Confused, Radiation vs Surgery

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John T
Veteran Member

Date Joined Nov 2008
Total Posts : 3539
   Posted 1/11/2009 1:47 PM (GMT -6)   
Hi Guys,
I've been reading a lot of threads on why a lot of you picked surgery vs radiation. The most common reason was that if surgery failed you could always use radiation as a backup, but if radiation failed, surgery was not a viable alternative.
Here's what  is confusing to me: I understand that if the cancer is contained in the prostate that the cure rate using surgery and radiation is the same. The most common cause of surgical failure is when the cancer has penetrated beyond the prostate and a positive surgical margin was not achieved or that the cancer has metastizied (high gleason and high PSA). It also seems logical to me that a higher positive margin can be achieved with radiation because you can radiate the area around the prostate.
A  reoccurrance after surgery is not a local reoccurance as the prostate does not exist. You can have a local reoccurance after radiation because there is still a prostrate; does any one have any stats on how often this occurs? I would guess that most reoccurances after either surgery or radiation are due to the fact that the cancer had already spread outside of the scapel or radiation beam.
I also think that an effective backup to either a surgical or radiation failure would be hormone therapy rather than more surgery or radiation. How often does the 2nd procedure really cure the cancer? Any stats? Do most reoccurances end up on hormones or chemo anyway?
Can any of you shed some light on my confusion? The side affects of all treatments are substantial and stacking the side affects from multiple treatments is not very appealing to me.
Diagnosed 10-08 at 63 with PSA of 33
PSA was 4.4 in 1999 and has risen steadily.
Had 13 biopsies and an endorectal MRI, all negative until 10-08. Two cores out of 25 with a gleason 6
2nd opinion with an oncologist said cancer found was insignificant, but suspected larger tumor somewhere.
Doppler ultrasound with target biopsy indicate a large tumor in the transition zone, gleason 7.
Bone and CT scans negative.
PSA3= 43; (high normal is 35)
Scheduled for Combidex MRI in Feb. (Lymph node imaging MRI done in Holland).
Location of tumor makes positive surgical margin unlikely.
Looking at IMRT with hormone therapy as soon as staging is complete with Combidex MRI.
Changed diet, eliminated all meat and dairy. Taking the normal supplements recommended for PC.
John T

Regular Member

Date Joined Sep 2006
Total Posts : 211
   Posted 1/11/2009 3:51 PM (GMT -6)   
As we know many people, including doctors, often have their own idea on what's the best treatment, and to justify their own notion come up with various well  used  quotations that are not necessarily logical or relevant for every situation.
Logically is it very difficult to compare historic results of various treatments as there are so many variables, including skill of doctors, individual diagnosis, and the great improvement in equipment and techniques used now compared to say 5 and more years ago, which is often what's being looked at regarding survival rates etc.
Often there can well be several treatment options in any given situation that will offer very similar potential outcomes, so it can come down to personal preference after consideration by an individual of which probable side effects are most acceptable.

Veteran Member

Date Joined Apr 2008
Total Posts : 844
   Posted 1/11/2009 4:53 PM (GMT -6)   

John: a positive surgical margin is a Bad Thing as it means positive for cancer -- contrary what we might normally think. A negative margin is desirable as it means clear of cancer.

I am a bit confused by your stats which say "location of tumor makes positive surgical margin unlikely" -- does this mean that the tumor is unlikely to be confined to the prostate? If so, surgery is a less attractive option, and radiation becomes relatively more attractive.

Surgery removes the prostate and a varying amount of tissue surrounding the prostate (margins). Even with negative margins (clear of cancer) there is no guarantee of "cure". It is always possible for a microscopic amount of the cancer to have escaped and not be noticed. Microscopic amounts in the margins may not be noticed by the pathology.
Escaped cancer can lurk in the prostate bed for years before making its presence known via rising PSA. A local recurrence like this is very treatable by radiation -- radiologists radiate the area where the prostate used to be.
But as you say, if the cancer has spread elsewhere, then the best option is hormone therapy.
Age 63. Other than cancer, in good health; BMI 20
Pre-op: No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores
7 March 2008, RRP, non nerve sparing
Two nights in hospital; catheter and staples out after 7 days
Continent, no pads needed from the get-go
Post Op: Stage pT2 M- N-; clear margins and lymph nodes; Gleason 4+4=8; prostate weight: 37gm
6-week and 7-month PSAs: 0
Bimix injections working well 

Veteran Member

Date Joined Feb 2008
Total Posts : 1821
   Posted 1/11/2009 4:56 PM (GMT -6)   
John T,
While the "cure" rates for surgery and radiation are pretty much the same, with surgery you usually get to know exactly where you stand. You will, after pathology know exactly the Gleason of the gland (biopsy only samples a portion, albeit a representative sampling) as well as the extent of the cancer (contained, focal extension, local spread etc). If there is no spread then PSA will drop essentially to zero and provide an accurate track thereafter. Should there be a relapse (there never can be a guarantee that microscopic escape from the prostate has not occured) following surgery then radiation is a follow up option with ADT available after or in conjunction with such radiation. On the other hand surgery following radiation appears to be fraught with problems. What prompted my decision to go with surgery was the desire to know exactly where I stood and although I naturally wanted to avoid it, have a back up plan available. Unfortunately all we can do is educate ourselves well on the disease and make a judgment balancing our hopes and expectations against the price we are prepared to pay.
1/05 PSA----2.9 3/06-----3.2 3/07-------4.1 5/07------3.9 All negative DREs
Aged 59 when diagnosed
Biopsy 6/07
4 of 10 cores positive for Adenocarcinoma-------bummer!
Core 1 <5%, core 2----50%, core 3----60%, core 4----50%
Biopsy Pathologist's comment:
Gleason 4+3=7 (80% grade 4) Stage T2c
Neither extracapsular nor perineural invasion is identified
CT scan and Bone scan show no evidence of metastases
Da Vinci RP Aug 10th 2007
Post-op pathology:
Positive for perineural invasion and 1 small focal extension
Negative at surgical margins, negative node and negative vesicle involvement
Some 4+4=8 identified ........upgraded to Gleason 8
PSA Oct 07 <0.1 undetectable
PSA Jan 08 <0.1 undetectable
PSA April 08 <0.001 undetectable (disregarded due to lab "misreporting")
PSA August 08 <0.001 undetectable (disregarded due to lab "misreporting")
Post-op pathology rechecked by new lab:
Gleason downgraded to 4+3=7
Focal extension comprised of grade 3 cells
PSA September 08 <0.01 (new lab)

Veteran Member

Date Joined Jul 2008
Total Posts : 603
   Posted 1/11/2009 5:18 PM (GMT -6)   
John T, My husband stood in your shoes eight years ago. The doctors at that point said that with a PSA of 16 and Gleason of 4 +3 that radiation would be the best....He had lupron to shrink the prostate four months before the external radiation and then the seed inplants...followed by another year of lupron. You would have thought that would have gotten the cancer, right?

Well, we did for four years....(by the way, four years goes by very fast), He was just getting his mojo back, when the psa began to rise,,,doubling in two months.....The surgeons at Sloan Kettering said that they could do salvage surgery..(one of the few places in the country that did salvage surgery two years ago..maybe more now), to debulk the tumor. They said a 40% chance of total cure with 2% chance of fistula...Well....

The side effects have been really difficult for Pete....because of the radiation damage. When you have radiation, it is like frying an egg...It cooks the prostate....leaving lots of scar tissue that will not heal properly. They did debulk the tumor, but when the surgery was over, the surgeon said to me that he was disappointed that there was a lot of scar tissue and that the cancer had positive edges and also lymph node involvement. That cancer had four years to grow.

Plus Pete got a fistula...connection between rectum and bladder... needed surgery for that....The radiated area has been an ongoing problem. So, to make a long story short....from my point of view, initial surgery makes a great deal of sense. Radiation can always be done in a salvage situation much easier for the patient. I think medical knowledge is about two years behind reality. No one told us two years ago the damage of salvage surgery. I am telling everyone now.. ...
..I guess I am somewhat worn out tonight, I just came from the hospital again...Pete had to have hip replacement due to worn away bone in his hip.....But after saying all of this, there are many who have done really well with the External radiation and seed implant.....If it works it is great.......Pete's radiation was very extreme, I believe, and it still did not get all of the cancer in the beginning. Diane
Husband Pete
dx Jan 2001 gleason 4 + 3 PSA 16.5
Seed implant and conformal radiation and Lupron from Jan 2001 to Jan2002
2005 Dec PSA began to rise from .5 to 8 within 6 months
Salvage surgery at MSK 9/06 Dr. Eastham
Fistula operation 2/07 MSK Dr. Wong
Many cystoscopies and ER visits with strictures
Catheter for one year....Catheter taken out Sept 07..
Total Incontinence since then....
PSA .52 3/08
AUS Operation at MSK Sept 8 2008 Dr. Sandhu
Activated Oct 28th Dr. Sandhu..MSK
Some difficulty with AUS arising Nov 10 2008
Meeting with Dr. Sandhu to discuss AUS problems and new PSA test Dec 11, 2008
PSA .6 12/08
AUS improving..only 2 pads a day and one at night
Complete hip replacement surgery Dr. Waters Gainesville, FL 1/9/09
Forging ahead to health!

Elite Member

Date Joined Oct 2008
Total Posts : 23549
   Posted 1/11/2009 6:03 PM (GMT -6)   
Welcome here, sorry you have to be here, but glad you found us. Great source of information, fellowship, and comfort. I subscribe to the theory of surgery first, radiation as a backup. Many would agree, some would disagree, ultimately, it's your choice, your body, your cancer, and your life. What Diane wrote above is what can happen when things go terribly wrong. Piano and Billy gave some good advice on the subject, and hopefully, many more will report in.

David in SC
Age 56, 56 at DX
PSA 7/7 5.8, 7/8 12.3, 9/8 14.9, 10/8 16.4
3rd Biopsy 9-2008 Positive 7 of 7 cores positive, ranging from 40 - 90%, G 4+3 & 3+4
Open RP surgery  November 14, 2008 at St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon, Non-nerve sparing, 4 days in hospital, staples removed 11/24/8, Catheter out on 12/15/8 on day 32.  Day 33, urine stopped flowing, new catheter put in 12/16/08, Catheter out 12/29/08.  After 7 hours, complete stoppage again, emergency room put in Catheter #3 early evening of day 45, still 12/29/08. 1/5/9 - Cath #3 out, dr. did cycloscope, saw potential blockage, put in Catheter #4, 1/9/9 - pre-op, 1/13/9 - corrective operation scheduled at St. Francis
Post-surgery Pathlogy Report:
Gleason 3+4=7, pT2c pN0 pMx, Prostate 42 grams, tumor 20% cancer
Contained in capsular, neg. margins apex, bladder neck, right lobe, neg. in seminal vessels and lymph nodes.
First PSA Post Surgery  Scheduled now for 2/9/9

Veteran Member

Date Joined Dec 2008
Total Posts : 3114
   Posted 1/11/2009 6:58 PM (GMT -6)   
Nothing is perfect in this arena,  (edited by myself  over the top for newbies)

Post Edited (zufus) : 1/12/2009 12:02:13 PM (GMT-7)

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