Adjuvent therapy question

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compiler
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Date Joined Nov 2009
Total Posts : 7205
   Posted 12/3/2009 4:14 PM (GMT -6)   
I may have the subject spelling wrong, but reading the PRCI web-site, they talk about different treatment options.
 
Basically, I am in kind of a IB group. My probability for a cure just using surgery is say 76% (based on the latest Sloan-Kettering Calculator). That site seems to suggest doing the HT thing for like 28 months and then going into surgery. My guess is that it would improve the probability of success to say 85%.
 
I'm not sure it is worth it. The side effects are lousy and I would still have surgery to look forward to. The surgery, after this therapy, would give little information as to where things are at (the prostate is shot). It seems to me that I am better off choosing surgery with the idea of IMRT as backup. HT would still be a tool if worse comes to worse.
 
I would appreciate other thoughts on this. I might be missing a few pros and cons.
 
Please discuss.
63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.
 
History of BPH/prostatitis.
 
PCA-3 test: 75.9
 
Biopsy on 11/30/09
 
Biopsy Report—Prostate Cancer

5 out of 12 positive

2 cores were 3+3 (I have to get the percentages) on one side

2 cores are 4+3 (5%)

1 core 3+4 (30%)

no peri-neural invasion

prostate is 45 grams

Stage: T1C

 


LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 12/3/2009 5:09 PM (GMT -6)   
Hmmm...which nomogram stated 76% cure with surgery with your stats? Guess I am using an old calculator...it showed the odds much higher.

I can't advise what is the best route for you to go...but I went surgery with the hopes of a cure in one treatment. If by chance that should fail then a second chance at a cure would be possible with salvage radiation. And should that fail then the hormone treatment is a good backup to hold the cancer at bay. Hormone treatments are generally used to reduce tumor size if used as adjunctive prior to primary treatment. You tumor size at this point doesn't lend to starting HT as the tumor is still small and hopefully still contained so that surgery could be used...or brachy is that is your choice.

Keep reading...lots more advice will follow from the experts 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 w/PNI - 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 Apr 2009 .06
                   9 month Jul  2009 .08
                 12 month Oct 2009 .09 


compiler
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Date Joined Nov 2009
Total Posts : 7205
   Posted 12/3/2009 5:20 PM (GMT -6)   
LV:
 
Poor choice of words. I meant 76% prob. of organ-restricted disease. 5 year survival without progression seems to be over 90%.
 
Check it out:
 
 
My numbers to put in is 4.19, 63 years old, 5 positive cores, 7 negative cores, and stage T1C
 
Mel
 
63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.
 
History of BPH/prostatitis.
 
PCA-3 test: 75.9
 
Biopsy on 11/30/09
 
Biopsy Report—Prostate Cancer

5 out of 12 positive

2 cores were 3+3 (I have to get the percentages) on one side

2 cores are 4+3 (5%)

1 core 3+4 (30%)

no peri-neural invasion

prostate is 45 grams

Stage: T1C

 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 12/3/2009 6:04 PM (GMT -6)   
Complier,
Choosing a treatment option because if it fails you have a 2nd backup sounds good, but in fact is faulty logic. You have to look at the reasons that local treatments fail.
1. The cancer is systemic and not local. No local treatment will cure you and no salvage therapy will work.
2. If you have surgery it can fail because you have extra capsular extension, or the tumor is located in a hard to get to place and not all of the PC cells are removed. In this case you can have salvage radiation with some degree of success. (about 30%) If in fact this is the case, you were not a good candidate for surgery in the 1st place and radiation would have resulted in a cure if used 1st instead of surgery. A color doppler ultrasound can give you a bettter idea if surgery will work.
3. You have a poor surgeon who fails to get all the prostate tissue. This is more common that one is led to believe. There is always prostate tissue left; good surgeons leave less.
4. Radiation fails because the dose given is not enough to kill the PC. With IMRT now being able to deliver 81 gys vs 65gys the killing power is much better. A combination seeds and IMRT will give close to 100gys, more than enough to kill everything in the prostate and 10mm to 15mm in the surrounding bed. If you have a reoccurrance it will in all probability be systemic and not local.
5. You have a poor radiologist who fails to target the entire prostate with the correct dose and leaves dead spots.
You can easily eliminate #3 and #5 if you choose only the best, most experienced doctors.
Having the pathology after surgery and knowing where you stand is always brought up as a major advantage; but what are you going to do with the information? 50% of extra capsular extensions never progress and you will just wait for your psa to rise indicating failure just like everyone else does before you do anything. Forget the final pathlogy; either your psa stays low and you are cured or your psa rises and the surgery failed. In either event you actions are based on your psa levels and not the pathology. Great pathologies have reoccurrances and poor pathologies sometimes don't. It's the psa not the pathology that indicate success or failure, unless the pathology reveals major PC in the ajacent organs. A color doppler can give you this information without having to operate.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4157
   Posted 12/3/2009 6:17 PM (GMT -6)   

John, that was a fabulous post.  I have "cut and pasted" it into my HW Save file as one for the ages...

Thanks,

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 9/1/09.  6 month PSA  1.4 and my docs are "delighted"!

Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/3/2009 6:17 PM (GMT -6)   
Mel,

I also read some of Strum's papers about neo adjuvant HT on the PCRI web-site. He indicated a significant improvement in negative margins with as little as 90 days of neo adjuvant HT. He also stated there wasn't any longer term data to know if the better margins translated into longer survival times. I had a 90 day dose of Eligard prior to my surgery and had a good outcome. The side effects from 90 days of HT were insignificant. I'll check in with you in about 10 years and let you know if it worked.

Good luck to you.

Carlos
Diagnosed 2/2008 at age 71, PSA 9.1, Gleason 8 (5+3)and stage T1c.  CT and bone scan neg.
Robotic surgery 5/2008, nerves spared, bladder neck spared with pelvic floor reconstruction.
All margins, SV and lymph nodes were neg. 
Staged pT2c, Gleason sum 8 (5+3).
Continent at 6 weeks. 
PSA <0.1 at 18 months, Nov. 2009.


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 12/3/2009 6:28 PM (GMT -6)   

Carlos:

 

Somewhere I read 28 months of therapy before surgery. Less than that was no good. Perhaps I misread or misunderstood.

 

I would absolutely not be opposed to a 90-day treatment

 

Mel


63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.
 
History of BPH/prostatitis.
 
PCA-3 test: 75.9
 
Biopsy on 11/30/09
 
Biopsy Report—Prostate Cancer

5 out of 12 positive

2 cores were 3+3 (I have to get the percentages) on one side

2 cores are 4+3 (5%)

1 core 3+4 (30%)

no peri-neural invasion

prostate is 45 grams

Stage: T1C

 


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/3/2009 6:35 PM (GMT -6)   
Mel,

Try this link. www.prostate-cancer.org/pcricms/node/195

Carlos
Diagnosed 2/2008 at age 71, PSA 9.1, Gleason 8 (5+3)and stage T1c.  CT and bone scan neg.
Robotic surgery 5/2008, nerves spared, bladder neck spared with pelvic floor reconstruction.
All margins, SV and lymph nodes were neg. 
Staged pT2c, Gleason sum 8 (5+3).
Continent at 6 weeks. 
PSA <0.1 at 18 months, Nov. 2009.


compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7205
   Posted 12/3/2009 7:01 PM (GMT -6)   

Carlos:

 

That article was VERY interesting. Yet, it was written 14 years ago. Surely we now have more data/food for thought?

If there is such a huge advantage, why isn't this standard treatment. Perhaps it is for Gleason 4+3 like I have?

 

Mel


63 years old
PSA-- 3/08--2.90;  8/09--4.01; 11/09--4.19 (Free PSA 24%), this after 45 days on cipro! DREs have always been normal.
 
History of BPH/prostatitis.
 
PCA-3 test: 75.9
 
Biopsy on 11/30/09
 
Biopsy Report—Prostate Cancer

5 out of 12 positive

2 cores were 3+3 (I have to get the percentages) on one side

2 cores are 4+3 (5%)

1 core 3+4 (30%)

no peri-neural invasion

prostate is 45 grams

Stage: T1C

 


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/3/2009 7:26 PM (GMT -6)   
Mel,

I don't know the answer to your question. I do know that Dr. Walsh indicated in his book that he didn't believe there was any advantage to neoadjuvant treatment. This may be a typical PCa thing where great minds disagree. I would also like to think that the PCRI web-site with noted Drs. like Strum, et all would stay up to date.

Carlos
Diagnosed 2/2008 at age 71, PSA 9.1, Gleason 8 (5+3)and stage T1c.  CT and bone scan neg.
Robotic surgery 5/2008, nerves spared, bladder neck spared with pelvic floor reconstruction.
All margins, SV and lymph nodes were neg. 
Staged pT2c, Gleason sum 8 (5+3).
Continent at 6 weeks. 
PSA <0.1 at 18 months, Nov. 2009.


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 12/3/2009 8:36 PM (GMT -6)   
Hey -- you are reading the wrong outcome numbers from the nomogram! I put in your figures and the number that matters is 88% chance of being progression free 10 years after surgery! that is to say "This tool predicts the five and 10 year probability that the PSA will remain undetectable and that prostate cancer will not progress or recur after radical prostatectomy."

You read the probability of organ confined disease -- who gives a rat's asss as long as PSA stays at zero

88%! Heck nobody will give you those odds that you won't be run down by a cellphone texting driver in the next decade
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day


O Buddy Boy
Regular Member


Date Joined Oct 2009
Total Posts : 106
   Posted 12/3/2009 9:30 PM (GMT -6)   
Hi Mel!

Sorry you're going through this. I have some strong opinions on this, but they are just that, my opinions.

I'll give you some background on where some of those opinions come from and you can decide, OK?

I have the bio-med industry in my bloodlines, I also married into it -- twice. One marriage to a PH.D./M.D. who lectures all over the world. The new wife was a ball-busting surgical nurse before she took a job at a Uro clinic. She saved my backside by dragging me into a free screening at her clinic ten weeks ago.

Right now, the prostate is gone, my boy proudly knows which direction the heavens are, I just threw away 1/3 of a pad that didn't have a leak in it all day, I walk five miles a day and I'm riding my bicycle 10 miles three times a week. My surgeon tells me the only worries I should have is where I should have my second honeymoon. Cool, huh?

Sure I'll have my PSA tests. But there is nothing I can do now. Not going to waste time worrying.

Oh, back to the docs. I have friends who are some of the best surgeons in the freakin' world. Back-porch, bourbon-sippin' buddies. The best kind. I have also spent -- no wasted -- too much of my time at doctor dinners, brunches and other soirees that were so boring they'd put a crack ***** to sleep. I have met so many so-called experts that I am convinced the word "expert" is French for "horse's patoot." Their reputations are like guys who wear too much cologne -- the reputations precede them, but there's something really stinky about the deal.

I live in an odd world where I see surgeons as people. Researchers are tremendously brilliant people who are fighting dragons with toothpick. To me docs aren't a big, fiery OZ who scares little girls, dogs, scarecrows, tin men and cowardly lions while hiding behind a curtain called their reputation.

I want a bright, well-practiced, modest person more concerned about curing me than preening his or her CV.

So here's my incredibly biased view on things. May sensitive toes wear good boots.

Read all the top papers?

Who's determining the top papers? The doc's buddies sitting on the NSF, fellowship or publication editorial board? You think Senators are politicians? I'd rather trust two (count 'em 2) guys with degrees in reading those papers than my efforts. I have a life to live, and if it's going to be short I don't want to spend it reading papers. I proofread and edited enough of them when I was married to it.

Fancy Doppler tests and months of opinions?

At GL7 everything I've heard is that it's a waste of money. Look at the Doc's financial interests when he's recommending doppler at GL7. Oh yeah, in six months, say you go from GL7 to GL8. Shoulda, coulda, woulda at that point. But hey, you were looking forward to HT, weren't you? Sure PCa grows slow. Oak trees grow slow, too, but one cracked my sidewalk last year.

HT?

No way will I volunteer to put my best friend to sleep. My dog was difficult. Willie? No way. Besides in the long run HT grows resistant cells. I'll save that for later if I have to.

Radiation?

Maybe it's because the Missus is a surgical nurse, but I hear horror stories every month, even back before she hired out of the hospital in general surger instead of a private Uro office. Radiation melts your prostate like it was one of your old toy plastic Army men under a blow torch. You become a surgeon's worst nightmare if anybody has to go back in there. And there is no going back to see exactly what stage your cancer was in before you had treatment. You essentially put a bullet through your path report.

She never mentions names because she can't. But that poor fellow with the GL9 that expert surgeons wouldn't touch ... he went EBRT, had ED in the first month and never recovered, incontinence so bad he left a 2-foot wide puddle in the consult room and didn't even know he was leaking. His PSA has never risen since the radiation.

Surgery?

For me, I feel so glad I didn't delay one freakin' week. I'm 10 weeks out of Dx and 8 weeks out of surgery. I'm loving every day God give me. I think I'l play Jai-Alai on New Year's.

That's my opinion. And that's my passion.

Where do you want to be in ten weeks?

OBB
55 yo
Dx:9/29/09
DRE: Susp
PSA: 3.5
Gleason: 3+4/7
6/12 Cores Positive; Sextants were 1%, 3%, 8%, 15%, 12%, 0%
RALP: 10/09/09
PATH:
Margins: Clear
Lymph Nodes: Clear
Seminal Vesicles: Clear
Gleason: No increase from biopsy 3+4/7
Some perineural and capsule invasion.
T2c,NO,MX
Incontinence: Minor. 1 light pad a day. Some days don't need it.
ED: Natural with encouragement. 20mg Cialis and pump just makes things more fun.


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 12/3/2009 10:31 PM (GMT -6)   
Bravo, bravo O Buddy boy.  I like it !
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