Dear Nebraska Guy:
Shown below are comments I recently posted for another patient who was trying to make a choice. I think this is equally valid for you.
First of all, I’m sorry you have to be here but I will tell you that you have found a good place for both information and support. I am one of the few brachytherapy patients that post on this forum. You will get lots of good advice from the surgery guys…some of it balanced, some of it clearly pro-surgery. And you will get what I hope will be balanced advice from me, but it probably will also be a little skewed with a pro-radiation bias. So, I’ll try to be a little bit organized and provide you with some advice from my perspective.
First of all, with early stage cancer you have time to research the heck out of your alternatives so you can feel comfortable that you are making an informed decision. If you haven’t bought it yet, I advise you read “Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer”. It’s not perfect, by any means, but is an excellent primer. Secondly, both of the options you are considering will most likely cure you. There are multiple long term studies for surgery and brachytherapy that indicate they provide basically the same cure rate for early stage cancer patients. Of course, each man is different and I suggest you plug your stats into some of the predictors available to see where you fall.
You should also make sure you consult at least three EXPERIENCED doctors to gather your options. They are your uro-doc surgeon, a radiation oncologist and a prostate oncologist. Many of the major cancer centers, e.g. Johns Hopkins, Duke, MSK, M.D. Anderson, etc., can provide those three in a multi-disciplinary team setting. Otherwise, you can and should still do it on your own. I highlighted “experienced” because there are definitive studies that demonstrate better outcomes if your practitioner has done 250+ procedures…let them learn on someone else.
You also might consider getting a color doppler biopsy to assist with your baseline. I didn’t even know such a thing existed but would have gotten one if I had known about them. The bottom line is to make sure you are totally comfortable with the decision. This is huge and they are messing with pretty important real estate!
As I said, you will likely get lots of advice here from the experienced surgery guys. The two choices I looked at were robotic and open. Robotic is newer but there are plenty of experienced guys now who can do it. I would have chosen robotic if I had chosen surgery. With surgery you get the aforementioned likelihood of cure, the immediate post-procedure knowledge of the pathology of your cancer and the psychological advantage of “having it out”, that is very important to some men (it was not to me).
But surgery is invasive, even the robotic kind. You have the inherent risks of major surgery, a catheter for some period of time (a week to months) and some time needed to recover from the operation. You also almost certainly will experience incontinence – typically improving over a period of months. You will most likely experience ED. That improves over time for most men, especially with the help of Viagra, Levitra or Cialis. There is some clear evidence that ED is psychological as well as physical. In other words, once you lose the ability to have erections, it’s tough to get them back because you are trying so hard to make it happen.
The things that some surgery docs don’t tell you are that you lose your ejaculate, your penis make get shorter and many men ejaculate urine.
One advantage of surgery that many surgery patients cite is the fact that, if the cancer recurs, you have salvage radiation as an option for further treatment. I personally find this a rather specious argument, since the cure rate from this "broad beam" radiation treatment is quite low and further treatment is likely to be required anyway.
This was my choice and, 8 months out, I’m glad I made it. I’ll let you know in 20 years if I’m still glad! You can read my “story” if you click the link at the bottom of my signature.
A typical poster-boy candidate for brachytherapy will have Gleason 6 or less, a prostate size of 50cc or smaller, Stage T1-T2, and PSA less than 10. With G-7, brachytherapy alone may also be used if all of the other criteria are met plus cancer found in only a few cores and with a small %. Otherwise, the doc will typically use HT to lower the prostate size and/or supplement the brachytherapy with a 4-5 week course of external beam radiation therapy.
Brachytherapy as a procedure is pretty non-invasive and is typically done on an outpatient basis. There is very little pain involved and the patient pretty much returns to normal activities within 48 hours. Besides the aforementioned curative power of seeds, the urinary effects are much different than surgery. There is rarely any incontinence, but a patient may experience some frequency and/or urgency during the first couple of months. Most docs put men on Flomax for 3 months to assure normal urinary activity. Pre-procedure, most patients take a written test about their urinary activities. If things are pretty normal pre-procedure, they are more likely to be normal post.
The same can be said for ED in brachytherapy patients. A patient performing well before seeding is more likely to perform well afterward. In any case, most of the “performing” patients return to sexual activity within a couple of weeks of the procedure. However, if and when ED occurs in brachytherapy patients, it is likely to be a couple of years down the road. If that happens, the same little blue pills that help surgery guys will likely do the trick for seed guys. In general, brachytherapy patients show somewhat less ED than do surgery patients when normalized for age, diagnosis, etc.
While “radiation after surgery” is generally available (but not highly successful) if the cancer returns for surgery patients, “surgery after radiation” is not usually an option for brachy patients. There are only a few docs who will do salvage surgery after radiation and personally, I would not recommend it. So, if cancer returns to a brachytherapy patient, the options are likely to be hormone therapy, cryosurgery, re-seeding or maybe even HIFU.
This got a little long, but I hope it helps. Best of luck to you; please let us know how you progress.