New Case Vignette Article "Management of Prostate Cancer" on New England Journal of Medici

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Rolerbe
Regular Member


Date Joined Dec 2008
Total Posts : 235
   Posted 12/18/2008 10:40 AM (GMT -6)   
The article covers a hypothetical case and reviews 3 treatment options:  "Expectant Management" -- i.e. watch and wait, Brachytherapy (seeds), and Radical Prostatectomy.
 
 
 
50 YO
PSA at Dx: 8.2
DaVinci RALP: 10/31/08
Negative margins, no extra-capsular involvement
One nerve spared
No follow-up PSA yet (next week).
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/18/2008 11:07 AM (GMT -6)   
That was excellent article, I wish we all had all options laid out like that before we made our choices, in the end, I voted for what I had, surgery, despite the setback and side affects. I thought it was interesting that under the coments, almost all of the physcians voted for surgery.

Thanks for sharing,

David
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 9-2008 14.9
 
3rd Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Non-nerving 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 - uncertain of what went wrong.
 
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. Left lobe: infiltrating tumor miscroscopically appears to extend to marked left posterior margin
 
First PSA Post Surgery  Scheduled for 1/5/9
 
 


Dave7
Regular Member


Date Joined Jul 2006
Total Posts : 202
   Posted 12/18/2008 1:51 PM (GMT -6)   

It was interesting that so many of the comments elected watchful waiting.

I'm not mentally tough enough for watchful waiting.  It's a strong man who can do that.  From the comments I get the impression that there is still some question about the overall benefit of PSA testing

Dave


Age:54
PSA 5/22/06: 5.6
DaVinci surgery: 9/14/06
Gleason: 3+3
Organ confined, clean margins.
Both nerve bundles spared.


Ziggy9
Veteran Member


Date Joined Jul 2008
Total Posts : 981
   Posted 12/18/2008 2:33 PM (GMT -6)   
As time goes by and the more I read I'm becoming more and more convinced that ten years from we'll look back at this time of being the days of over treatment for those with low risk PCa. I'm very thankful I stumbled upon my local university's Urologic Oncology Dept whose staff feels the same.
Diagnosed 10/08/07
Age: 58
3 of 12 @5%
Psa: 2.3
3+3=6
Size: 34g
T-2-A
 
2/22/08
3D Mapping Saturation Biopsy
1 of 45 @2%
Psa:2.1
3+3=6
28g after taking Avodart
Catheter for 1 day
Good Candidate for TFT
(Targeted Focal Therapy)
Cryosurgery(Ice Balls)
Clinical Research Study
 
4/22/08
TFT performed at University of Colorado
Medical Center at Denver Fitzsimons Campus
Catheter for 4 days
Slight soreness for 2 weeks but afterward
life returns as normal
 
7/30/08
Psa: .32
 
11/10/08
Psa.62
 
April, 2009
Final Biopsy scheduled to
complete clinical research study 
 
 
 

Post Edited (realziggy) : 12/18/2008 12:37:22 PM (GMT-7)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/18/2008 3:32 PM (GMT -6)   
Well, after surviving 3 bouts of an ultra rare cancer as recent as 8 years ago in my life, when I got the dx on the PC, there was no part of me that would entertain wait and watch, just my take on it. Never thought I would be dealing with cancer in myself again, so there was a lot of shock value to me.

David in SC
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 9-2008 14.9
 
3rd Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Non-nerving 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 - uncertain of what went wrong.
 
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. Left lobe: infiltrating tumor miscroscopically appears to extend to marked left posterior margin
 
First PSA Post Surgery  Scheduled for 1/5/9
 
 


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4177
   Posted 12/18/2008 3:40 PM (GMT -6)   

Dear Rolerbe:

This is an excellent article and, I think, a real contribution to this forum.  I hope the moderators will consider bumping this up and/or quoting it from time to time when new folks are looking for advice.  I think this fairly and clearly lays out 3 excellent options for those with early stage prostate cancer.  It's why I have continually encouraged "newbies" to examine all of their options and then make an informed decision.

David, I'm not sure why you commented that almost all physicians voted for surgery...maybe there was a summary that I missed.  But, if I read this correctly, there were comments under EACH option.  In reading these comments, it seemed to me that there were plenty of physicians favoring each of the three options for this particular case.

Anyway, what is crystal clear (again) is that there is no "one size fits all" for our disease.  The good news is that we have options and that is also the bad news.  What each of us had to do (or has to do) is take the time to research, study, discuss and pray (if that's appropriate) and find the best option for cure and sides for each of us personally.


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
27cc
Brachytheraply volume study done on 11/14/08
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort. 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 12/18/2008 3:44 PM (GMT -6)   
You are right Tudpock, I misunderstood the comment section after the vote in the article. I stand corrected.
Age 56, 56 at DX
 
PSA 2007 5.8
PSA 9-2008 14.9
 
3rd Biopsy 9-2008 Positive
7 of 7 cores positive, ranging from 40 - 90%
2 tumours noted, Gleason 4+3 and 3+4
 
Open RP surgery completed on Friday, November 14, 2008 at
St. Francis Hospital, Greenville, SC, Dr. Ronald Smith - Surgeon,
Non-nerving 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 - uncertain of what went wrong.
 
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. Left lobe: infiltrating tumor miscroscopically appears to extend to marked left posterior margin
 
First PSA Post Surgery  Scheduled for 1/5/9
 
 


RBinCountry
Regular Member


Date Joined Apr 2008
Total Posts : 270
   Posted 12/18/2008 5:10 PM (GMT -6)   
I think the article is very well done and the synopsis of each treatment type. I did not really have the option of watchful waiting - my diagnosis was considered by the 3 Urologist I visited as being too far down the road. It may not be fair for me or anyone else to really say what they would do or suggest, but I know that dealing with PC has been far different personally than looking in from the outside as I think most if not all the medical folk are doing.

As irritating as the side effects are, I think I would still want that rascal out of me. It is likely mental, but I believe knowing my makeup from having PC, the side effect problems would not be as bothersome to me as thinking about the unknowns of cancer within. Even with biopsy's there are no guarantees of accuracy, and when the pathology report comes if it is different it is more often worse than better than the biopsy shows. For me peace of mind is the big one. As close as a I can come to peace of mind, or knowing I have done all I can do leaving the rest up to the Almighty - that is my thinking. The quaility of life feeling like your walking around with a time bomb troubles me. It troubled me during the weeks I had a diagnosis before I went in for surgery. I know once I had made up my treatment decision I was anxious to get rid of the thing.

Well, I hope I haven't affended anyone - we are all different, but that is my take.

RB
Age 61 (now 62)
Original data - pre-operation
PSA: 5.1
T1C clinical diagnosis, Needle biopsy - 10 cores, Gleason 7 = 3+4 in 1 core (40%), 7 cores Gleason 6 = 3+3 ranging from 5% to 12%
All scans negative
Lupron administered 4/9/2008 for 4 months (with idea I would undergo external beam radiation followed by seed implants - then I changed my mind).
Robotic DiVinci surgery - Dr. Fagin (Austin) May 19th
Post operative - pathology
pT2c NX MX
Gleason 3+4
Margins - negative
Extraprostatic extension - negative
seminal vesicle invasion - uninvolved
1st Post PSA <.04
2nd Post PSA <.1 10/30/2008


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4177
   Posted 12/18/2008 10:24 PM (GMT -6)   

Hi RB:

Yours is a very interesting post and I think provides a real insight into the "whys" of treatment choice.  One of the benefits of this forum is the opportunity to exchange views on things like this.

Just to show you how people are different, I had very few of these needs to "get it out", see the pathology report or even worries about "cancer within".  For me, the peace of mind came with thorough investigation of options and making an informed decision that had a high probability of cure, i.e. as the literature points out, surgery and brachtherapy have essentially equal cure rates.  I clearly recognize the trade offs, embrace them and am confident in my decision...just as I'm sure you are with yours and realziggy is by enrolling in a clinical trial (which would have been too much uncertainty for me!).  Maybe one of these days some smart doc will do a psychological profile of patients who make different treatment choices...

In the short run then, for me, it's a no brainer.  I'm one week post procedure, have zero sides, have resumed all of my normal activities - except for sex, which will start again next Tuesday since the docs asked junior to take two weeks off post-procedure.  Yeah, I know there may be issues down the road but I have the peace of mind to deal with them as you do with your surgery issues.

Dramatically different but interesting perspectives, yes?


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
27cc
Brachytheraply volume study done on 11/14/08
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort. 


RBinCountry
Regular Member


Date Joined Apr 2008
Total Posts : 270
   Posted 12/19/2008 8:45 AM (GMT -6)   
Thanks Tudpock,
You completed the journey I started and I appreciate your situation and confidence. You obviously did the right thing and I wish you the very best.

RB
Age 61 (now 62)
Original data - pre-operation
PSA: 5.1
T1C clinical diagnosis, Needle biopsy - 10 cores, Gleason 7 = 3+4 in 1 core (40%), 7 cores Gleason 6 = 3+3 ranging from 5% to 12%
All scans negative
Lupron administered 4/9/2008 for 4 months (with idea I would undergo external beam radiation followed by seed implants - then I changed my mind).
Robotic DiVinci surgery - Dr. Fagin (Austin) May 19th
Post operative - pathology
pT2c NX MX
Gleason 3+4
Margins - negative
Extraprostatic extension - negative
seminal vesicle invasion - uninvolved
1st Post PSA <.04
2nd Post PSA <.1 10/30/2008

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