Surgery vs IMRT, is surgery the better option? Seems like IMRT is easier...what am i missing?

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a777
Regular Member


Date Joined Aug 2010
Total Posts : 22
   Posted 8/10/2010 11:12 AM (GMT -6)   
Well it happened, we knew it would and were expecting it, but it still sucks.

After diagnosis was told by the first doc (who is a urologist) because of young age surgery the way to go.
Went to see surgeon, was told "if you were my family member" I'd definitely do surgery.
So we're thinking surgery it is.
Still wanted to get the other side of it though.

We just got back from the radiation guy who said radiation is the way to go.
He did a prostate exam and said he did feel bumps and it was hard. It was his opinion that the margins would be positive. In that case he said if we did go the surgery route to be aggressive with the surgery. ie. nerve out, margins out.

He also explained if we did IMRT it would zap the prostate and some of the surrounding area. Success rates about 85% after 5 years.
He went on to say if we did surgery and needed to follow that up with IMRT side effects would be worse. The surgeon didn't mention that to us, he said it would be no problem.
Sounds like one treatment is the way to go, and you hope you solve the problem with that one.

So my question to you all...
Why would anyone choose surgery? Isn't IMRT easier and just as effective? Am I missing something?
Seems like a lot of people are going with surgery.
Thanks in advance!

Age-64
PSA- 9.9
G7 (3+4)
6 of 10 positive (two were 2% at 3+3 so nothing to worry about)
The part to worry about-
left base (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)
left mid (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)

SubicSquid
Regular Member


Date Joined Oct 2009
Total Posts : 252
   Posted 8/10/2010 11:27 AM (GMT -6)   
I think I, like a lot of guys, just wanted the cancer out of the body. I never even talked to the radiation oncologist. I felt that if the surgery didn't get it all, I had radiation as a back-up. This turned out to be the case. I ended up getting salvage radiation after open surgery. I keep thinking now, would I do it the same way all over again and I can't honestly answer the question. I've learned a lot more about PCa and treatments since my surgery and still find it to be one big confusing mess with no real winner as far as treatment goes. Everybody has their own opinion as to what is best, including all the doctors. All you can do is take your time, read a lot, talk to many doctors, and then decide for yourself what you feel is best for you. Squid.
*Age 63, PSA July 2009 .66
*Diagnosed July 2009, Biopsy: 2 of 12 cores positive, Gleason 3 + 5=8
*MRI and Bone Scan negative
*open Surgery October 22, 2009
*Prostate, both nerve bundles, seminal vessels, and lymph nodes removed during surgery.
*Post surgery Biopsy, Gleason 4 + 3; 2 positive margins
*ED - Yes
*30 day PSA (ultra-sensitive) .07
*90 day PSA (standard) <0.15
*01/10/10 - bladder neck stricture. opened during cysto exam. Cath #2 in for 5 days.
*03/01/10 - bladder neck stricture. Dilated during cysto exam. Cath #3 in place.
*03/11/10 - Bladder neck surgery. Cath #4 in place.
*03/15/10 - Cath #4 out. Great urine stream. Unfortunately, incontinence back to post surgery level.
*04/14/10 - Six month PSA .21
*05/15/10 - Incontinence basically under control. 99% dry. Wear pad daily at work "just in case".
*06/10/10 - Started IGRT. 39 treatments scheduled.
*07/27/10 - IGRT Complete. 39 treatments, 70gys.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 8/10/2010 11:30 AM (GMT -6)   
Your 4 cores that are Gleason 7 wiht 50% cancer is a big thing to worry about. Means you have a moderately agressive cancer going there, and thats just based on 10 tiny cores taken. Biopsies are like an estimate, you are hoping they are seeing most of the cancer.

Of course a surgeon is going to say surgery is best, and radiation oncologisit is going to say radiation is best. What did the radiation doctor tell you, if the radiation failed as a primary treatment? That is an important question to know. After surgery, most men head for radiation as a secondary treatment if their surgeries fail.

With surgery, once the prostate is removed, they will have the entire thing to analyze, to fully know the cancer's staging and extent, plus the main source of producing PSA will be out of you once and for all.

I wouldn't be looking at it as which is easier, you need to know which is better for your case. Any Gleason 7 case can be problematic, as it really depends on how much of the type "4" agressive cells are at work.

Radiation could be a great choice as a primary treatment, including seeding, with or with out additional radiation and/or HT included.

You don't have to rush a decision, but as a Gleason 7 with that much cancer, you sure wouldn't qualify for AS or any other kind of "watchful waiting" programs.

Getting a second opinion on that biopsy might be a good next step.

Radiation is not an easy ride, some people, myself included, have had a rough time with it. The side effects from radiation can hit you later, while the side effects of surgery hit you right away, and then hopefully improve over time for most men.

David in SC
Age: 58, 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, no problem post SRT
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16

Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, next test 11/10
Latest: 7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped 9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4, Caths #11 and #12 ,Cath #11 - 21 days, Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

LV-TX
Veteran Member


Date Joined Jul 2008
Total Posts : 966
   Posted 8/10/2010 1:09 PM (GMT -6)   
I was told that surgery would be the best route if everything (psa, age, biopsy etc) indicated that the surgery would be completely successful in remove all the cancer. If there was any reason to believe that the surgery would not be successful, then go the radiation route because the trama of surgery can be pretty harsh on men...especially as they get older with other health issues involved.

Based on your stats...I think you are approaching this correctly and looking at the options of radiation vs. surgery. But that is my take.

BTW welcome to HealingWell
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 
                 18 month April 2010   .19

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 8/10/2010 3:51 PM (GMT -6)   
I agree with your thinking. Laying down on a table for 8 weeks for 30 minutes is very attractive. I looked at it seriously.

I just want to say something that I am sure you may already know. All treatment options have potential side effects. No treatments are 100 % effective.

We have men on here who have had bladder damage, rectal damage, bowel issues, etc. from radiation. We have men on here who have incontinence and ED from surgery.

We have men on here who have had failed radiation and men on here who have had failed surgery.

Just be sure you know what you are buying. Sometimes it is easy to gloss over the portential bad things that can happen from a chosen treatment.

Welcome to HW, and good luck on your decsion and journey.
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,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1100
   Posted 8/10/2010 3:55 PM (GMT -6)   
Hello a777. First, I agree with the suggestion that you get a "second opinion" on your biopsy slides, from an expert in prostate cancer pathology. The same 4 or 5 experts have been recommended dozens of times on this board, so you can easily find them, but if you need names or contact info, let us know and I or someone here will provide it. It is not very expensive, and you might be surprised by the substantial number of times the expert pathologist disagrees with the initial reading. You certainly want to be making decisions based on an accurate reading of your biopsy slides. The expert pathologists can also provide additional information that may be useful in evaluating how agressive the cancer is, such as a ploidy analysis. There are also some newer tests that purport to be able to evaluate how agressive a tumor is, and therefore help patients make treatment decisions. Here is one of them: http://www.aureon.com/ I have no view on whether this is useful or not, but maybe worth talking with your doctor. Second, there are some predictive tools you can use to evaluate the likelihood that your cancer is organ-confined. One of them is the Partin Tables. Another is a nomogram from MSK. Here are links:

http://urology.jhu.edu/prostate/partintables.php

http://www.mskcc.org/mskcc/html/10088.cfm

This information -- the odds that your cancer is organ confined -- might help you make the decision about which treatment. (There are other such tools too).

If you are considering radiation, a couple of things to discuss with the radiation oncologist: (1) should you use adjuvant HT before/during/after the radiation, and for how long; and (2) any benefit to using seeds + IMRT, and which first.

Very tough decision -- a close call and each doctor believe in and is biased in favor of his/her own speciality.

A medical oncologist might be more "neutral" -- so maybe go for a "third opinion." But if you do that, make sure its a medical oncologist with expertise in prostate cancer. Otherwise, it might not be very useful.

Best wishes,
Medved
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 8/10/2010 4:45 PM (GMT -6)   

You have asked the $64,000 question and you will get 64,000 different answers.

From everything I have researched surgery has some advantages in certain situations; in very young patients, where a person's prostate is too large, if a patient has prior urinary issues. If the cancer is totally contained.

Radiation has advantages for older patients and those with health conditions. It is also better for indicated positive margins and nerve involvement. The most importan item that most patients and doctors leave out when try to decide is the size and location of the tumor. This can be accurately identified with a color doppler or an MRIS. If the tumor is in the Apex, transition zone or near nerves, seminal vessicle or close to the edge of the prostate then radiation would be a much better choice as the probability of a positive margin with surgery greately increases.

The side affects of radiation compared to surgery are much less severe, especially for a 64 year old as we don't heal as fast or as good as we did at 40. about 50% of the posts on this board have to do with dealing with the side affects of surgery, this alone should tell you something.

You should also investigate a combination of Brachytherapy and IMRT is it is more effective than IMRT alone with about the same side affects.

If you want some unbiased advice then get an MRIS and take the results to an Oncologist specializing in Prostate cancer and he can give you an unbiased opinion if surgery will be successsful or not.

The reasoning that surgery is better because you can have radiation after is the most faulty piece of logic yet. If surgery did not work it is because the tumor was in a spot in which the surgeon could not get all of it. If salvage radiation can cure this then it would have been better to have radiation in the 1st place and not suffer the side affects of two major treatments.

JohnT


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 8/10/2010 5:35 PM (GMT -6)   
JohnT,

In your radiation as the primary treatment methodology, which I understand why you feel that way, what do you really subscribe as a good salvage treatment if the radiation fails? Regardless of IMRT, Seeding, with or without HT added into the mix. What would you choose if your seeding ultimately failed?

To our new friend here, my official opinion is neutral in choice as it should be. But there is still a lot to be said for having the pathology of the entire prostate once its removed. Then, you are going to know more fully the real staging, Gleason, % of tumor, and locations of tumor(s) within
the gland itself. No way of knowing all that info without surgery. Plus, if there's a lot of cancer present, the "debulking" theory of removing the primary and most major source of the cancer has merit that surgery offers.

I don't have the stat in front of me, but surgery is still the overwhelming choice of primary treatment for PC, unless you got some to show that proves otherwise. Yes, there are plenty of uro/surgeons, regular surgeons, and not shortage of radiation centers. So there has to be another reason while surgery is still the number one choice in quantity.

What concerns me with our new friend in his stats, is the % of Gleason 7 found just in a low core biopsy. If it were upgraded, then it could even be more serious. I hold to the growing school, that Gleason 7 cases should be handled as if they were 8's or above in many cases. The Type 4 component is what makes the risk higher and more unpredictible to the patient. In my opinion, it leaves too much room for making a guess erroring away from treatment, or not having a treatment strong enough to make a difference on the first pass.

If ultimately my SRT does prove to be a failure, then the whole question of surgery vs. radiation as a primary becomes very mute to me, and the almost two years I have suffered with the effects of both surgery and radiation will to me, seem like an incredible waste of money and pain and suffering to have gone through for nothing in the end.

It is a tough choice, and there is no magic in making the decision, but I still come back to, with our new friend stats, I would want an independent review of the biopsy, and as you suggested, getting a neutral opinion from a good Medical Oncologist to help even out the surgical and radiation related opinions.

David in SC
Of course, the primary treatment needs to be the right one, and should be based on sound facts and opinions from the medical community, but a person still needs to have a good "backup" plan if the primary fails. Couldn't imagine anyone disagreeing with that logic.
Age: 58, 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, no problem post SRT
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16

Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, next test 11/10
Latest: 7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped 9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4, Caths #11 and #12 ,Cath #11 - 21 days, Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

Post Edited (Purgatory) : 8/10/2010 5:06:05 PM (GMT-6)


Cajun Jeff
Veteran Member


Date Joined Mar 2009
Total Posts : 4119
   Posted 8/10/2010 5:50 PM (GMT -6)   
a777, You ask a question that no one on here can give you the exact answer. Many have already gave valid points. I think the best point is try to find an onclolgist that specialises in porstate cancer and get the 3rd opinion. Actually the decision is going to fall on your sholders. There are advantages and disadvantages to all of the treatments. You weigh them out and make an informed decision.

Most of us guys that chose surgery did so with the thought "Get the cancer out" For many of us that is what happened others have had to follow up with radiation therapy.

Welcome to HW. I wish we could give you the answer that you are searching for but we are here for you.

Cajun Jeff
9/08 PSA 5.4 referred to Urologist
9/08 Biopsy: GS 3+4=7 1 positive core in 12 1 pre cancer core
10/08 Nerve-Sparing open radical
Surgery Path Report Downgrade 3+3=6 GS Stage pT2c margins clear

3 month: PSA <0.1
6 month: PSA <0.1
10 month:PSA <0.1
1 year: PSA <0.1
16 month:PSA <0.1

ED - Started Cialis at 3 months, tried all 3, 6 months added pump, 9 months Tried MUSE (YUCK) Bad experience.
1 year mark Found new Urologist visit was at 14th month post surgery
Started Injections, Caverject! (Success)
17 month: ED making improvements : Oral Meds gets me 85%

BB_Fan
Veteran Member


Date Joined Jan 2010
Total Posts : 1011
   Posted 8/10/2010 6:54 PM (GMT -6)   
A777, IMO radiation is a choice to strongly consider if it is very likely that your PCa is outside of the prostate, but still local. If you have surgery and they find that you have positve margins, or epe then they will probably want to irradiate after you recover from surgery. They may want to put you on HT during the recovery period. If you want to avoid both treatments and the related side effects, radiation may be the best choice. The question is, "what is your staging"? A second opinion and additional testing will help to get you to a place where you can decide.
Dx with PC Dec 2008 at 56, PSA 3.4


Biopsy: T1c, Geason 7 (3+4) - 8 cores taken with 4 positive for PCa, 30% of all 4 cores.

Robotic Surgery March 2009 Hartford Hospital, Dr Wagner
Pathology Report: T2c, Geason 8, organ confined, negitive margins, lymph nodes negitive - tumor volume 9%
nerves spared, no negitive side effects of surgery

One night in hospital, back to work in 3 weeks

psa Jun 09 <.01
psa Oct 09 <.01
psa Jan 10 .07 re-test one week later .05
psa Mar 10 .28 re-test two weeks later .31
psa May 10 .50

April 10 MRI and Bone Scan show lesion on lower spine, false positive.

Started HT 5/25/10 with 3 month shot of Trelstar. SRT scheduled for late July

psa July 10 <.01 HT at work

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 8/10/2010 8:14 PM (GMT -6)   
Wouldn't it just be easier to say "Another fine post by John T", (which I agree with), than copy the whole thing ?
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,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4268
   Posted 8/10/2010 8:36 PM (GMT -6)   
David,
Accoriding to The Prostate Cancer Study Group:
The largest cause of surgical failure in low and indermediate risk PC is microscopic cancer cells left around the nerves. This happens about 15-20% of the time and can't be seen by the surgeon.
Radiation also can hit an area in the bed up to 15mm, far greater than a surgical margin.
If I had a reoccurrance the first thing I would do is to determine if it is local or systemic. I would get an MRIS or some other type of dye enhanced fusion MRI and the get a color doppler targeted biopsy of the suspected area. If it was determined to be a local reoccurrance I would look at cryosurgery, cyberknife, and HDR Brachy as local salvage treatments. If I could not absolutely determine that it was local I would not do any salvage therapy and go on intermittent HT.
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


Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3887
   Posted 8/10/2010 9:50 PM (GMT -6)   
Here is how I am looking at it..With surgery, I have a 40-50% chance for a full cure..If that fails, radiation gives me another 30-40% chance..So I get two shots at rather poor odds. With radiation as primary, I get only one shot and the extent of my cancer will never truly be known..

However, radiation treatment is making great progress right now.. The latest IMRT machines are far more accurate in delivering their dose so side effects and unintended tissue damage are minimized and the total dose can be maximized..Along those lines, when seeds are combined with IMRT a total dose of 150 gray can be administered with no major increase in side effects..Recent studies have shown that this combination can be used even on high-risk cancers with better results that surgery, at least at the five year point..

You have discovered that treating PC is a BUSINESS, a very profitable business. The Surgeons and R-docs will FIGHT for your business. They both stand on firm ground as studies and statistics rate their effectiveness almost equally..They both believe THEY offer the best treatment! Much of the success of either depends on the SKILL of the doctor performing the treatment..So in the end, you will just have to make up your own mind as to what is right FOR YOU....
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 8/10/2010 10:01 PM (GMT -6)   
goodlife - i wondered the same thing, lol

johnt - i hear you, but why is surgery far more popular? and of course, when a prostate is removed, there is not little lights that light up showing the cancer or some dotted line that the surgeon follows. Also, there is no way of being 100% positive if it's local or systemic after a primary treatment failure, I thought that was a given. Since you couldn't absolutely know, wouldn't it still make sense to take a chance on a secondary treatment like many of us have done, even if the odds percentage wise aren't all that good? At least it would be a curative attempt, and one might make it into the good side of the numbers. The problem I see, is that with radiation first, if there is recurrance, the options are more vague and uncertain.

fairwind - even the skill of the surgeon/doctor isn't always enough, despite their stats and records. we have more than one man here that went to the best of the best, did all their due dilligence right, and still ended up with almost instant recurrance. each body is different, each PC case is different, you can still have two men with the exact same specs and age, and similar medical histories, and still end up with 2 different results from the same dr/surgeon.
Age: 58, 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, no problem post SRT
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16

Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, next test 11/10
Latest: 7/9 cath #6 - 41 days, 8/9 2nd corr surgery, 8/9 cath #7 - 38 days, mapped 9/9, 10/1 - 3rd corr. surgery - SP cath, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, Cath #10 43 days, 1/19 - Corr Surgery #4, Caths #11 and #12 ,Cath #11 - 21 days, Cath #12 - 41 days, 3/2- Corr Surgery #5, Cath #13 - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, Cath #17 - 39 days, 7/2 - Corr Surgery #6, Cath #18 - 13 days, Cath #19 - 17 days, Total Blockage, Cath # 20 - 7/19

montee
Regular Member


Date Joined Mar 2007
Total Posts : 315
   Posted 8/10/2010 10:04 PM (GMT -6)   
Sorry to hear about your diagnosis. Now you know what a lot of us have gone through trying to make the decision for initial treatment(you can look at my signature below to see I had to make one and against some uro advice) . Reminds me of a squirrel in the middle of the road looking at an approaching car, which way to go. What ever your decision, be comfortable with it. If you go surgery, be sure to investigate your surgeon beforehand and get the best you can as his or her skill will make a difference in the initial treatment and side effects, ED and incontinence.

I am not going to suggest anything, that is a decision only the person involved can make for himself. I have friend who was diagnosed about a year ago, and his uro has suggested watchful waiting (or watchful wishing as some call it). I want to tell him to get it out, you never know what you have until you have it out, but I have held back because that is something he needs to be comfortable with.
diagnosed sept 2006 @ 54 years old, live in Georgia, gleason 3+4=7, (r) lobe only

psa 4.7 (psa rose 1 point per year for 3 years, urologist said still under 4 and no concern. If I can find out about PSA velocity, why didn't he know!)

Told not to have surgery at Dana Farber as cancer had already penetrated prostate, in seminal vesicles, would have positive margins. Would only treat with radiation and HT

RP Emory Atlanta December 2006. Path-negative margin, negative lymph nodes, negative SV, both Lobes involved, 40% gland involved
multifocal perineural invasion, Gleason 3+4=7

1st psa April 2007-<0.04, 6 mos-<0.04, 9 mos <0.04, 1yr <0.04, 21 mos <0.04, 2 yr 0.04 (rising?) 26 mos-0.05, 27 mos-0.04, 29 mos 0.06 Sept 09 ,<0.04 3 year <0.04 39 mo. 0.07 (rising again) 0.07 2 different times 3 mos apart.,now seeing Rad. Onc.  next 2 tests with him 3 mos apart <0.05. 

t-dog
Regular Member


Date Joined Dec 2009
Total Posts : 154
   Posted 8/10/2010 10:21 PM (GMT -6)   
As a i.c. sufferer radiation was ruled out for me as my bladder has already been compromised and the docs felt that zapping things in the area would not be a good idea. When you re hashing things out be sure to take the rest of your health in consideration. Good luck.
Dx at 50 in 12/09 Merry Christmas its cancer....
3 of 12 positive, right side only, psa at dx 2.6 free%14
gleason 3+3=6
routine physical, no symptoms
Da Vinci performed Feb 2k10 by Dr Marc Milsten [hes got mad skills]
99% continent from cath out, mr happy fully functional at 2 weeks out!
path showed same gleeson with no other blips other than one slight margin, organ confined 20% right, 5%left, 34grams
Hernia repair Mar 2k10, hernia was side effect of the surgery
30 day psa 0.03- 90 day psa 0.01

IdahoSurvivor
Veteran Member


Date Joined Aug 2007
Total Posts : 1015
   Posted 8/10/2010 11:43 PM (GMT -6)   
With a PSA of nearly 10 and a Gleason of 7, you're wise to look at this carefully.
 
Surgery is still considered the "gold standard" by many doctors if all the stars line up and point to a great chance of cancer containment.
 
Many of us have done well with surgery, but some may have done better if a type of radiation would have been chosen first.
 
I have close friends with more aggresive cancer than mine who chose radiation and are doing fine now.
 
I'd suggest you get two or three more opinions if you can afford it and weigh the prospects for a cure with the associated side-effects.
 
All the best in your decision !
 
Barry
Surgery: Da Vinci; July 31, 2007; 54 on surgery day;
Pathology: PSA: 4.3; Gleason: 3+3=6; T2a; Confined to Prostate;
Post RP PSAs: 09/'07 <0.04; 12/'07 <0.04; 03/'08 <0.04;
06/'08 <0.04; 12/'08 <0.04; 06/'09 =0.06; 09/'09 <0.04; 12/'09 =0.05;
3/'10 <0.04; Latest PSA 6/'10 <0.01

BuiDoi
Regular Member


Date Joined Aug 2010
Total Posts : 234
   Posted 8/11/2010 1:46 AM (GMT -6)   
"Why would anyone choose surgery? Isn't IMRT easier and just as effective? Am I missing something?  Seems like a lot of people are going with surgery."
 
When I was first diagnosed, I (like so many others) began all means of study, and contacted anyone with an opinion.
One friend worked for what I thought was a Urologist, so I asked that she describe my situation and ask "What would YOU do?"
The predictable response was "Get Cut".  
The interesting fact was that the recommending doctor was a Professor in PC Radiation.
Cutters want to cut..  Rads want to Rad..  It's an industry..
For a Rad to say CUT    nono     surely says a lot.
 
A time later I met this Professor at a semina on PC, and he was honest enough to admit that Radiation after surgery, was far better than considering surgery after radiation..    Once irradiated - your goose is cooked ?  rolleyes
Is there something wrong with his thinking.
 
I had planned "Self-Cure" via diet and supplements (OPC), but many doctor friends warned me that only a few individuals get to write a book about DIY Cancer Survival, the  others are DEAD.
They also pointed out that it was far better to accept a 95% guarantee of cure, and then use DIY to ensure no re-occurrence.
 
 

Diagnosed @ 60 - Absolutely NO symptoms
New GP requested Full Bloods..
PSA 5.0 - DRE-Non-Palpable
TRUS Bx T1c - Geeson3+3=6 45% max
open-Cut - Nerve Sparing
Post Op. Gleeson3+4=7, 1.1cm3, Pos Margins
+8week PSA <0.01

Post Edited (PeterA) : 8/11/2010 1:29:06 AM (GMT-6)


An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1152
   Posted 8/11/2010 3:28 AM (GMT -6)   
John T said...

Radiation has advantages for older patients and those with health conditions. It is also better for indicated positive margins and nerve involvement. The most importan item that most patients and doctors leave out when try to decide is the size and location of the tumor. This can be accurately identified with a color doppler or an MRIS. If the tumor is in the Apex, transition zone or near nerves, seminal vessicle or close to the edge of the prostate then radiation would be a much better choice as the probability of a positive margin with surgery greately increases.

Hi John,

From everything I have read, transition zone tumours tend to be of a lower grade and well suited to a RP and are associated with better surgical outcomes. Have you read otherwise? If so, where?

Regards,

An


Husband's age: 52. We live in Sydney Australia.

In 2007 my husbands PSA level was 2.5.
In Feb 2008 it was 1.7
In Oct 2009 it was 3.67 with a free PSA ratio of 27
In Feb 2010 it was 4.03 with a free PSA ratio of 31.
In June 2010 it was 2.69

DRE normal.
Biopsy 28/4/2010: results, negative for a diagnosis of PC however 3 focal ASAPs on left side of prostate at base, apex and at transition resulting in the conclusion "...small acinar proliferation is suspicious but not diagnostic for prostatic adenocarcinoma."
Review of biopsy by experienced pathologist, results,
1 out of 12 core diagnosed with 10% of Gleason score 3+3 cancer (left transitional)
1 out of 12 cores with ASAP (left apex), suspicious but not diagnostic of cancer

Next steps: Nerve sparing RP on 20th August 2010.

My husband's maternal grandfather died of prostate cancer at 72. His maternal uncle died of prostate cancer at 60. Because he is the third generation to be diagnosed he has hereditary PC.

Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 8/11/2010 7:11 AM (GMT -6)   
Purgatory said...


johnt - i hear you, but why is surgery far more popular?


Dave,

Surgery is more popular for a very simple reasosn. The great majority of men are referred to a urologist after a high PSA, usually at the time of an annual physician with their primary physician. It is a urologist who does a DRE and biopsy, makes the diagnosis of PCa, schedules bone and CAT scans, and it is the urologist who makes the first recommendation for treatment. And as we have seen, urologists usually recommend surgery. And the reaction of most men is to believe that surgery will "get it out" and they will be done with the cancer, so trusting in the wisdom of the urologist they follow his/her advice.

I read an article somewhere that stated that about 90% of urologists recommend surgery over radiation. Does that not sound reasonable?

So I say whatever you do be skeptical of all advice, get a second and third opinion on the biopy and treatment, and educate yourself as best you can to the disease.

Sancarlos

PS My urologist recommended surgery. He insisted it was the only reasonable option for me.
Age 66
PC diagnosed 7/2009
Stage: T2c
Gleason: 9 (4 + 5), 6 of 6 cores positive
Bone, CAT and MIR scans negative

Treatment: brachytherapy (103 palladium), 100 gy, 11.15.2010 + hormone therapy (lupron) + IMRT on Novalis (February-March, 2010), 45 gy.

PSA at time of diagnosis: 11.9
PSA 10/2009, 5.0
PSA 12/2009, 0.56
PSA 5/2010, 0.15

Post Edited (Sancarlos) : 8/11/2010 6:46:03 AM (GMT-6)


BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 8/11/2010 7:36 AM (GMT -6)   
Sorry you have to be here. Sorry there has to be a "here". You mention "because of young age".. then you note age of 64. While any age including that one is toooo soon for anybody, you will see kids in their early 40s on this site fighting this disease. So it's really not that young. I asked 3 different urologists how long I would live if I did nothing.. all 3 gave me the same general answer "10 years". At birth, a currently 64 year old male born in the US had an average life expectancy of 75.6 years - http://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy .

I understand that "averages" are a tough way to decide one's life.. and that from a guy who used to deal craps and 21 in Vegas. But this diesease is so unique to each individual, and the individual's situation so unique itself, that averages are one of the few tools we have to share among us.

Preliminary indication you provide doesn't suggest reason to think the disease is super aggressive, or in a late stage. So in the old "if I were in your shoes" scenerio, i'd take that into consideration. As a general rule, if you suspect the disease has escaped the capsule (as your rad onc suggested) then radiation might be the move. Have we not a good test that can check that surrounding area?

My urologist tells me after the fact that had they know there were pos margins, they would have gone with radiation instead or RP.

So, the "averages" tell us that even doing nothing you might expect to survive close to your original expectancy (I am NOT suggesting doing nothing)... But that would give me (and does) a piece of mind).

If I were you, i'd do what needed to be done to see if it's contained or not. Or at least the closest and best estimate available. And that would drive my decision.

Wishing you the best, not trying to guide you in any 1 direction, just thinking out loud with the way I would advise a loved one posing the same question.
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Listed on patholgy as PT3, but with extraprostatic extension,
microscopic invasion of the bladder neck, PT3A is perhaps the case.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain! Update 7/14/2010: When I tried changing this sig a few days after creating it, system was broken. My new rad oncologist are discussing IMRT.. though he says he can see why waiting a bit and watching the PSA on super sensitive basis might make sense. I am leaning towards IMRT.. thinking is my body is pretty strong now, i'm 51, and if I can rid my body of this while trying to minimize the side effects.. I dunno. No really Good answers. When I said I didnt want radiation to the point of being a veg.. I really meant there is a limit as to where I wish to go in order to realize only a small increase in life expectancy.. and not that I am an unreasonable person. I do, after all, have an obligation to my wife and kids.

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4271
   Posted 8/11/2010 8:39 AM (GMT -6)   
Dear a777:
 
Well, you have initiated a well worn discussion/debate here at HW, i.e. which is better surgery or radiation? You will find no clear concensus here but I will wade in with an assessment of how I would logically look at your decision process, given your stats.
 
1.  Cure Rate.  To my knowledge there has been no long term, large scale randomized study of radiation vs. surgery.  However, there have been many, many separate and sometimes contradictory studies that detail the long term surgical and radiation cure rates.  Despite the confusion, my conclusion is clear...the long term cure rates for surgery and radiation are similar.  ADVANTAGE:  Neither.
 
2.   location of the Tumor.  According to you, there is some indication that your margins may be positive.  Reference the above posts by JohnTand BobCape...radiation has a better chance of curing you the first time than does surgery.  ADVANTAGE:  Radiation.
 
3.  Quality of Life.  With surgery you are likely to have immediate incontinence and ED.  The incontinence should lessen, the ED may not.  You will also likely have a shorter penis, no ejaculate and may ejaculate urine.  With radiation you are likely to have short term urgency and frequency that will lessen and may have longer term ED. There is also a small chance of rectal issues.  Overall, the long term side effects of sugery include higher rates of ED as compared to radiation.  Probably the best QOL comparision that I have seen was done by the New England Journal of Medicine a couple of years ago.  It showed much lower declines in sexual satisfaction from radiation patients than from surgery patients. BIG ADVANTAGE:  Radiation.
 
4.  Back up Plan.  Surgeons have been great at playing on patients fears about having a back up plan, i.e. you can have radiation after surgery but not surgery after radiation.  That only tells part of the story even though some posters even on this thread continue to preach that gospel.  The fact is that there are multiple salvage procedures for a failed radiation.  These include cyrosurgery, seeding with a different isotope, HDR Brachy and salvage HIFU.  The success rates for these salvage procedures are as high as for salvage surgery.  The bottom line is that you hope there is no need for a salvage treatment but ones are available for either choice.  ADVANTAGE:  Neither.
 
5. Knowing your Pathlogy.  If you have surgery you have an exact read on your pathology shortly after the operation.  With radiation you do not.  The real question is what will you do with the information once you have it?  There have been debates on other threads about the advantages of starting immediate post-surgery radiation or waiting for PSA rises.  If you are of a mind to wait, then having the information is interesting but not critical.  If you are of a mind to start immediate radiation if postive margins are noted, then the information is important.  ADVANTAGE:  Surgery.
 
6.  Psychology.  This is highly patient dependent.  If you are like me, my mindset was to "get it cured", so I was able to look at the facts fairly logically.  However, some men have a mindset to "get it out", in which case emotions rule over logic.  Only you can know which kind of guy you are.  ADVANTAGE:  Neither.
 
OK, so what would I recommend to you if you were my brother and knowing your stats?  I would encourage you to get your biopsy pathology read by a PCa expert, to seek an opinion from a prostate onlcologist, to get a color doppler and then to probably proceed with a combination of seeds and IMRT.
 
Good luck and please keep us posted,
 
Tudpock (Jim)
Age 62, Gleason 3 + 4 = 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 4/10/10.  6 month PSA 1.4 and now 1 year PSA at 1.0.  My docs are "delighted"!

a777
Regular Member


Date Joined Aug 2010
Total Posts : 22
   Posted 8/11/2010 8:50 AM (GMT -6)   
Thank you very much for all your advice.
I hope you understand how much it means to us.

Some really great points made.
Gives more perspective and things to think about.
It's really hard to get an overview from a Rad or Surgeon.

You guys are really helping,
again,
THANK YOU!

To medved or anyone else:
Can you please post those 4 or 5 prostate cancer pathology experts you mentioned?
I think this is something we might pursue.

All the best to you all.
Age-64
PSA- 9.9
G7 (3+4)
6 of 10 positive (two were 2% at 3+3 so nothing to worry about)
The part to worry about-
left base (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)
left mid (conventional type seen in 2/2 cores, involving 50% of submitted tissue, G7 (3+4-pattern 4 accounting for 40% of tumor)

April6th
Regular Member


Date Joined May 2010
Total Posts : 264
   Posted 8/11/2010 10:17 AM (GMT -6)   
Great discussion laying out the pluses and minuses of different treatments.

The only ironic thing is that the bulk of what I have learned about PCa treatments was learned after I made my treatment decision, which seems kind of backwards. (BTW, I am still very happy with my treatment choice, though)

Dan
Here are some of my stats:
Age:54
Father diagnosed with PC at age 72 - wasn't contained to prostate when found in 1992.
My PSA rose from 3.2 to 5.1 over the course of 1.5 years with Free PSA at 25% for the last two tests.
DRE showed no evidence of tumor but Uro thought my prostate was a little large for someone my age
PCa diagnosed 4/6/10 after biopsy on 4/1/10
1 out of 12 biopsy samples was positive with 5% of biopsy sample cancerous
Gleason 3+4
Da Vinci surgery on 6/1/10
Pathology report shows cancer confined to prostate and all other tissue clean
PSA tested on 7/15/10: Zero Club membership card issued (trial membership with 90 day renewal)

medved
Veteran Member


Date Joined Nov 2009
Total Posts : 1100
   Posted 8/11/2010 10:24 AM (GMT -6)   
There are other experts, but here are a few:

Helmut Bonkhoff http://www.prostapath.org/us/us-main.html (he's in germany, but dont let that deter you -- he works with US and other overseas patients)

David Bostwick in Virginia

Jonathan Epstein at Hopkins (Baltimore)

Jon Oppenheimer http://www.prostatelab.com/jrocv.htm

Best wishes,
Medved
Age 46.  Father died of p ca. 
My psa starting age 40: 1.4, 1.3, 1.43, 1.74, 1.7, 1.5, 1.5
 
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