, you all can read about it.

  So therefore, the words and the adjectives do matter, should matter and definitely one should use it judiciously.  After all, we all know "Words are weapons ....."  How true it is in case of Prostate Cancer.

  2.       The Fallacy of “Definitive Therapy” for Prostate Cancer – Soloway and Saum Lokeshwar, 2020

  This is an extension to what Mark wrote almost 9 years ago. Despite writing in the most read journal in urology of our times and appealing to the medical fraternity, nothing has changed over the last one decade. So do the proponents of using the term 'Definitive' therapy have something better to argue over what Mark is saying? Without getting biased, I don't think there is any argument which will make all us believe that what is universally agreed is always true. But he has given the evidence, analogy and rationale for using a better and meaningful term.

  I think it's a process, it will happen one day.

  You all remember Mark used to get really annoyed when someone used the word 'Superficial Bladder Cancer'. With repeated write ups in the journals and on the international podiums, he ran this campaign of using the correct terminology Non Muscle Invasive disease ( NMIBC )  rather than term Superficial . The proponents of this campaign eventually succeeded and now we all use the term NMIBC and not superficial which used to give  a sense of ' not too bad' disease and this was detrimental for the thinking  as well as management ,especially in pT1HG /G3  and Ca in Situ disease which unfortunately were clubbed in to Superficial bladder cancer.

  Same holds true for TCC Vs UC.  We all used to use the term TCC (transitional cell carcinoma) bladder /upper tract. But now we know the correct terminology is UC (urothelial carcinoma). So now most of the guidelines and text books use the term UC rather than TCC.

  3.       It’s Not a Radical Prostatectomy, It’s a Total Prostatectomy – AM Neider and Soloway (2008)

  Again this editorial was aimed at using the right terminology. I agree that the meaning of Total prostatectomy, Radical prostatectomy, Nerve sparing radical prostatectomy, Salvage Prostatectomy have different meanings.

  What I feel is that the term total prostatectomy might be the correct term, but it does not give an idea of what was the intent, like when we use the term Radical. One might be inclined to think that Total prostatectomy is not that 'aggressive /extensive' procedure as against to ' Radical’,  when people actually look for the real meaning of these two words.

  I personally feel the term Radical conveys the message that your intent is to be as 'aggressive and complete' as possible in terms of meticulous clearance of the disease. Adding nerve sparing and non nerve sparing hints to 'intent is cancer cure ' but at the same time 'sparing nerves is aimed at ' caring for quality of life / functional preservation.

  I think it's a 'Perception battle'. I am sure it will evolve with vigorous brainstorming arguments and counter arguments in future.

  But I think over all there is a point or two in what he is trying to convey.

  Regards,

  Makarand