Befuddled First Post: surgery vs. radiation in low risk case?

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MCinNC
New Member


Date Joined Sep 2010
Total Posts : 13
   Posted 10/5/2010 11:14 PM (GMT -6)   
Hello all. Really great forum you have here! Been reading a couple of months since my biopsy results came in (Gleason 3+3=6, 1 of 12 cores positive, 5-10% of tissue involved, latest PSA 2.4, DRE normal, T1c, father had PC, overall good health, age 56).

I've been trying to cram into my brain enough info to make a thoughtful and reasonable decision about what treatment option is best for me. I average a couple of hours a day reading about treatments and outcomes and probabilities and trials and studies. I've talked to some really smart doctors, surgeons, medical oncologists, and radiation oncologists, with a few more scheduled next week. I seem to be a "great candidate" for virtually every treatment anyone has ever thought of, including active surveillance. And rather than really good advice, I seem to get doctors who either just advocate for their speciality, or those with less of an obvious bias who just say all of the options are good. So, here I am - someone who knew and cared very little about PC two months ago - trying to become some type of medical scholar overnight to make a decision that will potentially have a HUGE impact on me and my family for the rest of my life. It is befuddling, and disappointing, to me that the medical profession is not more helpful with this! On the other hand, maybe it is just me, with a skewed and unrealistic perception of things...

Anyway, a basic question that I have still not resolved is the surgery vs. radiation choice, assuming that I do not choose AS. I'm having trouble figuring out the long term differences between the two for a T1c type of case. For those of you that had a case like this, and were healthy enough to be able to choose either, and who have a life expectancy of 20+ years, what made the difference in your decision making?

It seems like both have a high chance of successfully treating the PC without it reappearing later. It seems like both have likely unwanted side effects regarding urination and ED. And it seems like it is impossible to predict in advance with any real certainty what the particular side effects will be in your case.

I'm obviously still working to figure these things out, and may not have all my facts straight. I may be missing something obvious. But what others found to be important in their decision making would be of great interest to me.

Thanks for your help and for all the great information on these boards!

Mac

lnwm
Regular Member


Date Joined Oct 2010
Total Posts : 21
   Posted 10/5/2010 11:40 PM (GMT -6)   
Hi Mac - I know what you are dealing with as I went through the same thoughts since diagnosed last April. I have Da Vinci operation at 7:40 AM tomorrow (Oct 6) at Seattle Swedish Medical. Even as late as last night, I was second guessing myself about the decision and thinking I should go with Cyberknive. I have an enlarged prostate growing into my bladder and am on blood thinners for a heart valve. I am 58, T1C Stage 1, Gleason 6 but with 7/12 samples with cancer (5%-40%). My main decision points were 1) I want the cancer out 2) I would still have an enlarged prostate with other procedures and 3) I wanted a back-up option in case the cancer returned. With radiation, surgery is not an option to address later cancer since the organs will be "mush" as described to me.

Yes, there are drawbacks on all options and all men will respond differently so you have to weigh what is important to you and decide accordingly. Above all, get the best surgeon or medical provider you can find as experience seems to be the biggest success factor. My surgeon has close to 1000 robotic procedures under his belt and is well respected in his field.

Best of luck to you.
Age 58 Gleason 6 T1C 7/12 samples with 5%-40%. No prior family history of cancer.

English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2218
   Posted 10/6/2010 1:47 AM (GMT -6)   
Welcome Mac

It's the $64,000 question for almost all of us.
My response is thus not a recommendation merely an explanation of how I saw it and see it.

My first uro's concern was my age at diagnosis (48) the problem being: what treatment will give this guy as many more years as possible (and I agreed with him). Plus he was concerned about my quality of life during those extra years. (I agreed with that too)

Put simply I decided that my goal had to be: to be a man of 70 (or older) with ED - after all my dad lived till he was 95. I did not want to find myself pegging out aged 59 thinking I could have done more

I thus ruled out AS on the basis of my age. ie there were too many years available for me for the PCa to get worse, and in the waiting game I felt that you could wait too long and find that at the point when you did act you had left it too late.(I could work out that my Gleason 6 was only going to get worse, not better, and that if it suddenly got much worse between two biopsies I'd be kicking myself.) I thus decided to act then.

The next bit of analysis about what treatment to choose was based around the idea in my head that people with cancer tend to have it come back, even if their initial treatment knocks it out. So I looked at a bridge that did not need to be crossed as well: ie what are the options available to tackle a recurrence.

If I started with surgery, then I could always have radiation therapy at some time in the future to deal with a recurrence. However if I had RT first then it would not be possible to have RT again and nor would it be possible to do surgery as the RT would scar the area too much to permit removal of the prostate.
I can't really say why I rejected seeds, I guess that right from the outset I was perhaps conditioned to think that cancer=surgery. (Lots of family & friends are doctors and/or surgeons)

Tackling the cancer was far more important for me than ED and continence. If I didn't deal with the cancer it would be there every second of every day. If I got ED, it wouldn't kill me and I would have to adapt my sexlife, use meds etc. If I ended up incontinent, then it would be a nuisance, but it wouldn't kill me.

So I opted for (robotic) surgery.
Was it the right choice?
Well the first issue that arose post surgery was that my post-op pathology was worse than my biopsy: Gleason 7 instead of 6 and seminal vesicle invasion. I don't have any stats, but a lot of guys have had a post-op pathology come back with a higher Gleason. It is this lab report that really tells you what is inside you and surgery is the only way of getting the prostate gland to the lab.
And then my first post-op PSA was not zero either(0.1).
Next, I didn't even get much of a chance to start PSA watching either as my next PSA was 0.4 and I was sent to a radiotherapist.

So a year after diagnosis in April 2009 when I worked out that I could have RT as a second option I was actually having it.

I will never know what might have happened if I had chosen seeds and RT first up, but the good news is that by September 2010 my PSA is <0.1 at last, and however big the "rest of my life" is I can now simply get on with living it.

Alf
Born Jun ‘60
Apr 09 PSA 8.6
DRE neg
Biop 2 of 12 pos
Gleason 3+3
29 Jul 09 DaVinci AVL-NKI Amsterdam
6 Aug 09 Cath out
PostOp Gleason 3+4 Bladder neck & Left SVI -T3b
No perin’l No vasc invasion Clear margins
Dry at night
21 Sep 09 No pads daytime
17 Nov 09 PSA 0.1
17 Mar 10 PSA 0.4 sent to RT
13 Apr 10 CT
28 Apr 10 start RT 66Gy
11 Jun 10 end RT
Tired
BMs weird
14 Sep 10 PSA <0.1
Erections OK

MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 10/6/2010 2:21 AM (GMT -6)   
Hi Mac,

I went through the same things

Ultimately it came down to how each Dr answered this question

"Hi Doc, what would you do if the method of treatment you propose were done on yourself fails to remove the cancer ?"

Think of Plan B now, it will help you commit to Plan A. Know that you may never need Plan B but resolve with yourself that you covered that in your decision

Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 10/6/2010 4:54 AM (GMT -6)   
Couple reasons I elected surgery was that radiation could be done later if needed and the 25 to 45 trips for radiation didn't appeal to me at all. Snip snip and you're done.
Age 55 - 5'11" 215lbs
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
05/18/10 - 24 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.
Growing old is mandatory; growing up is optional..

RCS
Veteran Member


Date Joined Dec 2009
Total Posts : 1268
   Posted 10/6/2010 6:06 AM (GMT -6)   
Hey Mac,
 
You asked what others found to be important in their decision making process.  Great question and I feel that the answer varies with each individual.  I have found that what is important to me can appear to be trivial, or of lessor importance, to others.
 
In my case, I decided that it was most important to first "cure" the cancer; then, to be continent; and then to have no ED (prioritized first to third).  When I say I wanted to cure the cancer, I am implying that I did not think I was a good candidate for AS.  I probably would have started AS and then chickened out.  I wanted to treat the cancer.
 
My biopsy was Gleason 6 and apparently the cancer was confined to the prostate.  Because PCa is usually multi-focal and biospies often times miss PCa tumors, I felt that it was prudent (overly conservative?) to treat the whole prostate.  I figured my best chance for a "cure" was to either remove the whole organ with surgery or to use brachy and kill the cancer and the prostate in place. 
 
My Uro (a surgeon) recommended brachy; however, I had a large prostae and would have had to do hormone therapy to shrink the prosate before brachy.  I also felt that surgery would allow me to use radiation as a secondary treatment if I should have additional problems.  I chose surgery and was DaVincied.
PSA 2007 - 2.8; 11/24/2008 - 7.6; PCa Dx 2/11/09; age at Dx 62; RLP 4/20/09

Biopsy - Invasive moderately differentiated prostatic andenocarconoma; G 3+3=6; PT2C; No evidence of Seminal Vesicle or Extraprostatic Involvement; Margins clear; Tumor identified in sections from prostatic apex. 70 gram prostate. Continent after removal of cath.

ED - Trimix works well; levitra @ 90%
PSA - 7/31/09 <0.06; 12/1/09 <0.06; 3/29/10 <0.06; 8/4/10 <0.06

rhb47
Regular Member


Date Joined Mar 2010
Total Posts : 208
   Posted 10/6/2010 7:38 AM (GMT -6)   
Hi MC,

Welcome to the forum. I see that a few surgery guys have tuned in and I'm sure the brachy guys will too. My husband went with surgery for the same reasons stated in the above answers. He wanted the cancer out and he wanted a plan B (radiation) if he needed it in the future. The one bit of advice I can give you is if you pick surgery to get the very best surgeon you can find-we traveled to Orlando( 2 hours away) but would have gone further is needed. My husband's surgeon had over 3500 Da Vincis and feels it was the surgeon's skill that gave him such a great outcome. Good luck.

Renee
Husband diagnosed 3/10
Age 56, PSA 4.7, free 7.6%

Biopsy 5 of 10 cores positve-all right side-25% to 57%
Gleason 6
DaVinci surgery with Dr. Vip Patel scheduled 8/9/10

Post Op: Gleason 3+4=7
Negative surgical margins and lymph nodes
No seminal vesicle and angiolymphaic invasion
perineural invasion present
Both nerve bundles spared
No ED or incontinence
6 wk. PSA .01

Red Nighthawk
Regular Member


Date Joined Oct 2009
Total Posts : 289
   Posted 10/6/2010 8:07 AM (GMT -6)   
Mac, you are doing exactly the right thing right now. You are calmly and intelligently researching all your options. Too many guys jump for the first treatment presented to them, or they blindly trust their Uro's recommendation, and often it turns out to be a big mistake.

For me, I would have loved to try AS because I am married to a Vegan lady who could help me pull it off easily. However, my G7 ruled out that possibility for me.

My ultimate decision was between proton beam radiation or surgery. Like the others mentioned, surgery was a better option in my mind for a few reasons. You still have a viable Plan B (radiation) if you have a recurrence. That was big for me. Also, I had the feeling the cancer would be taken out of my body more so than with radiation. That's how I felt anyhow. Finally, once the prostate was removed through surgery, the actual pathology would be known, and not the estimate we get from a biopsy.

Btw, my Uro had 17 years experience doing open surgery, but recently had transitioned to daVinci robotic. Since I had decided upon robotics, I had to say bye, bye to my guy and began the search for the most experienced and successful surgeon I could find in my general area. I traveled about 2 hours to Brigham for the surgeon. Good luck and keep us posted on your journey.
Age: 63
Gleason grade: 3+4=7, pT2c NX MX
Robotic RP: Sept. 15th, 2009
No lymphatic/vascular invasion, seminal vesicles, margins tumor free.
Pre surgery PSA: 4.1
Post surgery PSA's: .04, .03, .02, .05, .02
ED: Improvement slow but there are positive signs. No incontinent issues.
Surgery: Dr. Jim Hu. Dana-Farber/Brigham and Women's, Boston

Post Edited (Red Nighthawk) : 10/6/2010 11:07:50 AM (GMT-6)


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4278
   Posted 10/6/2010 8:10 AM (GMT -6)   
Hi Mac, you have raised the age old question that has been debated and discussed on this forum many times but we are always happy to weigh in again for a new patient.  Like you I was in good health and had a long life expectancy.  I also consulted multiple doctors and researched this disease for untold hours.  At the end of the day for me it came down to logic and not emotion.  Here are the things I considered and it becomes clear why I chose radiation (brachytherapy for me):
 
1.  Cure.  In my case (and yours if I understand your stats correctly) the chances of cure were essentially the same for both options.
 
2.  The procedure itself.  Surgery was a big deal with potentially difficult recuperation.  Brachytherapy was an out-patient procedure where I was back to all of my normal activities in a couple of days.
 
3.  Urinary side effects.  Surgery gives incontinence for some time...potentially some incontinence for years.  Brachy gave me some urgency and frequency for a couple of months that was no big deal.
 
4.  Sexual side effects.  Surgery usually brings ED that may get better over time.  Brachy usually has no immediate ED but it may get worse after a couple of years.  Studies show the long term ED for surgery is worse.  Also surgery brings other sexual side effects that are not well publicized, e.g. shorter penis, no ejaculate, ejaculating urine.
 
5.  Backup plan.  With surgery there is the possibility of radiation later if the initial treatment fails.  With radiation surgery later is quite difficult.  This is true but only part of the story...and the part that urologists who want to sell surgery usually tell.  The truth is that there are backup plans with radiation that include re-seeding with another isotope, cyrotherapy, HIFU and surgery with a real expert.  "Cure" from a salvage treatment only results if the cancer is confined to the prostate.  And, the salvage results are generally the same for salvage after surgery or radiation.
 
6.  Knowing the final pathology.  This is a big "so what"?  Even with final pathology known after surgery most patients will do nothing until they get further evidence of cancer, e.g. rising PSA.  So the question is whether or not that knowledge is worth having surgery for.  In my case, the answer was clearly "no".
 
7.  What if the pathology indicated that my Gleason was higher?  Again, "so what?"  The radiation treatment is an effective as surgery with different G scores.
 
So, that was it for me.  Pure logic including the major fact that quality of life was important to me.  BTW, if you don't choose AS or one of the "usual" treatments, you could also consider something like targeted focal therapy which is showing great promise.
 
Good luck and keep us posted,
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 10/6/2010 8:11 AM (GMT -6)   
hello mac,

you are in that intense world of learning the ways of PC treatment. Most of us have spent many hours there. Sounds like you are doing all the right things.

this concerns me. remember, even the best biopsy is but an estimate. until there is an entire biopsy to do pathology, it is a good guess as to the extent ofthe true cancer. first, your staging, its most common to go from t1c to t2c after surgery, or worse. the positive - you show one positive core. how many biopsies did you have? is it possible the biopsy has missed the true extent of the cancer? the negagive - you said your father has/had PC, and now you have it, so that puts you in a higher risk category. the point - basing a treatment or non/treatment on a single biopsy slide has some element of risk. you are gleason 6 now, quite a few men do stay the same, we have had many that were upgraded at least a full grade, and a handful of lucky ones were downgraded. all the studying in the world isnt going to take the risk out of that part of the formula

for me: strong gleason 7 case with rapid PSA veolocity. no one believed RT alone would work. i wanted seeding, but at the time, didnt meet the criteria locally. left me with surgery, 2 years ago, only 15 robotics had been done, my own surgeon advised against it, he was very experienced open surgeon , so went with him.

as it were, due to complications in my own anatomy, open ended being the only viable option

to make long story short, surgery failed in 9 months, went through 2 months of grueling salvage radiation that left me a lot of perm damage, and as i write, jury is still out on the effectivness of the salvage job. real reason: rapid psa velocity prior to treatment.

that is my story, and my advice

good thing here, is that the brothers and sisters will back you all the way, once you know what you want to do or not do. good luck


david in south carolina
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7089
   Posted 10/6/2010 8:44 AM (GMT -6)   
Mac,
 
Lots of good feedback in the posts so far, but my first observation is that you pretty well nailed the "twilight zone" nature of PSA testa and PCa in general.
 
I had an initial biopsy that was positive in 9 of 12 cores, ranging from 4+3 to 4+4, up to 90%. That automatically eliminated AS. I wanted seeds, but was told by multiple clinics that I was too far along for that.
 
IGRT (45 sessions) offered me a 70% cure rate according to the Rad. oncologist, which did not give me a good feeling (in theory I could be around another 30 years or so).
 
When it is said that radiation "can not" be followed by surgery, it is a bit of an overstatement. It can be done, but you will find few surgeons who will attempt it. The difficulties presented, as I was told by my surgeon, make it extraordinarily hard to do.
 
So in the end I found a surgeon I felt good with, and did DaVinci. My Gleason came back 4+5, with EPE. I did IGRT afterwards.
 
ED is complete - side effect of the surgery, incontinence was getting better before radiation, but is static now.
 
 

Post Edited (142) : 10/6/2010 7:52:18 AM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 10/6/2010 10:14 AM (GMT -6)   
Mac,
Your basic goal should be to eliminate the cancer with the fewest side affects. In your situation my 1st choice would be AS with monitoring with color doppler and psa and PCA3. This will result in the least amount of side affects with little risk and future treatment can be done with similar resuts as if it was done immediately.
The least short and long term side affects are with Brachytherapy and achieve similar if not better results than surgery or IMRT. The 2nd least side affects are with IMRT and the most short and long term side affects are with surgery.
The only benefit for surgery with a low risk PC is psychological; "getting it out". If this is a psychological issue that you cannot get by them by all means have surgery.
The reoccurrance rate for low risk pc is very low and if it does reoccurr it rarely goes to matastis. There is no difference in treatment options for this typ of pc.
Please read "Invasion of the Prostate Snatchers" by Dr Mark Scholz for a good expalnation of low risk cancer and options.

JohnT
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7270
   Posted 10/6/2010 10:49 AM (GMT -6)   
I chose surgery for the reasons already mentioned (especially the radiation as a back-up plan). I felt it gave me a second bullet (which unfortunately I may have to use).
 
I was not a candidate for AS, but also I think it takes a special kind of mentality to do that. Not for me!
 
In retrospect, another good reason for surgery is that you will get the complete pathology and know what's what. Many folks with a G3+3 end up getting upgraded to a G7.
 
Mel
PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. First post-op PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3895
   Posted 10/6/2010 12:01 PM (GMT -6)   
MAC, I'm 5 weeks post surgery and I went around the block with this like everyone else..

You are 56 and it looks like you have a fairly low-grade cancer that is not life-threatening. Only THE BEST surgeons can deliver the Trifecta..A cure, no incontinence, no ED....With your prostate gland GONE, your sexual apparatus is never going to be the same, work the same again..Talk this over with your wife, it's more important than you think.."You will have a dry ejaculation" Not necessarily..Many men have very wet ejaculations with urine replacing semen..While surgery is fast, cheap, and can almost always produce a cure in men with your stats, the percentage of men left with serious side effects is considerable.

Radiation, especially seeds and seeds combined with IGRT are just as effective at providing a cure and they avoid most of the side effect problems common with surgery..True, as time passes, the damage done by the radiation becomes more apparent and in the unlikely event you have a recurrence, your options are more limited..Cost can be an important factor for many people, radiation is very expensive, check what your copays will be..

If I were you, I would base my decision on the side effect percentages suffered by each type of treatment, and what types of side effects you are willing to accept. But what ever you do, have it done by the best doctors you can find..You may have to travel and you may not. You can find good doctors everywhere...Good Luck!
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
age 61: 5.2
age 64: 7.5, DRE "Abnormal"
age 65: 8.5, " normal", biopsy, 12 core, negative...
age 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
age 67 4.5 DRE "normal"
age 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP performed Sept 3 2010, pos margin, one pos vesicle nodes neg

riverbend
Regular Member


Date Joined Mar 2009
Total Posts : 39
   Posted 10/6/2010 12:10 PM (GMT -6)   
This is a great article written by a very thoughtful reporter for the NY Times. I give him a lot of credit for presenting this because he is a perfect example of someone who likely would have been harmed by taking his prostate cancer lightly....he's one of those with a very aggressive cancer.

I had almost the same exact stats the original poster has. I was 45. I opted for proton radiation. Personally I believe that surgery is overkill for these stats. 18 months later, if I had the decision to make over again, I'd choose AS. Having said that, I never 2nd-guess my choice....most people here don't...nor should they.

http://well.blogs.nytimes.com/2010/08/30/a-rush-to-operating-rooms-that-alters-mens-lives/

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7270
   Posted 10/6/2010 12:40 PM (GMT -6)   

Fairwind:

I personally fear the SRT effects more than the surgery. (But I am 100% continent so maybe that's why).

I fear mostly the possible bowel problems. Over the years I have had occassional bowel problems (mostly constipation). I also have 'rrhoids that bother me about once a year at most. But when they bother me...OUCH!

 

I worry about SRT creating a permanent problem in this area.

 

Mel

 


PSA-- 3/08--2.90; 8/09--4.01; 11/09--4.19 (PSAf: 24%), PCA3 =75 .
Biopsy 11/30/09. Gleason 4+3. Stage: T1C. Current Age: 64
Surgery: Dr. Menon @Ford Hospital, 1/26/10.
Pathology Report: G 4+3. Nodes: Clear. PNI: yes. SVI: No. EPE: yes. Pos. Margin: Yes-- focal-- 1 spot .5mm. 100% continent by 3/10. ED- in progress. First post-op PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06

Burlcodad
Regular Member


Date Joined Nov 2009
Total Posts : 254
   Posted 10/6/2010 1:12 PM (GMT -6)   

I dont have much to add to the thoughtful comments of everyone that has already posted. 

It was less than 13 months ago that I was in a similar situation.  I spent hours a day reading everything I could on the alternatives.  Given my age, low PSA and G6 (which turned out to be 7 (3+4)) my uro and my readings told me I had a lot of options that would all work well.  My uro did not suggest an alternative(although I believe he was leaning to surgery) but was a great sounding board for me as I wrestled with my choice of action. Just when I thought I came to a decision , I found reasons to look in another direction. I was driving myself crazy.  I eventually chose surgery for many of the reasons given already - getting it out, having a backup plan etc.  The other reason that swung me towards surgery was when a radiologist suggested surgery as a first option given my age and the possibility of secondary cancer 15-20 years down the road from radiation treatment.  Although improvements in the focus of the instruments are constantly being made, he seemed to think that the possibility still existed.  Perhaps I am being presumptious , but i do plan to be around in 20 years and just didnt want to have to deal with that then.

As others have said, no matter what treatment you decide on , try to find the most experienced doctor that you can.  I am confident that the skill and experience of my doctor made a huge difference in my outcome and recovery.

Best of luck - remember we are all here for you - so dont hesitate to ask questions.  There are many experienced and caring folks here to help you however possible.

 

Ray

 

 


JoeFL
Regular Member


Date Joined Oct 2009
Total Posts : 420
   Posted 10/6/2010 1:21 PM (GMT -6)   
Mac,
 
I started out leaning toward surgery for all the reasons you have already read above. After more research (including spending a lot of time on this site), I finally decided that, if cure rates were comparable, I wanted the treatment that would give me the best ongoing quality of life. I was greatly influenced in this by having an extended family member who is battling incontinence 3 years after open surgery and can't be as active as I am. I finally opted for a BT/IGRT combination and have been very happy with the results (with the full understanding that I might have some issues further down the road).
 
You have already learned, as did the rest of us, that you will not get "the answer" from the docs. Decide what is most important to you and your family, take the plunge and then don't second guess yourself. Regardless of what you choose, you will find a lot of support here on HW. Regards,
 
Joe
Age 67 PSA 4.5 Biopsy 9/4/09 Bostwick Labs 5 of 8 sections (5 of 11 cores) positive-Gleason 3+3=6 Stage T1
BT on 12/11/09 (84 seeds of Palladium 103) Home same day/no catheter. Some burning, frequency, urgency for 6 weeks. No incontinence, mild ED. Normal activity within 3 days. 25 IGRT sessions ending 3/22/10 - some fatigue until 30 days after last treatment. PSA on 5/26 - 0.1 PSA on 9/1 - 0.1

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 10/6/2010 2:03 PM (GMT -6)   
fairwind - dont fully agree with your good post. i feel strongly, it should always be cure, incontinence, ed, and in that order. shouldn't be based around anything but the best cure possible. i am old school that way.

mel - i should be the poster child for what can go wrong with salvage radiation. even when i was dx with pc, i was so afraid of having to go through radiation a second time in barely 10 years, and i let my drs know of that fear. i know what happened to me with radiation this time might be rare, but it happened, and now 7 operations later, i am in the condition that i am in, and still not sure if the radiation worked or not.
no one should go into it lightly.

david
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

briantopp
Regular Member


Date Joined Sep 2010
Total Posts : 24
   Posted 10/6/2010 6:20 PM (GMT -6)   
In his post above, Jim/Tudpock sets out a case of brachytherapy which I agree with, word-for-word. So I'll just offer you my own experience. I went in for a brachytherapy procedure last Tuesday. I took three days off on general principles and was back at work Monday. I feel fine, and am having nothing like the kind of side effects many of our brothers on this forum report from other alternatives. The research credibly suggests my chance of a cure is at least as good as the alternatives (somewhere around 90%) given that my numbers were similar to yours. So I would recommend this form of therapy in the right circumstances -- always remembering that I have a big appointment three months from now to see if it worked.

All the best
bt

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3895
   Posted 10/6/2010 6:39 PM (GMT -6)   
"fairwind - dont fully agree with your good post. i feel strongly, it should always be cure, incontinence, ed, and in that order. shouldn't be based around anything but the best cure possible. i am old school that way."

I feel EXACTLY the same way Dave.. It's just that I feel his chances for a CURE are excellent with either surgery or radiation and if that's the case, side effects need to be considered carefully..

Expertly performed robotic surgery would STILL be MY choice, but I'm trying to keep the playing field level..JMHO...

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25394
   Posted 10/6/2010 6:43 PM (GMT -6)   
fairwind, you are correct, i may have read too much into your verbage, plus can you trust a guy on pain killers, lol.
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
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 11/10 ?
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, on Catheter #21, will be having Ileal Conduit Surgery in Sept.

MCinNC
New Member


Date Joined Sep 2010
Total Posts : 13
   Posted 10/6/2010 9:31 PM (GMT -6)   
Thanks for all the thoughtful posts!   It is very helpful to see that others have faced the same issues, and very insightful to hear about the decision making process that each person used for their own reasons.
 
Inwm, hope your surgery went great today.  Best of luck to you.
 
Alf, I agree totally with you on the AS thinking.  If I happen to live another 25 years, the odds are very high that my PC will progress eventually to a point that requires treatment. 
 
The harder question for me is thinking about AS for the short term, not long term.  What about monitoring things for, say 5 years, enjoying life w/o side effects for the time being, understanding that treatment will likely be sought then.  This idea also seems helpful in considering a "new" option like CyberKnife, which doesn't have a lot of long term data yet - and you would have more info to evaluate when making your treatment decision.  (I'd also be interested to see if real changes in your diet, re fat, red meat, dairy, etc, would have an obvious effect on PSA and disease progression.)
 
Speaking of CyberKnife, has anyone chosen to have it?  It seems to promise the benefits and cure rate of traditional radiation therapies with some likelihood of fewer side effects due to better targeting, technology, etc.   But again, as applied to prostate treatment, it seems a bit early to draw any firm conclusions.
 
Lots of good points about having a backup plan.  For those who chose surgery and have needed or are planning to use radiation as a salvage therapy, is there a standard radiation therapy used for this?  Is it targeted where the prostate was formerly located, thinking that the PC is still localized there?  Or is it a more broadly targeted treatment?
 
Jim, thanks for the explanation for your choice of brachy.   Is the expectation now that urgency and frequency issues are the main urinary issues, as opposed to blockages from scar tissue or bladder damage, etc.?  (My dad had some form of EBRT 20 years ago and did have periodic episodes where he would have to go to the ER to get help releasing urine.)  And with ED, how long out should those effects be apparent if they are going to appear?  Is your expectation that ED can be treated with pills, or will this likely require additional remedies?
 
Joe and JohnT, you each chose a form of BT.  What were your expectations going in as to likely urinary and ED problems that you might experience vs. those likely with surgery?  
 
bt, glad your procedure went well and hope that the 90 day numbers look good!
 
david in sc, your story is incredible.  Surely you are due to have something good happen in your treatment! 
 
thanks again to everyone.
 
Mac 
 
 
 
 

Age 56. 7/22/10 biopsy results confirmed on 8/17/10 showing 1 of 12 positive, with 5-10% of core tissue involved. Gleason of 3+3=6, PSA before biopsy 2.3. Nothing on DRE. Family history (father) with PC. Stage: T1c. General health good.

Currently considering all treatment options.

Post Edited (MCinNC) : 10/6/2010 8:39:12 PM (GMT-6)


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4278
   Posted 10/7/2010 10:06 AM (GMT -6)   
Mac, as I understand your stats the "temporary AS" plan that you suggest does seem to make some sense.  And, who knows, it may turn out to be long term AS.  There have been some studies posted in this forum recently (by Casey and JT as I recall) that show that if the AS protocol is followed properly then later treatment is just as effective as treatment now.  Also, Dr. Scholz among others believes that there will be more progress made in Pca treatment in the next 5 years than in the past 20....so new and better treatments may be available to you if and when you need them.
 
However, as I'm sure you know, AS doesn't mean just forgetting about the cancer and checking back in a few years.  It means proper staging now as well as follow up monitoring and testing by a doc who is experienced with AS patients.  Also, AS is not without controversy and I would encourage you to read some of the threads on this subject that have been posted on this forum over the past couple of months.  There are varied opinons here and it's well worth hearing them IMHO.
 
Re the questions you asked about Brachy, the issues of bladder damage or scar tissue blockages are very rare with modern Brachytherapy.  That's not to say that they can't happen, but they don't happen often with an experienced BT team who use modern techiques and equipment.  So, yes, the main urinary issues are simply the urgency and frequency for the first couple of months and those are usually controlled well with Flomax. Re the ED with BT, it usually occurs by the 2-3 year mark.  That's not to say it can't happen later but 2-3 years is pretty much the norm.  One of the best indicators of post BT ED is pre-BT potency.  That is, if it was working well pre treatment there is a better chance that it will work well post treatment.  And, as I stated in my earlier post, the long term ED rate for BT patients is still lower than for surgery patients.  If the ED does occur, the same treatments for it are available to BT patients as for surgery patients, e.g. the various ED meds on the market. 
 
Part of my thinking on the ED aspects of brachy went like this:  First of all my chances of ED were less than with surgery and secondly if I did get the ED at least I would have another 2-3 years of normal sexual activity before onset.  Hey...another 2-3 years of anything good at our ages is a positive!  By the way, so far so good for me...coming up to the 2 year mark with no SE's.
 
Hope this helps,
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 9/10/10. 6 month PSA 1.4, 1 year PSA at 1.0. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643

JoeFL
Regular Member


Date Joined Oct 2009
Total Posts : 420
   Posted 10/7/2010 10:39 AM (GMT -6)   
Mac,
 
Going in, my expectations regarding urinary issues were some short term (6-8 weeks) burning, urgency and frequency. Since I already had some frequency prior to the BT, these were not a big concern for me. I did not worry about incontinence based on what I was told by my uro and onc rad and by the fact that I don't think I have ever read anywhere on this site about a BT guy that had incontinence issues. And it worked out just like that....burning sensation, urgency, frequency which have all but disappeared....no incontinence. I do still take one flomax a day.
 
As to ED, I wasn't sure what to expect since each man is different. My docs told me that, as a general rule, most men have some initial ED which improves over time. That has been the case for me...and without any pills. I don't have ED but I also don't have as much desire/libido as I did before the BT/IGRT. To what degree that totally returns remains to be seen. I also understand that there can be a delayed ED effect with radiation after a couple of years....but I also had ED risk with surgery.
 
There are no guarantees in this game. That said, I feel that I got what I was looking for....a treatment with a 90+ cure rate chance with minimal side effects on my QOL.
 
Hope that helps....regards,
 
Joe
 
PS - Where are you in NC? I have family in Charlotte.
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