New data on the different results of the very top surgeons

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John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 1/26/2010 12:01 PM (GMT -6)   
Interesting article on differences between surgeons; It reinforces Dr Strum's mantra of only choosing the very best artist to perform your treatment.
 

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It has long been known that patient outcomes and complications after prostate surgery vary among surgeons to a greater extent than may be accounted for by chance.

In an article to be published shortly in the Journal of Urology, Bianco et al. have now reported that such so-called “heterogeneity” is also evident even among experienced, high volume surgeons. In other words, which of two experienced, high volume surgeons that a patient gets treated by may impact his long-term outcome post-surgery.

The authors studied data from 7,725 patients with clinically localized prostate cancer treated by a total of 54 surgeons at 4 major American academic medical centers between 1987 and 2003. Biochemical recurrence was defined as a serum PSA level ≥ 0.4 ng/ml, followed by a higher level. The core results of this study were as follows:

  • There was statistically significant heterogeneity in the prostate cancer recurrence rate that was independent of surgeon experience (p = 0.002).
  • 7 experienced, high volume surgeons had an adjusted 5-year prostate cancer recurrence rate < 10 percent
  • 5 experienced, high volume surgeons had an adjusted 5-year recurrence rate rate > 25 percent.
  • Significant heterogeneity was still evident after the authors made appropriate allowances for possible differences in patient follow-up, patient selection, and stage migration.

The authors conclude that a patient’s risk of recurrence after radical prostatectomy may differ depending on which of 2 surgeons the patient sees and gets treated by – even if the surgeons have similar experience levels.

Now we should be clear that The “New” Prostate Cancer InfoLink is far from surprised by the results of this study. We are all aware that there is a big difference between a competent surgeon who does a lot of procedures and “one of the very best.” This is as true for surgeons as it is for sculptors or artists. Most professional artists are not Rembrant or Picasso!

As the authors point out in the full text of their article, a key question here is how the gap can be narrowed between “the very best” and those who are highly experienced but not quite as good technically — and that’s if you accept the premise that surgical skill and technique really are the underlying cause of the heterogeneity (which will be disputed by some).

From a patient point of view, however, there is a simple lesson here. “Good” may not be good enough, and “experienced” does not necessarily correlate to “highly skilled” or “one of the best.” Of the 7,725 patients in this study, 853 were treated at the Cleveland Clinic, 4,168 at Memorial Sloan-Kettering Cancer Center, and 1,704 at Wayne State University Harper University Hospital, which are three highly reputable prostate cancer centers. But exactly who carried out the operation seems to have made a very real difference.

The range of outcomes in this study is perhaps the most serious issue. The “very best” experienced surgeon in this study had a 99 percent probability of biochemical recurrence-free survival among his/her patients. The “least good” experienced surgeon could offer his patients only a 73 percent probability of biochemical recurrence-free survival. That’s a 26 percent variance in outcome!

The bottom line, to quote Bianco et al., is that “Heterogeneity in medical outcomes is undesirable and suggests that some patients experience a less than optimal outcome.” Deep down, the urology community has known that such heterogeneity has existed for years. The “New” Prostate Cancer InfoLink congratulates the authors for finally providing concrete evidence of such heterogeneity. We hope that this will rapidly lead to insistence on superior training, greater skill levels, and greater patient focus among those physicians who wish to make a career out of prostate cancer surgery. A greater focus on active surveillance as first-line management for low risk patients, combined with a real focus on high quality in surgical and radiotherapeutic procedures when they are necessary might massively impact the “harms” all too commonly associated with the active treatment of localized prostate cancer.


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


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 1/26/2010 1:43 PM (GMT -6)   

Eight year old study – wonder if it has or will change since the invention of the robotic version of surgery. Or do they suggest we toss a coin.

 

And does the article factor in surgeons who:

1) consume alcohol

2) are married and beat their wives

3) are single and wish they had a wife to beat

Etc etc bla bla bla

 

Sorry I’m not a big fan of statistics where very few things like surgeons aren’t the same.


Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 1/26/2010 2:06 PM (GMT -6)   
Appreciate the posting, but its hard for me ( a surgery guy) to draw any meaningful opinion from the stats. Would like to see it summarized and to the point. There are many subjective points in this study, each would need looking at.

Surgeons aren't machines, they are men/women like the rest of us. A great surgeon may have a bad day, a completely unknown surgeon may be brilliant in his/her own obscure arean of operation.

We have men right here at HW, that went to the best of the best of surgeons and to the top 10 hospitals that have had quick surgical failure and the need for RT or SRT, so what does that say?

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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Magaboo
Veteran Member


Date Joined Oct 2006
Total Posts : 1211
   Posted 1/26/2010 2:11 PM (GMT -6)   
Whenever I read about all those fine surgeons that have done so many procedures and have become so expert at performing these operations, I can't help but feel some shame, guild and sympathy for all those poor guys that were 'sacrificed' to allow those surgeons to become as 'expert' as they are. Let's all give a moment of  thought for all those poor guys that made it possible for us now to be treated by those those 'experts'.
Just my rant for the day..
Hoping that everyone is doing well.
 
Magaboo

Born Sept 1936
PSA 7.9
-ve DRE
Gleason's Score 3+4=7, 2 of 8 positive
Open RP 28 Nov 06 (nerve sparing), Post op staging T3a
Gleasons still 3+4=7
Seminal vesicles and lymph nodes clear
Catheter out 15 Dec 06, Dry since 11 Feb 07
All PSA tests in 2007 (4) <.04
PSA tests in 2008: Mar.=.04; Jun.=.05; Sept.=.08; 3 days before Rad Start=0.1
Salvage RT completed (33 sessions - 66 Grays) on the 19th Dec., 08.
PSA in Jan., 09=0.05; July 09=<0.04; JAN 10=<0.04


Im_Patient
Veteran Member


Date Joined Aug 2009
Total Posts : 670
   Posted 1/26/2010 2:33 PM (GMT -6)   
When I was first diagnosed, my urologist at the time said that he was no longer performing surgeries (nearing retirement), and referred me to a new surgeon in his group. After some research, I told him that I just could not justify going to someone that had performed less than 100 surgeries, and asked for a referral outside of his group. "Yeah, I had to deal with that attitude the first few years of my career too" was his response, and I could tell I had hit a bit of a nerve. I know we have a chicken and egg problem with our surgeons, and they have to get expert practicing on someone, but I have (had) just one prostate and one opportunity for a surgeon to get it right.

"You are your own best advocate" has to be the attitude you have to adopt regarding your health. Consider yourself more informed than a vast majority of the population for just having found this forum.

I am in violent agreement with you, Magaboo, I mourn for those early subjects, if they had bad outcomes. I am just really, really glad I was informed enough and took enough of the initiative to become educated enough to know this is one of those things that matters more about the skill of the surgeon than ANY other factor.
Gleason, 3+4; PSA, 7
Robotic Prostatectomy, March 2008 (Age 48 then), nerves both sides spared, post surgery analysis confirmed 3+4 Gleason,
cancer contained, no penetration, lymph nodes clear
PSA consistently <0.1 since surgery


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 1/26/2010 2:50 PM (GMT -6)   

I don't know why this is so hard to accept; It simply says that some doctors are exceptional and get consistantly better results than even experienced doctors. This has been known for quite some time, but this study actually confirmed it and quantified it.

We take it for fact that other areas have exceptional performers like Tiger in golf and Buffet in stocks. Why is it hard to accept that there are exceptional surgeons, exceptional radiologists and exceptional oncologists that consistantly get better results than other experienced doctors in their respective fields.

I think we have come to believe that the treatment we get can be replicated easily by technology and experience. This study shows that there are still significant statistical differences among the most experienced surgeons and that surgical skills are much better in some doctors regardless of the experience level.

99% vs 75% cure rates are very statistically significant and can't be ignored by pretending these differences don't exist. If this documented difference existed between treatment options we would all choose the treatment with the best cure rate without thinking twice.

The real question we should all be asking is who are these exceptional doctors and how do we find them. We know the medical community will never publish these names.

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


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 1/26/2010 3:39 PM (GMT -6)   
If surgeons are born great, and experience is no the absolute indicator of gettinmg a great jo,. then not sure how much means or money would effect this. There are those who have laid out the big bucks fir what they thought was a tpp nothch experienced surgeon, and still has a reoccurence.

While it is true, a non-insured person might get a less experienced doctor, he may get the next Tiger of surgery.

And if course the AMA would never allow a posting of a doctors success rate in a list somewhere.

Kind of curious how government healthcare would effect this. If they say you must go to this hospital and see your governmet assigned surgeon, doesn't sound very promising either.

Oh well, life is a crap shoot some times.

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 injection
No pads, 1/1/10


medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1100
   Posted 1/26/2010 3:57 PM (GMT -6)   
The problem with this information is what you can do with it if you don't have the names of those surgeons who have the best success rates, and almost the best, and not nearly as best, etc. QUESTION: "OK, I accept the proposition that if I go to someone who is really terrific, I have a materially better chance of a good outcome -- so who should I go to?" ANSWER: Sorry, I won't tell you. So what do I do? I can take a guess that the guys with the best success rates are Scardino, Catalona, Walsh, Partin, [add names]. But really, I am just guessing. They are famous but I don't know if they have the highest rates of non-recurrance among similar patients.
Age 45.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5
 


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 1/26/2010 3:59 PM (GMT -6)   
The real question we should all be asking is who are these exceptional doctors and how do we find them. said...
BINGO. We all love statistics.....They are good as guidelines.
 
And then there's the part about these exceptional doctors having bad days too...Ya think ol Tiger could go out this week and shoot 25 under par considering that his LIFE is MESSED UP. (see my last post about doctors beating wives) 

medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1100
   Posted 1/26/2010 4:22 PM (GMT -6)   
OhioState -- what is the best day of the week and time of day to have your surgeon do the surgery? I would have assumed this would depend on the individual surgeon (to the extent it matters at all). Personally, I am still a bit groggy at 8am and, though I try hard, maybe not at my best. I think much better after lunch. But the guy next door is sharper right after he works out, at 7am.
Age 45.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5
 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 1/26/2010 4:29 PM (GMT -6)   
For the record, the American Medical Association (AMA) has less than 19% of licensed doctors in the USA comprise its membership. It represents but a fraction of doctors.

Goodlife, your comment rings true. Many new doctors are talented surgeons early on, but the problem is that they are more prodigy than common. It takes time for a physician to hone his skill. Tiger Woods did not just start golfing when he became a pro, he was a golfer all his life. Surgeons start operating when they become pro, and they certainly never operated as childhood prodigies. It takes time to become a great surgeon, and using one with more experience is a common sense recommendation. But when you do get a great surgeon doing his work well, the results are such that make the argument about side effects far less relevant. I always recommend a great surgeon. They are not too difficult to find and they are in most regions around the US. I don't know about other countries, I'll let those from those ares speak up, but I know that great surgeons will have folks travel from all over to have them do their thing.

Relapses happen in every form of treatment. A good surgeon will identify your prognosis possibilities from the surgery results and the pathology, and make a good call on the recommendation of the next course of action. Mine recommended that I see a great oncologist in Las Vegas as opposed to traveling back and forth to his center from Nevada. So far the plan has been a good one...So was the surgical results...

Andrew, the way the "Ignore" feature works best at HealingWell is if you don't respect someone, you should use it to not view their comments, this as opposed to you telling them to do so. I saw nothing offensive in goodlife's post, but if you felt it was offensive, then you have the most options. Certainly use the Ignore feature or agree to disagree.

Tony
Prostate Cancer Forum Co-Moderator


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 1/26/2010 5:22 PM (GMT -6)   
With several hundred thousands men getting a new PC dx everyyear, and assuming many of them wanting to be treated, and then many of them wanting surgery, there''s not enough of the "super surgeons" to go around, and certainly not enough operating room in the entire country to accomodate them, even if they wanted to.

For the average man, with average resources and average health insurance, I think most end up with their best local choices. Again I say, there are thousands of fine doctors and surgeons that you are never going to find on a "top ten list". Sometimes I feel, its being implied that if you settle for anything less then the best, that you are shorting yourself. I don't happen to believe that for a moment. Again, I look at the failures of the "brand name doctors", or look at the ones that "cherry pick" their patients to keep their sucess odds up high.

We can't all go to the Sloans or the Ford Hospital or John Hopkins, etc, for any number of reasons, including family and logistics. I think some of this mentality is what my radiation oncologist told me one day, that men in particular, want to feel like they are in some kind of control with their cancers, its gives them a sense of confidence if they are doing the thinking and making the choices. Whether the average patient, myself included, really has the ability to choose and know the difference would be hard to prove or quantify.

For my new brothers, that are out there still pondering their treatment choices, and if that treatment choice should include considering surgery, then don't be scared off if you are working with local uro/surgeons and local hospitals, etc. Doesn't mean they are bad, and certaintly doesnt mean they can't do a stellar job on you.

Trouble with stats and reports (And as a professional lifetime accountant), numbers can be made to show you whatever angle you want them to show, you have to know the motivation and purpose behind the numbers, the emphasis that is trying to be made. Not against facts or knowledge, but how facts and knowledge are being used to sway people into one treatment or the other.

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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 1/26/2010 6:03 PM (GMT -6)   
David,

I like that. We certainly see guys here who have had what we consider the best, yet they are having reoccurence. That does not mean the doctor had a bad day. IT simply means that either there PC wasn't contained, wasn't local, or the perineural invasion got them.

It also comes to mind that the 8 year old study may not reflect the last 3 or 4 years when DaVinci has really come into its own. Skill levels are vastly different I woul guess.

I was lucky maybe. I could go to Cleveland Clinic because it is 2 hours away. But maybe I wasn't, and got a hotshot with poor technique that has worse stats than[ the local guy who had only done 150, but was the Tiger of surgery

At some point, we need to again say, it is what it is. Life doesn't alway deal us 4 aces. As Jeff's japanase saying translation said, play the cards you are dealt.

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 injection
No pads, 1/1/10


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 1/26/2010 6:13 PM (GMT -6)   
David,
I have one book that I kept from College - "How to Lie With Statistics". It reminds me of exactly what you mention. But then when the Dr. said 98% - I knew I would be in the 2% club - just my fate.
And I did have great treatment from a new hospital with the latest edition DaVinci - had to wait a week just to be sure they used it on someone else first. The doc was not new, fortunately.

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 1/26/2010 6:20 PM (GMT -6)   
David,
Unfortunately people who live near major urban centers or who have the means to travel will get better results than those who use a rural community setting. This is unfortunate, but it is also reality.
Also I agree that a lot of work and research will uncover the best. A few phone calls to oncologists asking them who they would have do their surgery is a good place to start, as they see the results of a lot of failed treatments. Also asking surgeons who they would choose may be akward, but could produce some good leads. Mentors who run USTOO chapters are also a good source. We all know Epstien, Boswich, and Oppenhiemer in the Pathology world, but exceptional radiologists and surgeons may be harder to identify.
Again it's up to each patient to make his own decision of how he wants to approach his treatment, but I am glad that this information is made available so an informed decision can be made. That's the purpose of this forum.
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 1/26/2010 6:22 PM (GMT -6)   
good life, good answer to what i was talking about, and trust me, not jealous of those that can and do use the best of the best, more power to them if they can swing it.

what i have learned from my medical team, is that each case of cancer is so unique to that person, and so much of it is at the genetic and dna level, probably something that was defective from the moment of conception. No reflection against one's concept of God either.

its not about fault, its about cure hopefully, and for many of our brothers, they should live on as usual in their lives and more like than not, something other than PC will take them to the next world.

i do believe strongly in the knowledge abates fear mentality, and we should be open minded about info from all sources, and no matter how brilliant our docs and sources may be, when push comes to shove, we, as lay people, have to make our own choices, and of course, live with those choices. every cancer is different, every one of us has little nuances in our genetic make up and in our real life medical historys, and whatever else we were exposed to in our lives, so there are so very many factors along the path.

all in all, from my time here at HW, most men overwhelmingly make the best choice they can for themselves, and as brothers and gentlemen, we respect those choices, and give our support without question or judgement.

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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 1/26/2010 6:47 PM (GMT -6)   
142 - i am glad it worked well for you, as it does most men here. and when/if you get your string of zeros in the months and years ahead, you will feel good about your decision process. if it doesnt work that way, like it hasn't for some of us, don't go blaming yourself, just find out all you can about the next step, and move forward.

johnt - your thread here was another good one, it leads one to reflect if they are already in the past tense with treatment(s) and hopefully for our newest brothers, will make them think a second, third, fourth, time about what they are dealing with, and think through the best way to treat their own personal PC case. the longer i am here, the more i am convinced that all men new to this world, really take the time to think through all options, including the much discussed AS option
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: 1/10 .12
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 43 days, 1/10 - Corrective Surgery #4, and Caths #11 and #12 in at the same time


MaxBuck
Regular Member


Date Joined Jan 2010
Total Posts : 75
   Posted 1/26/2010 7:36 PM (GMT -6)   
John T said...
The real question we should all be asking is who are these exceptional doctors and how do we find them.
Frankly, I have found that interviewing nurses is probably the best way. That, and asking doctors I know socially who are not in the same specialty.
Dx at age 56: Oct 09; PSA 5.8, followed up by 9.9 two weeks later (reproducibility of test - ?)
Biopsy ind cancer in 8/12 cores: Gleason 8 (4+4)
open radical retropubic prostatectomy Dec 4 09
Post-op pathology: 56 g weight, cancer in 21%, Gleason 7 (4+3, tert 5); margins clear, no lymph node involvement (0/9), perineural invasion present, T2c N0Mx (but showed clear from distant metastasis in pre-op bone scan and CT scan)
Continence data: 1 "panty liner"/day, with minor leakage when I get up from long seated position
ED pretty complete: some erection possible but current non-functional


B&B's World
Regular Member


Date Joined Mar 2007
Total Posts : 120
   Posted 1/26/2010 10:00 PM (GMT -6)   
My husband and I went to a meeting, late in 2006, of the local Prostate Cancer support group, as advised by the information I had gathered from a study conducted (I think) at John's Hopkins Medical Center which cited better outcomes for those PCa patients who exercised, meditated, changed diet and joined a support group (I consider HW one..). At this meeting, a man in his 60's told of his excellent experience and recovery, and referenced Dr. Ahlering having been his surgeon. I was already familar with Dr. Ahlering due to my research, and B ended up being about his 550th RALP patient, in Feb of 2007. Last summer, a doctor in our family met a peer of Dr. Ahlering at a medical convention and his name came up. The colleage said they call Ahlering an "alien" due to his more-than-human stitching ability. Now, 3 years later and "zero's" all the way, we are happier than ever that we diligently searched out the best of the best.

Becky

Age 51

Gleason 3+3

PSA from 3.2 to 4.3 in one yr

Biopsy 11/06

DRE negative

4 of 12 cores positive, one lobe, less than 10%

Inflammation only second lobe

Stage T1C Clinical Dx

PSA prior to surgery: 3.9

Da Vinci Prostatectomy 2/27/07:

PCa in BOTH lobes 5-10% of gland

Gleason 3+3

Negative tissue margins

Bladder, seminal ves, vas deferntia negative

Two inguinal hernia repairs

Catheter removed 1 wk after surgery

Full continence (no pad needed) 1 wk after surgery, then intermittent drips 4 wks out

Full erection, 12th day after surgery

2 mo’s post-op, some ED after penetration

3 month PSA 0.03

6 month PSA non-existent

1 year   PSA  non-existent

1 1/2 yr PSA  non-existent

Erectile function--up and running!

Two year anniversary on 2/27/09-Sex life back to normal!

Three year anniversary coming up-PSA non-existent on 1/5/10!

 


Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 1/27/2010 8:32 AM (GMT -6)   
While I know that the original intent of this post was simply to share important information (thank you John T), I can't help but feel a sense of guilt because I didn't push John to seek a second opinion from a "center of excellence". While I had made the phone calls to Sloan Kettering, NYU and Columbia Presbyterian (all in NYC) and offered John the chance to speak with one or two of them, he opted to stay with our "local" urologist/surgeon who is no slouch when it comes to prostate cancer. Would working with one of these hospitals made a difference for us? In all likelihood, I think not. But, for those patients whose disease is more complex, more advanced, or simply not treatable through standard methods, these experts can make the difference between life and death.

As David (Purgatory) has stated several times, there are probably thousands of excellent doctors who are more than capable of dealing with most cases of PCa. Which brings us back to the age old question of determining who these are.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (single small EPE in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009- 0.1, September 0.3, October back to 0.0, December 0.0. Thank you God!


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 1/27/2010 9:18 AM (GMT -6)   
Sephie,
I discussed my case by phone and email with several other doctors. The downside was that my lab was one of the best, and based on the biopsy they all (-1) agreed on the surgery as the best starting point. So I can't really second guess my decision regardless of what happens, as only one doctor pushed radiation, and offered pitiful result / side effect outcomes.
I stayed with the doctor who diagnosed me, and at +14 weeks (tomorrow), I know I will soon face salvage radiation because of the post-op pathology, even though my first psa was 0, but that is what I was dealt.

I think that I have to be confident of my DaVinci and doctor/hospital choice unless proven wrong.

David - I'm waiting for that second 0 (knock wood) before planning summer vacation.

Sephie
Veteran Member


Date Joined Jun 2008
Total Posts : 1804
   Posted 1/27/2010 9:31 AM (GMT -6)   
142, we too stayed with the doctor who originally diagnosed my John's PCa...and haven't regretted our decision. We have been truly lucky with a kind and caring urologist/surgeon who always has time to talk with us, often calling us at night when he has more time to give us. I would recommend our doctor to anyone in the area in need of a excellent doctor.
Husband diagnosed in 2/2008 at age 57 with stage T1c. Robotic surgery performed 3/2008. Stage upgraded to T3a (single small EPE in posterior left). Perineural tumor infiltration present. Apex margin, bladder neck and SV negative. Final Gleason 3+4. PSA: 0.0 til July 2009. August 2009- 0.1, September 0.3, October back to 0.0, December 0.0. Thank you God!


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4274
   Posted 1/27/2010 12:01 PM (GMT -6)   

I have no doubt about the validity of the concept originated in this thread...frankly it is just common sense so I don't think any of us should be surprised that the "best of the best" deliver the most successful results.

And, I think there have been several good suggestions about how to find the really good doctors, e.g. asking other doctors, nurses, etc.  There is also one other approach...I found that most experienced doctors keep their own personal statistics re cure rate and SE's.  No, these are not necessarily vetted for accuracy, but I found it was worth asking and reviewing these numbers when interviewing docs for my treatment.  One particular doc said he didn't think it was necessary to keep such stats...I quickly ran the other way...

In the end, I vectored in on my radiation oncologist via discussions with other health professionals, his patients, reviewing his statistics and, of course, the personal feeling of trust that I got from discussing my case with him. 

I think the real value of this thread is not to debate our past approaches but rather to encourage our newly diagnosed breathren to use as much due diligence as possible whe making this very critical decision.

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 12/09.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 1/27/2010 12:46 PM (GMT -6)   
Whenever studies like this are posted we always have a few that are either suspicious of all studies and statistics, and others who only look at the studies that support their decision and find fault whith those that indicate that there could be better methods.
EVERY DECSION WE HAVE MADE IN TREATING OUR DISEASE WAS BASED ON A STUDY USING STATISTICS THAT OVER TIME BECAME AN ACCEPTED PRACTICE OVER THE OLDER METHODS.
Why did you get a psa test, and why did you get it at 50 instead of of 20;
Why did you get a biopsy? because your psa reached a statistical level
Why did you choose your treatment? Can taking an asprin or herbs works just as well.
The doctor scrubed up before your surgery because a statistician a hundred years ago found that the death rates for delivering mothers was greater in deliveries with doctors in operating rooms than with midwife's two doors away.
How will you determine when you have a reoccurrance?
I can go on and on, but without statistics and studies proving the effectiveness of every procedure and drug we would still be using holy water and Witch Doctor chants to cure us.
Modern medicine relies on studies and statistics and certainly they have some bias and limitations. They are peer reviewed and methods and content can be challanged, but to dismiss them outright because they don't agree with your beliefs or decisions is not a valid arguement.
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


JoeFL
Regular Member


Date Joined Oct 2009
Total Posts : 420
   Posted 1/27/2010 1:13 PM (GMT -6)   
Many good points made above about the value of due diligence and experienced surgeons by the very experienced and thougtful guys (and a few gals) on this thread. That said, no matter the path you take there is risk. The Tiger analogy is apt. Even prior to his recent implosion, he had days when he did not have his "A" game...or even his "B". That has to happen in the medical world as well.
 
You make a well informed choice, don't look back and make the best hand you can with the cards you are dealt. The value here, as pointed out by Tudpock, is to help others not make a hasty decision. This site helped me slow down and think about some things that I needed to include in a final decision....for which I am most grateful to all.
 
Joe67
 
__________________________
 

Age -67 PSA - 4.5

Biopsy  (9/4/09) - Positive in 5 of 8 cores. In those 5 cores, 5 of 11 samples were positive. Gleason 3+3=6. Stage – T1C  Ct and Bone scans negative

 

BT performed on 12/11/09. 84 seeds of Palladium 103. Surgery at 7:30 - Home at 12:30 same day with no catheter. Side effects as expected -  some burning, frequency, urgency. (Blood in urine stopped after 1 week).  Resumed daily  1 ½ mile walk after 3 days.

 

BT will be followed with 25 IGRT treatments beginning Feb 8. 

 

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