New data on surgery revealed by Scardino

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 12/16/2009 7:04 PM (GMT -6)   
The following article gives Scardino's view on surgery; it is a must read.
Some of his findings:
Surgery much better on high risk cases.
Sugery used too much in low risk cases
Data shows higher rates of incontinence and ED with robotic than open.
And other surprising thought from one, if not the premier surgeon in the US.
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


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/16/2009 7:40 PM (GMT -6)   
Excellent article, John. I had seen some minor figures on robotics at one point that hinted that ED/Incontinence issues might be slightly worse than with open, but this is first time since someone of his reputation talking about that.

With my personal stats, makes me feel like though my surgery failed in the classical sense, it still made sense to do it first.

It should make men with low grade PC think twice about jumping into surgery. Gleason 6, low # of cores, low % of cancer in cores, lower PSA numbers, no serious family PC heritage. With men with better criteria and stats, I think they should be more open to non surgical options, and I am saying that as a surgery guy.

Thanks for posting this.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


Carlos
Regular Member


Date Joined Nov 2009
Total Posts : 486
   Posted 12/16/2009 7:55 PM (GMT -6)   
Thanks for posting the article John T. I have been second guessing myself on my choice of treatment for over 18 months. Maybe I didn't screw up after all.

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.


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/16/2009 8:17 PM (GMT -6)   
I saw this early this morning, and I applaud Scardino's report. As Mike Scott point's out in the post about the differences between robotic and open is the surgeon skill not the procedure. Most who do robotic have less experience than those who do the open procedure. As time moves on skill sets will improve on the robotic. I believe that surgeon skill is most important when selecting a doctor, and I have been pretty much saying that since I selected a doctor with over 1500 procedures. Mine was robotic, and my plumbing is good, even after IMRT radiation. It's quite a bit of good luck to do both and have the results I do.

Scardino's point about high risk cases is two fold, surgery is more successful when used in high risk cases than low risk cases, particularly those who could choose active surveillence as their treatment. But Scardino also points out that mortality is better with surgery in high risk cases than with radiation and that he has the data to back it. In part because he has the prostate examined and can determine sooner and better as to what and when to add salvage and adjuvant therapy. This step could be radiation or hormonal therapy, or both.

Imaging techniques (CDU, MRI, Prostascint, CT etc.) available anywhere today do not have the ability to provide the clear picture a dissected prostate can. And once a prostate is removed, PSA becomes an excellent and instant surrogate for disease progression. You have the best data available. Surgery also allows a patient to bypass radiation unless adding it is needed. Radiation, absolutely, is part of the surgery protocol but only should it be needed. Most don't ask the question, what if surgery fails?

I mentioned that 20 year studies will be of very important value, and they indeed will. Ten years studies are almost useless when comparing treatment modalities.

Tony
Prostate Cancer Forum Co-Moderator


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2461
   Posted 12/16/2009 8:20 PM (GMT -6)   
Thanks for posting John,
Being a Gleason 8, I'm glad I decided to have surgery instead of radiation.
Age: 67 at Dx on 12/30/08
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09 Dr Fagin, Austin TX
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Posterior lateral lesions measuring 1.5 x 1.4 x 1.0 cm showing focal capsular penetration over a distance of 3mm.
Prostatic adenocarciroma accounts for approx. 10-20% of the hemisphere.
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx, Negative margins
seminal vesicles clean, lymph nodes: not dissected
continent after 4 months
8 weeks PSA test 4/7/09 result <0.1
5 months PSA test 7/9/09 result <0.1
8 months PSA test 10/9/09 result <0.1


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 12/16/2009 9:02 PM (GMT -6)   
Tony,
I got the impression that Scardino was only using the MSK data to conclude that open had better results than robotic. This would exclude the less experienced robotic doctors as MSk has the most experienced doctors using both techniques. I'm I mistaken in this assumption?
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


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 12/16/2009 9:05 PM (GMT -6)   
Tony, I agree with your take on that article too.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA:
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 in place


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/16/2009 9:30 PM (GMT -6)   
John,
I can't say. I also can't say they have the most experienced at anything. Just that MSK is a great center. But I, as an advocate, have seen consistent results from the well known surgeons on both sides of that discussion. Kawachi, Wilson, Fagin, Menon, Patel (for example), have many patients here with excellent results with robotic, while Carroll, Walsh, Catalona, Scardino (also just examples), have great track records with open surgeries. All are great surgeons, and all will have that one case that just frustrates even them as doctors. If they say they haven't, time to move on. But I have seen all of these guys speak and they acknowledge that each case is different. A skilled surgeon will likely reap excellent results. Much is also true when comparing great radiation oncologists. But remember, in the case of EBRT, the radiation oncologists seldom operates the machine that does the work. The surgeon always operates the console in robotic. There are many lesser known names in every modality that are fantastic doctors, but the data on them makes this decision of choosing them tougher. The names mentioned above have extensive backgrounds in their work.

Tony

LOL I edited my own post. Tewari is a robotic surgeon. He spoke at the Scientific Retreat in Tahoe, and for some reason I noted open. He didn't speak about surgery mainly so I missed it. For the record, I think Catalona is "the most regarded surgeon" and he is also one of the founders of the PSA test.
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 12/17/2009 12:04:48 AM (GMT-7)


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 12/16/2009 9:58 PM (GMT -6)   
John,

Thanks for pointing out this well quaified opinion. As a G9, I too am thankful for surgery, and that my other opinions were pointing me in a good direction.

The one amazing stat I picked up on was the difference in average time for salvage treatment. 13 months for surgery, and 69 months for radiation. Not sure why that is. Could it be that many radiation series also include an HT element, which could in the end, mask the symptoms ?

Goodlife
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injections


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 12/17/2009 12:18 AM (GMT -6)   
Goodlife,
After surgery if it is not successful PSA is high or will rise rapidly, or they can see a positive margin from the path and salvage can start fairly fast.
In radiation it works over a period of up to 3 to 5 years. There are still PC cells in the prostate; they are still alive but cannot reproduce because their DNA has been changed by the radiation. As they finally die the psa drops. The psa may drop for a period of years until it reaches a nadir, if it fails, then it starts rising again. It has to rise at least 3 consecutive times before it is consider a biochemical reoccurrance. This is why it could take up to 69 months to actually identify a local reoccurrance. If the reoccurrance is not local the psa will rise a lot faster a lot earlier.
Hope this makes sense.
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


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 12/17/2009 3:31 AM (GMT -6)   
Goodlife,
John has it mostly. But it is possible that PSA may rise soon after surgery or never achieve a non-detectable number... And not necessarily will it rapidly rise. It may take months or years to rise. But the PSA becomes a surrogate for disease progression quickly. It's as quick as you can get this information. This is opposed to the radiation definition of relapse where you define a relapse by waiting until you achieve a lowest PSA number then wait until you rise two points, or three consecutive rises. That could take 69 Months on average.

Tony
Prostate Cancer Forum Co-Moderator

Post Edited (TC-LasVegas) : 12/17/2009 1:35:44 AM (GMT-7)


Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3743
   Posted 12/17/2009 10:50 AM (GMT -6)   
And once again, the incontinence data matches what we have found here in our unscientific study with about 90 responses. open had better continence rate than Robotic. The Scardino data showed continence over time for both surgery techniques, see slide 21. Sixty percent of open surgery patients were continent at 7 months. It took Robotic patient 18 months to reach that level.
If I had only known....
Jeff (still at 3 pads per day but sleeping through the night with Nyquil.)
DX Age 56. First routine PSA test on April 8th: 17.8. Start 2 weeks of Cipro to rule out protatitis.
May PSA: 22.6, 3 weeks later: PSA: 23.2.
Biopsy 6/10/09: 7/12 scores positive, Gleason 6=3+3. Bone scan and C/T scan negative.
RP DaVinci -7/21/2009 @ Univ of Roch Medical Center
Left nerve gone, right partial spared.
Catheter removed - 7/31/2009 Pathology report received:
Gleason 3+4=7 Tumor size: 2.5 x 1.8 cm location: both lobes and apex. No Malignancy in Seminal Vesicle, vasa deferentia, lymph nodes 0/13
Extraprostatic extension present; Perineural invasion: present, extensive
Prostate mass 56 grams. Pathologic Stage: pT3aN0MX
Post Surgery Status:
Potency - 12/11 5 months, Still no activity, zip. Using pump daily since 11/11.
Incontinence - 8/20 4 full pads per day
.. 9/7 3-4 full pads per day (I'm going to try cutting down on fluids. Bad idea. I know.)
. 9/27 2 months: Still 3 pads per day.
11/14 4 months: Still 3 pads per day. 420ml/day, 91 um leak.
12/11 5 months: Still 3 pads per day. 400-450ml/day Experimenting with Nyquil.
Post Surgery PSA - 9/3 6 weeks - 0.05; 10/13 3 months - 0.04 undetectable.


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 12/17/2009 10:50 AM (GMT -6)   

Thanks very much for the reference to Scardino's presentation.

A human interest sidenote: when Rick Lewin, president of Yale University, was diagnosed with prostate cancer earlier this year, he went to Peter Scardino for his surgery.  When Lewin was asked why he didn't go to the Yale-New Haven Hospital, he deflected the question by saying that he felt very comfortable with Scardino - an alumnus of Yale!

Zen9


No family history of PC.  PSA reading in 2000 was around 3.0 .  Annual PSA readings gradually rose; no one said anything to me until my PSA reached 4.0 in September 2007, at which point my internist advised me to see a urologist.   
Urologist advised a repeat PSA reading in six months = 4.0 .  Diagnosed May 2008 at age 56 as a result of 12 core biopsy.  Biopsy report by Bostwick Laboratories = Gleason 3 + 3. 
Interviewed two urologists - the one who did the biopsy and another - the latter had the biopsy slides re-examined = Gleason 3 + 3. 
Then went to M. D. Anderson Cancer Center in Houston in July 2008 and met with a urologist and a radiologist.  Biopsy slides re-examined yet again, this time by MDA's internal pathology department = Gleason 3 + 4.   
Chose da Vinci surgery over proton beam therapy; surgery performed at M. D. Anderson Cancer Center on August 15, 2008.  Post-operative pathology report = four tumors, carcinoma contained in prostate, clean (negative) margins, lymph nodes clear, seminal vesicles clear.  Gleason = 4 + 3. 
Minor temporary incontinence; current extent of ED uncertain due to lack of sexual partner; refused treatments for ED as being pointless under the circumstances. 
PSA readings: 
November 2008 = <0.1 ["undetectable"]
June 2009 = <0.1   
December 2009 = <0.1
 

New Topic Post Reply Printable Version
Forum Information
Currently it is Tuesday, September 25, 2018 6:17 PM (GMT -6)
There are a total of 3,006,642 posts in 329,385 threads.
View Active Threads


Who's Online
This forum has 161841 registered members. Please welcome our newest member, RICHGEN.
311 Guest(s), 9 Registered Member(s) are currently online.  Details
borrelioburgdorferii, 73monte, pombear, Killjoy123, Tredye, John T, ks1905, dontscopeme, Noggin2u2