Choosing surgery because of salvage radiation option.

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John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 4/13/2009 5:40 PM (GMT -6)   
I keep reading posts on this site that state the main reason for choosing surgery was if it didn't work you could always go to salvage radiation. For some reason I just don't get this logic.
 
There are many good reasons to choose surgery and this is a very good option for many, but choosing it because you can get salvage radiation as a back up is not one of them.
 
The cure rate for reoccurances is about 30% which is very low.
If you have a reoccurance it is either local or systemic. If you have a high gleason the probability of it being systemic is high and beyond the reach of both surgery or radiation.
 
If the reoccurance is local it can only be because you have a positive margin somewhere or the surgery was botched and they left some prostate tissue. Getting the best surgeon will reduce botched surgeries.
 
One can reduce the possibility of positive margins through imaging
such as MRIS, or color doppler. If it shows that the PC has penetrated the capsule or if it is near something else that is hard to get to then surgery is not the best option. Radiation can get better margins in these cases.
 
If radiation is done correctly it should kill all the cancer in the prostate and give wider margins and kill cancer near the ureatha and seminal vessels where it is difficult to get clear margins. You can also radiate the pelvic bed to kill any stray cells and kill suspected PC in the pelvic lymp nodes.
 
Stacking multiple treatments with their own side affects is not very appealing to me. I would rather have one that get's the job done the first time.
 
Seed implants and cryo surgery and even radical surgery are salvage options in radiation if it is local. None are great options and this means that the initial dose given was not sufficient and can be eliminated by going to a top radiologist.
 
I would like to hear other opinions on this or have someone point out what I'm missing.
JohnT
 
 

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/13/2009 6:07 PM (GMT -6)   
JohnT,

I think there are two versions of this thinking, if one has a low psa, low grade case of PC, then chosing radiation or surgery or even watchful waiting on it's own merit makes sense. Chances of either treatment getting it all is much higher.

In version 2, which covers a certain percentage of us, with high PSA, high Gleason, 7 or more, there is always the containment issue. Using me as an example, had a great surgeon, post surgical pathology looks squeaky clean, that should be it, but as my dr. told me, with a PSA velocity such as I had, there is still a chance a cell or two, or more already escaped and just won't show up at this point. So planning to have a do-able salvage treatment makes perfect sense.

Very few would argue the difficulty of salvage surgery as opposed to salvage radiation, where if they have to radiate after the fact (surgery), the damage it does is of less importance.

When I made my choice, I was going for the best shot at containment while I still had the chance, before things got any worse by waiting. That was my primary motivation. As a second motivation, yes, I knew the sequnce of a secondary treatment made a big difference, so I chose to know that I could do radiation if I am one of the unlucky 30% downline that has to deal with reaccurance.

That's my take on it. I could be wrong, but I haven't heard of a single story of a sucessful salvage surgery treatment at HW yet. The few that did that, it was a disaster, no disrespect to someone that either had to or made that choice.

That's just my take. I do agree, one's primary treatment choice should be based primarily on what gives the best shot at eradicating the cancer on the first pass. That is what I and my dr/surgeon are hoping for in my case.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/13/2009 8:54 PM (GMT -6)   
John,
I don't know if it is us you are trying to convince or yourself that radiation is the best treatment for you. Results indicate radiation is not superior, but is on a par with surgery. However figures indicate that surgery has a slight edge as the years pass post treatment. If "radiation kills cancer in the prostate as well as killing cells in a wide margin together with eliminating Pca in the seminal vesicles as well as the pelvic lymph nodes" then local occurrence following radiation would be very, very low compared to surgery. This clearly is not the case as figures indicate. It is a fallacy to declare that if it fails to do so then that must be because it was not done correctly and by an incompetent doctor . Equally it is incorrect to state that local occurrence following surgery is purely indicative of the skill of the surgeon. In addition, the best scans today still are not foolproof which is why a great many choose surgery...............post surgery you can be reasonably sure of where you stand locally. Radiation also involves its own particular set of risks and side effects. Very few surgery patients have bowel complications ( which to me would be much worse than bladder problems) which can a d do occur with radiation patients. Heavy internal scarring following radiation is not unusual and is often the cause of disastrous complications with post radiation surgery. All in all I would assume that most who elect surgery do so on the basis of
(1) Psychologically I want that out of my body
(2) I want to know the true extent and grade of the cancer
(3) Should there be a local re occurrence I want another bite at the cherry.
Most members weighted up what they felt was important to them and based their treatment selection on those criteria.
Bill
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)
PSA February 09 <0.01


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/13/2009 9:23 PM (GMT -6)   
Well said, Billy, agree completely
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


stxdave
Regular Member


Date Joined Nov 2008
Total Posts : 65
   Posted 4/13/2009 9:54 PM (GMT -6)   
Hi John T,

I think you may be over-thinking this. The first physician a patient talks to about his confirmed prostate cancer is a urologist. One of the arguments given to advance the surgical option in lieu of others is the ability to perform other salvage operations in case of recurrence.

Full RP rather than robotic is defended by the fact that all tissue is open to hands-on inspection including lymph nodes and seminal vesicles.

Many of these assertions may seem to be an exaggeration to some but I am sure the urologist is convinced he is advising the patient for what he considers to be the best option.

Salvage surgery is much more difficult than salvage radiation and requires no special talents.

It seems reasonable to me that a patient might repeat the urologists logic when defending his treatment option.

Dave
Dx'd 1999, Age 60, PSA 43, Gleason (3+4=7), T3c
42-3d EBRT w/Lupron/Casodex for 24 months and PSA remaining to be <0.1 for the entire 24 month period.
July 2001 - 2nd opinion required to go intermittent ADT.
MDAnderson biopsy revised Gleason (4+5=9).
Intermittent ADT, Lupron only, with PSA threshhold established at 1.0.
March 2007 - Diminishing returns with Lupron, conferred with MDA urologist for bilateral orchiectomy. Uro asked for biopsy of prostate again. Biopsy resulted in tumors found with Gleason (5+4=9).
August 2007 - RRP and bilateral orchiectomy. PSA <0.1
99% continent immediately
September 2008 - PSA 0.45
November 2008 - PSA 0.67
December 2008 - Resume Casodex
December 2008 - Stricture in bladder neck requiring surgical removal. 99% incontinent immediately.


Life is not waiting for the storm to pass, it's learning to dance in the rain.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 4/14/2009 1:30 AM (GMT -6)   
As much can be said about defending their options as can be said about why many newer RT modalities have not passed the test of time yet. My oncologist (not a urologist or a surgeon) pointed out that EBRT, Estrogenic drugs, and surgery were still the only treatment options that have stood the test of 25 years and beyond. EBRT back then was not good at all. Usually burning everything in the vicinity as well as the prostate. Estrogenic drugs at the time killed many patients with side effects. Many ten year studies exist on PBRT, ADT, and soon IMRT and IGRT. Also brachytherapy. The problem is that PCa is a twenty plus year disease. And of the current options available surgery has the best twenty year record.

Dave, I believe you meant salvage surgery requires a master surgeon skills, not the way I read your post. There really is no training for what a surgeon will encounter after the tissue was previously burnt with radiation. There have been several debulking surgeries that have had success. But the definition of why to debulk is not the same as why to's of salvage treatment.

Surgery isn't going anywhere soon. It is by far the most common treatment for prostate cancer totalling about the same of all other local treatments combined. We will see a drop in surgeries as more opt for emerging technologies, and that may or may not be a good thing. But we won't know until those treatments pass the test of time.

John, my reasoning for surgery first is justified in studies. I am not like all of the guys here but there is case history for the T3 guys that shows starting with surgery, then HT with RT, delivers the best 8 and a half results in the current study. In addition RTOG 9413 also shows that with clarity, though the newer studies are the ones I am watching. I'm a stat in them.

Tony
Age 46 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (January 13, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/14/2009 7:57 AM (GMT -6)   
There are still very sound reasons and a whole lot of case histories to justify why having surgery as the primary and the most frequent treatment method of all times thus far as the "gold standard". It gets the prostate out of the man, it still the best way we have of knowing the extent, quantity, staging of the cancer in the prostate itself, as well if there is any extension to lymph nodes, seminal vessels etc

I think in the future, some of this 3D mapping, color dopler imaging will take some of the pre-surgery guess work out of the formula, and may eliminate surgeries for ultra low level PC cases.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 4/14/2009 10:07 AM (GMT -6)   
Guys,
I'm not promoting any treatment option, and as I said surgery is a very good option for many men. I think people should have the best information available in order to come to their own decisions. In a few cases such as Tony's it makes perfect sense, but I'm not convinced that having salvage radiation as a back up is good reason to pick surgery and to some it has been the main deciding reason. I also think that many are making decisions without all the information they need to come to the best conclusion.
It's not a surgery ,vs radiation discussion, It's a logic and information discussion.
JohnT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

JohnT


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/14/2009 11:28 AM (GMT -6)   
But learning that salvage surgery is a bad alternative to a failed radiation treatment is good knowledge and needs to be factored into one's treatment choice. A person needs to know that. Again, I go back to saying that radiation as a first choice treatment can still be an excellent solution for low grade PC. Gleason 6 or less, low PSA velocity, PSA well under 4.0. That's the range where the cure rate for radiation is so good.

But for the rest of us, I think it is important to know the sequence of treatment options, not just the option itself. The order can be just as critical as the choice in the event of reaccurance.

Despite having surgery for my PC, I am not pro-surgery only. In my previous cancer bouts, it required mutiple surgeries, some unneeded after the fact, but there was no other way of knowing at the time without removal of suspected tissues, and extensive rounds of radiation. So it took both to "cure" those cancers.
Made it to the ten year mark, and only now, my original oncologist thinks I am safe.

We still all agree, there is no one cure package fits all, too many variables, and some of it is subjective and by the choice of the patient, and some of it, call it providence, or the blind luck, just a good call.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


jetguy
Veteran Member


Date Joined Sep 2006
Total Posts : 741
   Posted 4/14/2009 7:24 PM (GMT -6)   

Hey John, I'm a rad guy and your post interests me.  I think that you are dead nuts on.  I almost always agree with Bill about most things, but respecfully think he is full of sierra here.  Love ya' Bill, but you are in error.  (Bill and I have similar personal beliefs.  Tony and I don't, but we have broken bread and Tony is a guy I admire.)

I suggest that you learn what you can and read biker90's recent post.  It's perfect.  Find it, for it will free you if you understand it.

Please do what it is that You Do!

Regards,

Bill


August of 2006, PSA up to 4.2 from 2.7 one year ago. 
October free and total PSA 12% free and 5.0 total.
A month, or so later, 4.7.
Late in the year decide on Image Guided IMRT.
Begin 43 treatments on January 23, 2007 and finish on March 23.
 
Wow, almost two years behind.  I had a typical radiation bounce that
scared me, but it seems to be ok.  PSA is about 1.0 which is ok for
a rad guy at this stage of the game.
 
Got my FAA medical certificate back four months after starting my
treatment.  It's still a First Class, just jumping through a few hoops.


BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 4/14/2009 7:57 PM (GMT -6)   
Don't get me wrong here. Although I too had surgery I am neither an advocate for surgery as THE treatment nor do I think that radiation is any better or worse a treatment. What is best for each of us depends on pathology, grade and stage and the patient's personality. What tipped my decision was the scans available today cannot detail accurately enough (for me) the extent of the tumour and this was important to me. In hindsight my only regret is being swayed in selecting robotic by the blurbs of the advantages of its whiz-bang technology.
Bill
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)
PSA February 09 <0.01

Post Edited (BillyMac) : 4/14/2009 8:14:19 PM (GMT-6)


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/14/2009 9:09 PM (GMT -6)   
Billy, the blurb of technology and trendiness is why I chose open, plus living in an area where at the time, it was all too new here, only 15 had been done period. I wanted a good experienced open surgery dr that had done hundreds, and would have his hands on my inners, and that's what I got, lol.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


SHU93
Regular Member


Date Joined Aug 2008
Total Posts : 328
   Posted 4/15/2009 1:39 PM (GMT -6)   

So in my case, if my PSA rises I have 30% chance of the cancer being completly destroyed by Salvage radiaition? I thought the #'s were higher.

Do those #'s matter based on your Gleason Score and months PSA free?

Are there any other alternatives after surgery other then this and Hormone treatment?

Thanks.
Age Dx 37, 7/2008
First PSA : 4.17 5/2008
Second PSA After 2 weeks of antibiotics : 3.9 6/2008
DRE: Negative 5/2008
Biopsy : 6 out 12 Postive all on right side, Gleason 7 (3+4).
Bone Scan/CAT Scan: Clear 7/2008
Cystoscope: Normal 7/2008
Prostate MRI: Normal 7/2008
Da Vinci Surgery 7/2008
PostOp: T2c (On Both sides), margins clear, seminal clear, nodes, clear. Gleason 6(3+3).
First PostOp PSA 9/2008: <0.01
2nd PSA 12/2008: <0.1 (Different Lab then 1st)
3rd PSA 3/2009: <0.1
 
 


55 and healthy in NJ
Regular Member


Date Joined Apr 2009
Total Posts : 58
   Posted 4/15/2009 3:29 PM (GMT -6)   
I just wanted to thank John T for starting this thread, as it captures exactly what I have been struggling with.
 
Greg

Age 55
Physical exam (01/22/2009): blood pressure 130/85, good EKG; basically all-around healthy
PSA 4.9 (02/05/2009)
Urologist DRE observed slightly hardened left lobe (02/19/2009)
Chest X-ray normal (02/23/2009)
Biopsy (03/03/2009)
PCa present in all sextants, <5% to 50%
Prostate gland 37 grams
Gleason score 7 (in two sextants, scored 6 elsewhere)
 
Surgery (daVinci robotic) consult with Michael Esposito, M.D., http://www.roboticurology.com/ (03/30/2009)
Radiation oncology (Varian IMRT/IGRT RapidArc) consult with Mark Macher, M.D., http://www.njneuro.org/fp/gammateam.asp (04/08/2009)
Other resources: Dr. Peter Scardino's Prostate Book (Peter Scardino (Sloan-Kettering), 2005); Urologic Robotic Surgery (Michael Esposito, Vincent Lanteri & Jeffrey Stock, 2007)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 4/15/2009 4:47 PM (GMT -6)   
SHU93,

The 30% number is the cure rate for all salvage treatments. I would assume that if your pre stats were low and the reoccurrance is local the cure rate could be higher, but I really am only guessing.
If all the margins were clear and if all the prostate tissue was removed it is unlikely that the reoccurance would be local; in that event ADT3 is the appropriate treatment.
I think the most difficult thing in any reoccurance is determining if it is local or systemic. You have to know where the PC is before you can treat it effectively. If I ever had a reoccurance I would get every scan available and biopsies to locate the source. If I couldn't determine if it was local I would go to ADT3 without wasting time and incurring the side afffects of any salvage treatment.
The other salvage treatments are seeds directly to the tumor area and cryo surgery. These can be done for both surgical and radiation failures. Salvage surgery for radiation failure is not a very good option. IRMT for a localized surgical failure is a good option.
I disagree with Billy Mac because I think that today's imaging technology can give you a good idea of tumor location; it's not perfect but nothing is. Color doppler identified the location and size of my tumor and a telsa 3 MRI confirmed it exactly. MRIS missed it altogether (I was told later that it was a telsa 1.5 machine) Newer imaging technology that fuses MRIS, Color doppler, DEC MRI, and diffusion MRI can give you a pretty good idea of tumor location and size and posssibly agressiveness; then there is always 3D saturation mapping. Before I want anyone cutting on me I want to know if the cutting is going to get it all. If not then I'm going to something else that will. It's just common sense. I'm forunate I found a doctor that willing used all the newer scanning technology. All my previous docs weren't aware that it even existed and never gave me that option and I know now that the recommended surgery would have been a failure.
JohnT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


cave88
Regular Member


Date Joined Jul 2008
Total Posts : 76
   Posted 4/15/2009 7:43 PM (GMT -6)   
Gentlemen,
Quite an interesting topic going on here. I tend to believe like BillyMac. I never even really considered radiation as a first source of treatment. I did have a positive margin. Hopefully, if psa rises it is localized, and can be radiated. I believe I know where I stand.
John T, I do agree with some of your assertions as to positive margins, etc.
I lurk a lot, learn a lot here.

Thanks
age:  44
1st psa Apr 08 3.06
2nd psa 6/16/8 4.02,  DRE showed nothing abnormal
biopsy 7/10/08 positive 5 of 12
Da Vinci 8/04/8 Parkview Memorial in FT Wayne IN 
gleason 3 + 3 = 6
prostate 27 g, 4 x 4 x 3.1 cm
Stage:  pT2cNXMX
margins:  apical margin involved
no extraprostatic extension of tumor
seminal vesicle involvement: absent
1st post-op psa, 3 month, 0.11 11/08
2nd post-op psa, 6 month, 0.12 2/09/09
 
 


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4275
   Posted 4/16/2009 12:13 PM (GMT -6)   

Dear JT:

This is an interesting thread but, your post on another thread about cognitive dissonance should make you realize that most of us will rationalize our treatment decisions including the relative importance of post surgical radiation as a backup plan for surgery patients...

Having said that, I'll still weign in on this with my commentary.  My primary point is that psychological reasons can be a powerful motivator in making a treatment choice.  I do not believe, as you postulate, that having the radiation option available after surgery is invalid reasoning.  However, I do believe that the relative weighting of that can be vastly different in different men.

Let's take an example.  Say we have a 60 year old man with early stage cancer.  PSA is 5, nothing found on DRE, Gleason 3 +3, normal sized prostate and a couple of core samples with 25% or so cancerous.  That man has pretty much the full range of treatment options available.  So, what factors does he consider when making his choice?

1. Cure rate of treatment.

2. Short and long term urinary issues.

3. Short and long term ED issues.

4. Invasiveness of procedure.

5. Potential bowel issues.

6. Need to have a "backup plan" if primary treatment doesn't work.

7. Need to "get it out" of his body (the cancer that is).

8. Need to see pathology immediately after procedure.

I think both rad and surgery guys would agree that "cure rate" is number one with all of us.  After that the similarities diverge based on the psyche of the particular individual.  Now I will generalize a bit…the surgery guys seem to place a high degree of importance on items like “getting it out”, seeing the pathology and having a backup plan.  The radiation guys appear to weigh low invasiveness and fewer immediate side effects as higher motivators than backup plan or the other surgery motivators.  For me personally, I felt that there was a very high likelihood of cure so I didn’t worry too much about backup plans.  I figure that, if I had either surgery or seeds and either didn’t work, I would probably end up on HT eventually anyway, so I didn’t weight the loss of the option of having post-surgery radiation as very important.

I guess my point is that, while I do believe that the surgery guys’ point about an extra backup plan is valid, it’s not that important to me (and I’m guessing not to you) because of the weighting I personally give to some of the other factors listed above.

I’m sure I didn’t solve anything here, but this hopefully adds another perspective to this thread.

Tudpock


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
2 of 16 cores cancerous
27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 4/1/09.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 4/16/2009 1:31 PM (GMT -6)   
Tudpock,
I agree with everything you said. Very well put.
JT

64 years old.

I had an initial PSA test in 1999 of 4.4. PSA increased every 6 months reaching 40 in 5-08. PSA free ranged from 16% to 10%. Over this time period I had a total of 13 biopsies and an endorectal MRIS all negative and have seen doctors at Long Beach, UCLA, UCSF and UCI. DX has always been BPH and continue to get biopsies every year.

In 10-08 I had a 25 core biopsy that showed 2 cores positive, gleason 6 at less than 5%. Surgery was recommended and I was in the process of interviewing surgeons when my wife's oncologist recommended I get a 2nd opinion from a prostate oncologist.

I saw Dr Sholtz, in Marina Del Rey, and he said that the path reports indicated no tumor, but indolant cancer clusters that didn't need any treatment. He was concerned that my PSA history indicated that I had a large amount of PC somewhere that had yet to be uncovered and put me through several more tests.

A color doppler targeted biopsy in 11-08 found a large tumor in the transition zone, gleason 6 and 7. Because of my high PSA Dr. suspected lymph node involvement, 30% chance, and sent me to Holland for a Combidex MRI, even though bone and CT scans were clear.

Combidex MRI showed clear lymph nodes and a 2,5 cm tumor in the anterior. I was his 1st patient to come up clear on the Combidex which has a 96% accuracy,

I've been on a no meat and dairy diet since 12-08 and PSA reduce to 30 while I awaited the Combidex MRI.

The location of the tumor in the anterior apex next to the urethea makes a good surgical margin very unlikely. Currently on Casodex and Proscar for 8 weeks to shrink my 60 mm prostate. Treatment will be seeds followed by 5 weeks of IMRT while continuing on Casodex and Proscar. So far no side affects from the Casodex.

As of April 10 and 7 weeks on Casodex and Proscar PSA has gone from 30 to 0.62 and protate from 60mm to 32mm. Very minor side affects. Doc says all this indicates tumor is not aggessive

Awaiting schedule for seed impants

 


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/16/2009 2:16 PM (GMT -6)   
I would be willing to bet....that a vast majority of decisions for treatment were actually performed by the doctor that made the recommendation initially. A very very small percentage of men will actually research treatment methods before making their decision. I only base this on the number of newly diagnosed men that have had treatment and then post on a board...either this one or any other forums. And due to the number of senior men that are not savvy to the computer...I would bet even more that this is the case. The internet is a powerful resource...but only has grown in popularity in the last 10 to 15 years if that much.

So I don't know how much thought is really put into the treatment selection by most men. Albeit it is getting better with the word of mouth and the media attention of late for prostate cancer.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/16/2009 2:51 PM (GMT -6)   
Les, usually, I agree with most everything you post, but on the above post, I think it's generalizing. I researched for months and months, both online and with books before I ever found this site. Glad I found it, got a lot of good information and support and friendship here.

It was almost take a good scientific poll to determine the breakdown of men that were well armed and researched before their treatment, and those that werent. Just my take.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/16/2009 3:49 PM (GMT -6)   
David...I agree it was generalizing at best, but in the emails and phone visits I have had with many men...most of the time not alot of research was done before making their decision. It comes from the attitude (including me) that your doctor knows what is best for your individual health. With my knee surgeries, skin cancer and including my lung problems, I had always followed the advice given by the doctor including any referals by doctors. It wasn't until the prostate cancer and having my sister with breast cancer at the same time that I even began searching for info. It started with the searching for breast cancer and the possibility of genetic association that I stumbled on the sites dealing with the complexity of prostate cancer. You don't have so much discussion or treatment options with other cancers as I know you are very aware of in dealing with your own multiple cancers. So yes...it is generalizing...but I think it was relevent to the discussion here.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/16/2009 5:40 PM (GMT -6)   
Les, I catch your drift now better, wasn't trying to hammer you. I have always been a very compliant patient with all my maladies over the years, but, I am a very informed patient. I have "fired" specialists before - didn't like their attitudes or approaches. Being married to a nurse gives me an edge I think with a lot of medical advice I have been given over the years. Some people (patients) are too non-compliant, and they end up messing themselves up in my opinion. There is a reason why it takes so long to become a dr or nurse, and I am certainly not qualfied to second guess everything.

The prostate cancer is a different breed of trouble, as we all know here, no set rules, no "normal", no way to really know how you will react to treatment, or the side affects of treatment. That makes it much, much harder to know what is the right thing to do. I think, overall, there is no absolute right or wrong here. We do have to be educated the best we can, and go for the best treatment possible with whatever resources one is blessed to have or not have.

While I have been through a lot of other "stuff" prior to PC, they were mostly predictable ailments in how they were treated and the followup.

I think we do the right thing here at HW, compare stories, experiences, sucesses, failures, etc - all together so that we can glean from each other, and of course, support each other.

I hate the whole PC thing, despite my treatment and reasonbly good results so far, but I never feel like it is over with, and it may or may not be, like a sword over my head for months or years to come. And more importantly, other than being on guard and informed better than I was at the start, I really don't have any real control over it, and I think that is what bothers me, and perhaps a lot of the other men here.

Thanks for your imput, as usual.

David in SC
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


Swimom
Veteran Member


Date Joined Apr 2006
Total Posts : 1732
   Posted 4/16/2009 6:53 PM (GMT -6)   
Decisions are as unique as the person making them I think. Paul for instance; he wasn't a radiology candidate so that narrowed his options. He would likely have chosen surgery as a first option saving radiation for a rainy day if need be but, who knows? His age played a significant role in his choice as did the clinical pathology. Having so many treatment choices does make decisions more complicated.....

swim
 


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 4/16/2009 9:05 PM (GMT -6)   
Very true what you are saying there, swimom. With my original cancers, there was no choice but surgical removal. When they put me through radiation after the 2nd reaccurance, they admited that it was an educated guess to try that, because they knew there was no chemo formula that would do any good. So I had to go with the flow that time, there was nothing to decide.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 6 month on 5/9
 
 


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 4/17/2009 8:07 AM (GMT -6)   
David...part of where alot of this was from some news concerning a husband of one of my wife's friends at her work. He is young, 48 with PCa and followed his urologists recommendation for surgery without giving it anymore thought than that. He even followed the urologists recommendation at what hospital to go to. I am trying to get more info, but it appears that during the surgery, robotic I think, his colon and bladder were damaged. He has add at least 2 additional surgeries to repair the damage and is scheduled for another one in a week or so. According to my wife his stats were better than mine at the time of his original diagnosis. I don't have the full story, so there is more to this than what I have said, but the point was, he made a decision without researching the doctor, the hospital or the procedure and is now suffering terrible side effects. His wife is just now starting to ask questions...after the fact. Sometimes we men, tend to try to keep private our health issues and won't discuss it much with anyone especially strangers.

All I know, is if I had just followed my GP's recommendation for the urologist he referred me to...I probably would not have had the good outcome I had. My GP is new to the area and did not know about the reputation of the local hospital or the urologist he referred me to. Thank goodness I did know and I researched before making a decision.
You are beating back cancer, so hold your head up with dignity
 
Les
 
Age 58 at Diagnosis
Oct 2006 - PSA 2.6 - DRE Normal
May 2008 - PSA 4.6 - DRE Normal / TRUS normal
July 2008 - Biopsy 4 of 12 Positive 5 - 30% Involved Bilateral - Gleason (3+3)6 Stage T1C
Robotic Surgery Sept 18, 2008
Pathology October 1, 2008 - Gleason 7 (3+4) Staged pT2c NO MX - Gland 50 cc
Seminal Vesicles and Lymph Nodes clear
Positive Margins Right Posterior Lobe
PSA 5 week Oct 2008 <.05
                   3 month Jan 2009 .06
                   6 month April 2009 .06

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