Postive Surgical Margin rates of Open versus Robotic, 3%, 8%, etc.

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EdwardL
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Date Joined Dec 2010
Total Posts : 10
   Posted 1/14/2011 2:03 PM (GMT -6)   
I'm going to have a prostatectomy in the weeks ahead and have seen two good surgeons. One has only done open surgeries over his 20+ years and has done about 1,400 of them. The other has done about 500 open and then switched to daVinci eight years ago and has now done 700 of those.

When asked the question on what their positive margin rate was for organ-confined patients in my category (Gleason 6, 3+3, T1C, 1 core of 12 with cancer), the open surgeon said 3% and the daVinci surgeon said 8%. The open surgeon is passionate about his statistics and has meticulously collected them for 20 years. He says he and only 1 or 2 others in the country have such statistics on their surgeries. I'm not sure the daVinci surgeon is that careful with his numbers although he is one of the best in my big city and very well-regarded.

I'd prefer to go the daVinci route due to the assumption that it will be less invasive for me though I'm not sure I believe these claims 100%. There are several well done studies (Univ. of Michigan, Vanderbilt) that show daVinci prostatectomies are not any easier to recover from than open procedures, don't reduce blood loss, and are not less painful.

I'm going to get both these surgeons to clarify how they came up with their numbers and over what time period and exact patient demographics. But, if they turn out to really be 3% for the open surgeon and 8% for the daVinci surgeon, doesn't it make sense to go with the open surgeon who has a 5% less-chance of leaving cancer behind? Is an 8% positive margin rate for daVinci high? I know Walsh says across all surgeons at Hopkins and over 10K surgeries, the organ confined cases showed a 1.3% positive margin (pg. 295). He doesn't seem to clarify whether that includes open and robotic as I believe they use daVinci at Hopkins as well.
April 2007 PSA: 2.9
July 2008 PSA: 3.2
Aug 2010 PSA: 4.3
September 2010 biopsy: Gleason 6 (3+3) T1C, 1 core positive out of 12

Post Edited (EdwardL) : 1/14/2011 6:46:38 PM (GMT-7)


compiler
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Date Joined Nov 2009
Total Posts : 7213
   Posted 1/14/2011 2:11 PM (GMT -6)   
Are you sure? The studies I've read indicated much less blood loss and a quicker recovery with Da Vinci.
 
However, the biggest factor is the skill/EXPERIENCE of the surgeon.
 
When I did my research, I was going to choose the best, most expeienced surgeon regardless of open  or robotic.
 
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. PSA on 3/10/10-: 0.01. PSA on 6/21/10--0.02. 9/21/10--0.06; 1/4/11-0.13 CRAP!

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/14/2011 2:27 PM (GMT -6)   
Edward,

From every clinical indicator you've provided, you have only a tiny, microscopic amount of prostate cancer. There are many men your age who likely have more PC than you have who will never know they have it, and will likely die of something other than PC. Many men with your clinical diagnosis forego radical treatments in favor of changing their lifestyle (diet/nutrition, exercise and stress reduction) to keep their PC fully under control. With the small amount that you have, it is unlikely that you will have a positive margin no matter which surgery technique you choose.

I hope this helps...

English Alf
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Date Joined Oct 2009
Total Posts : 2216
   Posted 1/14/2011 2:40 PM (GMT -6)   
No two patients are the same thus no surgeon will ever have operated on a guy with the same amount of cancer as you, nor with a guy whose prostate is exactly as big/small as yours, nor in exactly the same location as yours etc.

A surgeon who has never operated on any patients whose cancer is close to the edge of the gland will have a record of 0% clean margins. Conversely a surgeon who has only operated on guys with cancer right on the edge of the capsule may have a very high percentage of positive margins.
Thus whether you are at risk of positive margins seems to me to be more down to where the cancer is located in the prostate than the skill of the surgeon. And they can't tell exactly what's inside you adn where until afterwards!!

A good surgeon is always going to be better than a bad one regardless of whether it´s open or robot, and by good I mean a felow who puts you at your ease, communicates well and gives you confidence to put your life in his hands.

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 CT
66Gy 28 Apr to 11 Jun 10
Tired + weird BMs
14 Sep 10 PSA <0.1
12 Jan 11 PSA <0.1
Erection OK

John T
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Date Joined Nov 2008
Total Posts : 4237
   Posted 1/14/2011 2:51 PM (GMT -6)   
Ed,
You have to be careful in how you interpret the data. For truely organ confined that has been confirmed after surgery, the rate of positive margin for low risk PC is about 5%. (pathological staging). For low risk characteristics with clinical staging (pas and gleason) the number is 15%.
This is because the clincal staging (the information you have in which to base a decision) may not be accurrate. The cure rate across major institutions for clinically defined low risk PC is 85% for surgery and 95% for pathological confirmed low risk.
The rate of positive margins is very surgeon dependent. Scardino at MSK published data that showed that the best surgeon had a positive margin rate of 11% and the worst a 45% with an average of 24%. This is across all gleason grades and the rate for low risk is much lower.
Therefore you real risk of a positive margin going into surgery is 15% and if confirmed after surgery that it was indeed a localized G6 is about 5%.
All that being said, I agree with Casey that you have a very good chance of having clinically insignificant PC which is common in most men, and any radical treatment will more likely do more damage than the cancer ever would.
JohnT

wd40
Regular Member


Date Joined Jan 2008
Total Posts : 218
   Posted 1/14/2011 3:07 PM (GMT -6)   
I am one of the few that had both open and divinci. I can tell you the small holes healed and gave me much less trouble than the big hole. Both easy to tolerate.

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 1/14/2011 3:44 PM (GMT -6)   
With all due respect, questionaboutit, in case you hadn't heard, we are in the midst of a prostate cancer overtreatment epidemic—men with the smallest amounts of prostate cancer being aggressively treated when very likely they did not need aggressive treatment at all. With the clinical characteristics provided by Edward, there is nothing less than what he has that is still called "prostate cancer."

If his doctor, who is probably also one of his possible surgeons, is not telling him this, then it is clearly in his best interest to obtain this information from somewhere...and experienced guys on this forum are probably as good an initial source as any.

It is intuitively obvious to the casual observer that nobody is a doctor here...

normek
Regular Member


Date Joined Feb 2010
Total Posts : 49
   Posted 1/14/2011 4:04 PM (GMT -6)   
Casey, I have to agree with question. You don't know the age of Edward, you dont know his family or medical history, you dont know is psa level, or how fast his psa level is rising,  yet you advise him that he doesnt need surgery, radiation or seeds. I dont get it.

Dave7
Regular Member


Date Joined Jul 2006
Total Posts : 202
   Posted 1/14/2011 4:05 PM (GMT -6)   
I had the DaVinci and the worst part of recovery was the catheter.  Otherwise, it didn't seem like I'd even had surgery.
I would think the DaVinci is less invasive than the open.
 
I wouldn't spend too much time investigating the surgeons statistics.  There are too many variables involved, including the fact that guys that aren't doing as well are less likely to respond to post surgery surveys.
 
 

sheepguy
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Date Joined Nov 2010
Total Posts : 763
   Posted 1/14/2011 4:14 PM (GMT -6)   
Being a frequent , but casual lurker, I would say that it is obvious only in title that no one is a doctor here. Many postings imply, if not outright state, a level of urological understanding that is well beyond that of any urologist. I would not be surprised if many of the posters place more credence in information found here than from their doctors.

Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/14/2011 4:18 PM (GMT -6)   
normek, PSA in Aug was 4.3 ng/mL.

Age doesn't effect amount of cancer he has...the smallest amount possible based on what he reported here: "Gleason 6, 3+3, T1C, 1 core of 12 with cancer".

While I did not advise Edward that he "doesn't need surgery, radiation or seeds", I did relate that many "men with your clinical diagnosis forego radical treatments." Then, you may have not noticed, I replied more directly to his question about positive surgical margins.

Do you "get it" now, normed?

EdwardL
New Member


Date Joined Dec 2010
Total Posts : 10
   Posted 1/14/2011 4:24 PM (GMT -6)   
I'm 52 and both my father and my only sibling had prostate cancer. My father had a prostatectomy in his late 70's, my brother had brachytherapy two years ago at age 55. Every member of my family has had cancer of one form or another, going back two generations. 3 of 4 grandparents and my mother died from it. My urologist (the daVinci surgeon I mentioned earlier) has said there is a 1 out of 7 chance based on MSK nomograms that I would not live to the average age of mid 70's. I'm not comfortable with the 1 out of 7 chance. I also would worry too much doing active surveillance. So, I'm ok going through the operation.

Thanks for all the helpful comments. What I'd really like to focus on here is about the positive margin rates of surgeons. To give a bit more detail on the two surgeons I mentioned before, the open surgeon is saying his 3% is for those in pathology stage 3 (those with NON-organ confined cancer where it has spread outside the capsule) and the daVinci surgeon is giving his 8% for those with pathology stage 2 (contained within the capsule). Most likely, I would end up in a pathology stage 2. So, that makes the open surgeon's numbers look even better.

Of course, the daVinci sounds newer and less-invasive but I'm not really worried about the short-term. Going through either type of procedure sounds terrible! But, I'm sure I will get through whatever happens. Long-term cancer control is really my only concern.
April 2007 PSA: 2.9
July 2008 PSA: 3.2
Aug 2010 PSA: 4.3
September 2010 biopsy: Gleason 6 (3+3) T1C, 1 core positive out of 12

Post Edited (EdwardL) : 1/14/2011 2:47:46 PM (GMT-7)


Casey59
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Date Joined Sep 2009
Total Posts : 3172
   Posted 1/14/2011 4:41 PM (GMT -6)   
Edward, unforutnately, I don't think there is any input beyond what I've already said on the likelihood of you having a PSM for either approach, either doctor.

Have you run your clinical inputs in the MSK nomogram yourself? Try it here:
http://www.mskcc.org/applications/nomograms/prostate/

I entered your info in the MSK nomogram, and it says you have a 98% of progression-free probability after 10-years. It appears to me that 10-years is as far out as it goes.  I cannot tell how someone is able to use the MSK nomograms to project out further than 10-years.
 
 
 
 
 
edited after Edwards' correction

Post Edited (Casey59) : 1/14/2011 3:25:11 PM (GMT-7)


BillyMac
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Date Joined Feb 2008
Total Posts : 1858
   Posted 1/14/2011 5:05 PM (GMT -6)   
Question,
I have to agree with Casey and JohnT here. Currently there is much debate concerning over treatment for PCa. Have a look at the link below. Autopsy on men over 50 reveals that fully 30% have evidence of prostate cancer ---------- over 80 that figure is 70%. Yet the death rate from Pca is 3%. This means that the vast majority of those with prostate cancer will not die from it. It is frightening to think of the unnecessary surgery that is being carried out. The posters are not telling EdwardL not to have surgery but rather suggesting that given he has 1 core of 12 positive (we do not know the percentage of that single core) with the lowest grade Gleason currently given he should certainly think seriously about the next step ------- not just say as most of us did before we knew more about the subject -----" cancer???? Quick, help, get it out!!!" That may be Edward's ultimate decision but it should be based on sound knowledge and not fear.

www.fpnotebook.com/Urology/Hemeonc/PrstCncr.htm

Edward,
The internal surgery for both open and DaVinci is exactly the same ------- the only difference is how they get in there. The larger incisions of open may take a week or so longer to heal and may entail a little more blood loss (usually not a problem). But either way the internal reconstruction will have you out of action for at least 6 weeks so it doesn't matter too much either way. The skill of the doctor, irrespective of method, is paramount.
Bill

Post Edited (BillyMac) : 1/14/2011 3:19:10 PM (GMT-7)


Tony Crispino
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Date Joined Dec 2006
Total Posts : 8128
   Posted 1/14/2011 5:11 PM (GMT -6)   
Edward,
Pete Scardino and Bill Catalona, both very highly regarded in their combined 70 years+ in treating prostate cancer, were present at an American Urological Association meeting I attended last year in San Francisco. At that conference both were very adamant that in their experience surgery still presents the best chance at a cure for low and medium risk prostate cancers. Pete Scardino get's quoted as saying certain thing that often get misinterpreted in online forums and I think it's important to note. He does clearly outline in his book that a bad surgeon is not uncommon and that factor does reduce your percentages of a successful operation when not carefully selecting an experienced surgeon.

The prostate cancer nomograms at the Memorial Sloan Kettering website are derived from the urological and radiological centers at MSK and can provide you predictive outcomes depending on what treatment you might select. Your doctors claims are reasonably in line with these nomograms.

It is my understanding that while there are chances of positive margins at any risk level, positive margins do not necessarily determine if a treatment was successful, but rather only show if you are at increased risk for biochemical failure. Successful treatment of prostate cancer can be measured numerous ways but the most logical is biochemical failure and prostate cancer specific mortality. Positive margins at surgery is one of the most commonly misinterpreted ways to determine success. Because surgery is recommended before any radio therapies, it is with full understanding that if positive margins are present, radiation is still within standard treatment protocol of the patient but that even that may be unnecessary. It's important to note that a very large number of men who had positive margins never have a relapse of the disease after treatment.

I hope this information may help you...Good luck in your journey...


PS: I am 4 yours after my RP in February. I had positive margins and local mets in my seminal vesicles. I did some followup therapies and to date I have never had a rise in PSA (still undetectable).

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Post Edited (TC-LasVegas) : 1/14/2011 3:46:14 PM (GMT-7)


John T
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Date Joined Nov 2008
Total Posts : 4237
   Posted 1/14/2011 7:25 PM (GMT -6)   
Questions,
There is definately "clinically insignificant" prostate cancers. The data from Hopkins, UCSF and many other institutions support this. It is G6 or less, psa density<1.5 and no greater than 30% cores positive and no one core >50%. 70% of men with these stats will show no signs of progression of their cancer. The longest studies to date are 7 years. For the 30% that do progress it is usually within the 1st 3 years and treatment has exactly the same cure rate as immediate treatment. These are the facts and supported by many institutions. It is time that we recognize that not all prostate cancers are the same; some are very dangerous and some are pretty harmless. Currently the only way of knowing this is to watch it over a period of time and see if it progresses through a rise in psa or by another biopsy showing a higher gleason grade. You can choose to believe what you want but the facts are the facts and are pretty consistant no matter where you look.
You just cannot get by the fact that 50% of all men over 50 have some PC, but only 4% actually die from it. What about the other 46%? Most are living normal lives without ever knowing they even have cancer.
Edward,
If you are certain that you want surgery that's your decision. I would not be concerned with positive margins for a G6. As Tony mentioned about 50% of positive margins never have biochemical reoccurrances (rise in psa) and even fewer have clinical reoccurrances (cancer that can be detected by a biopsy). Even if a G6 has a biochemical reoccurrance it is unlikely that it will develop into a clinical reoccurrance.
Unless you have a rare varient it would be very unusual for a G6 to cause death. G3 cancer cells don't live very well outside of the prostate and it very difficult for them to matastize.
You have a very curable cancer and any treatment will work about the same. At this point you are splitting hairs. Pick the best doctor for the treatment you wish to have as this will have much more impact than the treatment you choose.
JT
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.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/14/2011 8:22 PM (GMT -6)   
Hello Edward,

You ask some good and legitimate questions. I had open surgery, at the time (2008) in my area, robotic surgery was too new and only a total of 15 for prostate cancer had been done. My surgeon had almost 30 years experience, doing all open surgery. Prostate surgery is major and complex surgery either way. We have men here that had open surgery and only stayed 2 days in the hospital, and men that had robotic that stayed a week. Averages are just that, averages. I needed 4 1/2 days in the hopsital for mine, but had good insurance, so that part didn't matter to me.

As far as bleeding, that is getting to be more of an urban legend from the past. Severe bleeding and blood replacement is very rare in modern open surgery. Also, the argument of magnification is often blown way up, there are some advantages to that issue with robotic, but a good open surgeon with lit and magnified head sets can see just fine.

A lot of RP surgery involves complex sutures and stiching, the tactile feel of a good, experienced open surgeon is hard to replace with a robot. I liked knowing that my surgeon had his hands in fingers in there, and with his experience level, he knew what things should feel like.

Also, you don't have the being filled with gas issues with open surgery, some men here have reported terrible problems with gas and pain issues.

As far as postive margins, one surgical method over the other isn't going to determine that. The cancer is invisible to the surgeon, either method, there is no dotted line to follow. A good surgeon does the best he can. A positive margin can happen in a G6 case as easily as a high grade case. Lot of factors there at work.

In some surveys, perhaps not fully scientific, it almost looks on the surface, that men are suffering higher rates of ED and incontinence via robotic surgery. I think the jury is out on that one, but worth looking into and thinking about.

You want the best surgeon you can get with whatever rescources you have at your disposal, that is my advice. Whether you heal up from several smaller holes, or one larger incision, the complexity of the surgery is the same inside.

Take your time and choose well, there is no re-play button on your choice of a primary treatment if needed. On the surface, looks like your numbers might make you a good candidate for "seeding", so by all means, seek and get the advice of a good radiation and medical oncologist.

David in SC
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

daveshan
Regular Member


Date Joined Jan 2010
Total Posts : 363
   Posted 1/14/2011 8:46 PM (GMT -6)   
EdwardL

I'm 100% behind David (Purgatory) on this one!

I had open surgery March 1 of last year, in at 0630 on Monday out of the hospital at 1830 on Tuesday, cath' for 2 weeks and today I'm in very good shape both ED (with the help of vitamin "V") and drip wise. In our little community up here the guys I know who went robotic are having more issues than the open guys, it's a small enough sample that no positive conclusions can be drawn but I'm darn glad to have had the surgeon I had.


He also makes a great point about taking a bit of time and looking at radiation options, my Uro' insisted I talk to both another surgeon and a radiation oncologist before deciding on a path to take. I'd urge you to do the same.

Best of luck to you
Dave in Durango CO
Diagnosed 12-09 age 55
07-06 PSA 2.5
01-08 PSA 5.5 (PCP did not tell me of increase or schedule follow-up!!!!)
09-09 PSA 6.5 Sent for consult with Urologist
11-09 Consult, scheduled for biopsy, found out about PSA from '08 (yes I was pissed)
12-09 Biopsy, initial Gleason 9 (4+5) later reduced to 8 with tertiary 5, ain't much but I'll take it.
01-10 Bone Scan, "appears negative"
03-01-10 RRP in Durango CO by Dr Sejal Quale and Dr Shandra Wilson, no naked eye evidence of spread, Vesicles and lymph nodes taken for microscopic exam.

03-16-10 Removal of cath' and pathology results of samples.
Multifocal carcinoma with areas of Gleason pattern 3, 4 and 5, Overall Gleason grade 4+4 with tertiary 5, Bilateral involving 21% of left lobe, 3% of right lobe, Invasion of left Seminal vesicle, Tumor focally present at left resection margin, 9 lymph nodes removed all negative, Tumor staging pT3b NO MX

04-23-10 PSA <0.04....... 06-07-10 PSA <0.04..... 08-03-10 <0.04
05-03-10 1 week without pads
06-28-10 ;-)

EdwardL
New Member


Date Joined Dec 2010
Total Posts : 10
   Posted 1/14/2011 8:56 PM (GMT -6)   
Thanks so much everyone for all the helpful comments so far. I forgot to mention that I did see two well-regarded radiation oncologists about brachytherapy. I'm lucky to have so many experts in that field in my city as it mostly started here. The radiation experts told me that surgery was a better option for me due to being 52 years of age because there is a slight risk of radiation side effects in later years. I was hoping to have seeds as it sounded relatively simple. That was the only time I wished I was older than I am!
April 2007 PSA: 2.9
July 2008 PSA: 3.2
Aug 2010 PSA: 4.3
September 2010 biopsy: Gleason 6 (3+3) T1C, 1 core positive out of 12

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 1/14/2011 9:58 PM (GMT -6)   
Edward,

I should add, that my first choice was for Seeds, but my numbers didn't qualify me for them in my area. Should also add, that though I had open surgery, had I chosen robotic, they would have had to aborted the surgery and switch to open due to a complication in my prostate bed itself, so in the end, I made the right choice for me.

Sounds like you are doing your homework, and getting some good opinions, thats the best way to choose.

Whatever you choose to do, we are a patient to patient support group with a lot of experience. We are not, however, doctors or experts.

David in SC
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 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3783
   Posted 1/14/2011 11:13 PM (GMT -6)   
So Ed, you got a lot more information than you bargained for.. Don't fall into the trap of focusing on a single issue..Margin percentages are very hard to accurately calculate and in the end, are not that important as part of the over-all picture..There are many men here with reoccurrences that had negative margins..

one sees this ans similar statements quite often:

"This means that the vast majority of those with prostate cancer will not die from it. It is frightening to think of the unnecessary surgery that is being carried out. "...

The FACT is 32,000 men died of prostate cancer last year...Much depends on your age..If you are 70 or 80, as many men diagnosed with PC are, then active surveillance is a no brainer...Chances are you WILL die from something other than PC...But if you are 45-50-60 years old with a life expectancy of 20-30-40 years, that's a long time to expect your PC will remain "indolent" and harmless.

There is a lot of LUCK involved with the successful treatment of PC..ALL of the treatments have SERIOUS side effects and potential complications..There is no agreement in the medical field as to the best treatment method and the internet is rife with conflicting claims based mostly on anecdotal evidence, hearsay and personal opinion..

Have you read any books on the subject? Walsh's book is good, very detailed, but from a surgeons viewpoint..The latest book out, "Winning the battle Against Prostate Cancer " by Dr. Gerald Chodak contains the results of the latest studies and he goes to great lengths to remain unbiased..Just the facts...

Surgery does offer some advantages.. the entire prostate can be examined and your true "stage" can be determined. With G-6, a successful surgery means you are done..If it fails, radiation can be used as a back-up treatment and a cure is still possible..If money is an issue, Surgery is much cheaper than radiation..

The downside? five years post surgery, 80% of patients who choose it have serious ED issues..30-40% have incontinence issues, 60-80% report their penis was shortened...

You and I are at opposite ends of the PC spectrum..I was Gleason 9..Chose surgery, robotic, Post surgery PSA 0.9 (PSA 7 at biopsy) 100% continent, 100% impotent..Suffered a hospital acquired staph infection in lower abdomen, six days in hospital, a month on IV antibiotics...two weeks with an abdominal drain..It's not always "a piece of cake".....I'm now undergoing salvage radiation and hormone therapy in a last ditch effort..

Best of luck to you as you begin your journey..
Age 68.
PSA at age 55: 3.5, DRE normal. Advice, "Keep an eye on it".
age 58: 4.5
" 61: 5.2
" 64: 7.5, DRE "Abnormal"
" 65: 8.5, " normal", biopsy, 12 core, negative...
" 66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
" 67 4.5 DRE "normal"
" 68 7.0 third biopsy positive, 4 out of 12, G-6,7, 9
RRP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT NOW

Newporter
Regular Member


Date Joined Sep 2010
Total Posts : 225
   Posted 1/15/2011 12:32 AM (GMT -6)   
A word of caution regarding clinical staging from biopsy:

My clinical staging was very similar to yours: 1 core out of 12 had < 5% cancer of Gleason 6. After surgery, pathology staging showed cancers in multiple places with some places Gleason grade 4 (scores of 7 or 8). Often time, biopsy under estimate the amount of cancers in your prostate.

As for positive margin, the surgeon who operated on me kept statistics and told me when he started robotic RP in 2003, the whole hospital's positive margins for Da Vinci were about 25%. Today his own positive margin statistics is <5% overall, for all patients.
65 Dx June-2010 PSA: 10.7, biopsy: Adenocarcinoma, 1 core Gleason 6, 3 cores atypia; Clinical stage T2; CT, Bone Scan, MRI all negative

8-23-10 Robotic RP; Pathology: Negative margins; Lymph nodes, Seminal Vesicle clear; PNI present; multiple Adenocarcinoma sites Gleason 3+3 with tertiary Gleason grade 4. Stage: pT2,N0,Mx,R0

Catheter out 8-30-10 no incontinence, no ED. Jan PSA: <.1

BillyMac
Veteran Member


Date Joined Feb 2008
Total Posts : 1858
   Posted 1/15/2011 4:23 AM (GMT -6)   
questionaboutit said...
BillyMac,

I had my first biopsy in June, 2010. It found no clearcut sign of cancer, only some cells that were suspicious for cancer on the left side. The second biopsy in August found definite cancer on the left side and some suspicious cells on the right side. The cancer was staged as a Gleason 6. Surgery was Sept 9. I had cancer throughout the gland with tumors on both sides and one focally positive margin and a large amount of Gleason 4's. I ended up a 2Tc, Gleason 6 with the 4's noted beside the score. The pathology report did not include cancer volume but the surgeon, looking at the slides, said about 85%. I can't remember if they did 35 or 45 samples but all were cancer.

My doctor said he was glad that I did not put off the surgery until winter or take six months to raise money to go to Mexico for ultrasonic ablation. I think men with PCa should be very wary of the concept of indolent, non-aggressive or insignificant PCa. There are no safe cancers.

I think you misinterpret the statistics that derived from the autopsies of 50 year old men. Had these men not died from heart attacks, wrecks or other causes at the young age of 50, the undetected and untreated PCa may well have killed them a few years later. It does not make PCa any less dangerous just because some men die earlier from other causes. It still needs to be detected and dealt with.


No, you are misinterpreting the data. If 30% of 50 year old dead men have identifiable Pca revealed at autopsy then by extrapolation 30% of not dead 50 year old men will have identifiable Pca. Using your criteria that once Pca is identified, then out she comes baby, means that 30% of 50 year old men need to have their prostates removed. That is clearly outrageous as only 3% of the male population die from Pca. Nobody here diagnosed Edward ------ his doc did. His doc said Gleason 6, 1 out of 12 positive, Stage T1C PSA 4.3 (the 12 month increase from 3.2 is a cause for concern). Based on that diagnosis by his doctor, the suggestion by Casey and JohnT to proceed with caution is sound. Active surveillance does not mean forget about it. If on active surveillance, given those stats, it would be prudent to have another biopsy in 6 months and 24 cores would be better than 12. The opposite advice "Holy s*it you've got cancer, chop it out!" is every bit as bad as "just forget about it"
Bill

Post Edited (BillyMac) : 1/15/2011 2:33:18 AM (GMT-7)


English Alf
Veteran Member


Date Joined Oct 2009
Total Posts : 2216
   Posted 1/15/2011 9:35 AM (GMT -6)   
My Father-in-law has PCa, he is 74, he has had PCa for over 14 years, he has had no treatment. Ergo some PCa is not aggressive. Active surrveillance was his choice when he was 59 due to other health issues as he has heart problems and diabetes.

On the other hand given how soon I had a BCR after surgery I'm inclined to think I had an aggressive type.

Anyway...
A new book about Cancer has just been published in the UK. it is a Beginer's Guide written by professor Paul Scotting and published by One World. (My son gave it to me as a Christmas present!!!)

Professor Scotting is Associate Professor of Genetics at the University of Nottingham.

In the context of this thread the most relevant thing he says about PSA screening etc is on page 130:

".....However, other than in the USA, population-wide screening has not been generally adopted. Two large studies recenty carried out in the USA and Europe failed to provide convincing evidence that these tests are sufficiently reliable. In particular blood PSA levels can be high in those without cancer or low in those with cancer. As a result, despite the fact that screening and early diagnosis of this cancer might reduce mortality by twenty percent, as many as forty-eight men could be treated for every life saved. In other words screening would be likely to result in significant unnecessary surgery with its associated risks and side-effects."


So, yes I think there are people opting for surgery, or being pushed into it, when they don't need to, or don't need to rush into making a decision. However, the trouble is that as yet nobody has indicated how you're meant to tell if you have the nasty or slow PCa.!!!

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 CT
66Gy 28 Apr to 11 Jun 10
Tired + weird BMs
14 Sep 10 PSA <0.1
12 Jan 11 PSA <0.1
Erection OK

normek
Regular Member


Date Joined Feb 2010
Total Posts : 49
   Posted 1/15/2011 10:23 AM (GMT -6)   
John, I’m trying to grasp all this PC info, stats and percentages. In one post you agree with Casey that Edward has a very good chance of insignificant PC, where radical treatment would likely do more damage than the cancer ever wood. In another post you quote Hopkins data on what constitute insignificant PC.
With the info that Edwards posted, how are you able to determine his psa density is <1.5 and that his positive core was not over 50%, to come up with the conclusion that “there is a very good chance is PC is insignificant.
Also Hopkins do not recommend management of PC for Men in their 50’s and with a family history of PC.
I just think advise is given or suggestions are being made on this forum without knowing all the relevant or required information.
dx at age 45

psa 3.6, increase of 1.3 from previous year
1 of 12 cores positive, gleason 3+3=6, stage T1C
Surgery January 8th 2010, cath out January 15th 2010
Path report; gleason 3+3=6, 35% of prostate and both lobs involved, upgaded to stage T2C,
organ confined, 1 focal positive margin
Dry and no needs for pads at 8 weeks post op
ED improving at 8 months
3rd post op PSA .01
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