Getting close to a decision

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life partner
New Member


Date Joined Mar 2011
Total Posts : 5
   Posted 3/17/2011 7:12 PM (GMT -6)   
My partner has been diagnosed with borderline intermediate/high risk prostate cancer. PSA 6.5 four out of twelve biopsies cancerous Gleason grade 9. We have been working with Dr Raul Hernandez in San Francisco/Daly City who does Robotic surgery. He seems very knowledgeable, is a good listener and gives thorough answers. He has ordered a prostate MRI to see if the cancer has spread after which we will be deciding on a treatment, and, from all we've researched, robotic surgery looks like our best bet. My partner asked Dr Hernandez how many Robotic surgeries he has done in the past and he has only done about twenty five. Has anyone here been treated by him? Had surgery from him? Everyone talks about Peter Carroll at UCSF as the best but our fear is that trying to get an appointment with him may delay treatment by an unacceptable amount of time and we know from the numbers that we are under a time crunch to deal with this situation. A comfort and trust level has definitely been established with Hernandez, which may compensate for the rather small number of procedures he's done with Robotics.

Mackattack
Regular Member


Date Joined Jan 2011
Total Posts : 78
   Posted 3/17/2011 7:26 PM (GMT -6)   
I would strongly encourage you to interview other surgeons. With only 25 surgeries under his belt, most experts would say that Dr. Hernandez is still early on the learning curve. This surgery and the skill of the surgeon are far too important to you and your partner to allow him to be learning the procedure with your partner.

There are many other surgeons out there with much more experience. You would be well served to consider several surgeons before making a decision.
PSA 3.9 - October 2010 at annual physical
PSA 4.1 - November 2010 after a month of antibiotic, DRE Normal
Age 41 in December 2010 at Dx of 6 of 12 cores positive T1C and Gleason 3 + 3

open RP on 2/14/11 at Mass General

Post Surgery Pathology Report: Gleason 6, T2, Cancer in 35% of Prostate, All Margins Clear

Radical
Veteran Member


Date Joined Mar 2009
Total Posts : 739
   Posted 3/17/2011 7:33 PM (GMT -6)   
I agree with Mackattack, 25 surgeries, really is no where near enough experience.
I understand with a Gleason 9, time is not on your side, but please research some more surgeons, before you rush in.
Thankfully his psa is relatively low.
Hoping all goes well for your partner, please keep us posted.
Age 53yrs [Gold Coast Qld, Australia]
PSA 4 Gleason 7 [3+4=7]
RP 24/12/08 Dr Philip Stricker [Sydney]
Upgrade Gleason Score 7.6 [4+3=7]
Stage 2 Margin status- Focal Involvement
ED- okay with Meds.
PSA at 2 yrs, no change remains 0.03
"Every-day in Every-way I Get Better"

Post Edited (NotHard) : 3/17/2011 7:40:22 PM (GMT-6)


life partner
New Member


Date Joined Mar 2011
Total Posts : 5
   Posted 3/17/2011 7:46 PM (GMT -6)   
Thanks to both of you. We have recommendations at UCSF and Stanford and will pursue them.

formypops
New Member


Date Joined Nov 2010
Total Posts : 12
   Posted 3/17/2011 7:52 PM (GMT -6)   
I agree with other posts. Patrick Walsh's book recommends at minimum someone who has done over 300 to 400 surgeries.  We opted to go with someone who did 1500. Also make sure you ask you will do the actual surgery and how much a resident will do. You want to make sure they do it. Maybe they have the resident remove lymph nodes, etc which is fine but the major stuff should be by the guy you choose.
Also when scheduling tell them he is a Gleason 9. Many of these offices will accommodate you for a sooner schedule or a cancelation list.
Good luck and all the best.

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 3/17/2011 8:01 PM (GMT -6)   
You may even consider asking how many open prostatectomies he has done and consider that route. open and robotic are really equal in results.

I am also a Gleason 9, and I elected to have surgery. But the odds are good that you will need radiation also. If I were to do it over, and found the right doctors, I may have chosen seeds and IMRT, or just IMRT.

It is a confusing time of dealing with reality, learning so much about prostate cancer, and the treatment options. The tendency is to rush, when in all likelihood, 6 months wouldn't make a lot of difference in the outcome.

I would advise multiple opinions from multiple disciplines. Seek out experienced doctors. It is generally felt that a doctor needs several hundred surgeries to be considered to have mastered robotic. That is not to say your doctor won't do a fine job, but with a Gleason 9, you need every advantage you can get.

Good luck on your journey. I am 2 years post op and feeling great.

Goodlife
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

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3753
   Posted 3/17/2011 8:16 PM (GMT -6)   
Please do not limit your search to surgery. High Dose Radiation brachytherapy has proved to be as effective over a ten to fifteen yer period and has far fewer and less severe side effects, Jeffrey Demanes MD is the pioneer having performed HDR since 1981 and heads up the radiology at UCLA medical center. Also a Dr Hsu in California is expert as well. Check out the procedure and long term results at www.cetmc.com.

I recently had HDR here in Atlanta and am very pleased. I also had IMRT and hormonw therapy. My post treatment PSA is ,0.10. I was G7 with all cores positive. HDR is preferred in the intermediate and high risk situations which your partner clearly is. The problem with surgery in that situation is that there is a high probablilty of cancer escaping the gland and requiring radiation after surgery. Why go through two sets of risks and side effects?

My urologist would not perform surgery on me and I confirmed that the greats like Walsh and Sardino wouldn't either because they won't operate on people that have a significant probability of the cancer being slightly out of the capsule.

I trust your doctors have walked you through the Partin tables and nonograms....if not they should. It will give you a better idea as to the type of treatment that will do the most good wiuth the least harm.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard shot and daily Jalyn started on 10-7-2010.
IMRT to prostate and lymph nodes 25 fractions started on 11-8-2010, HDR Brachytherapy 12-6 and 13-2010.
PSA <.1 and T 23 on 2-3-2011.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25380
   Posted 3/17/2011 8:36 PM (GMT -6)   
Welcome here, glad you found about this place. You got some pretty good advice going already here, while the stats don't look or sound good, now is the time to think long and hard about a primary treatment. There isnt any "re-set" button once you have treatment.

Ask lots of questions, talk to as many doctors as possible.

Good luck and keep us well posted.

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 2/11 1.24
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 9/10,

davidg
Veteran Member


Date Joined Feb 2011
Total Posts : 4093
   Posted 3/17/2011 8:45 PM (GMT -6)   
i would urge you to seek someone with more than 25. If you have to, travel, it's worth it. You only get one shot at the surgery and you need someone who is skilled and experienced. I think that once you make that decision you'll feel more serene about it all.

life partner
New Member


Date Joined Mar 2011
Total Posts : 5
   Posted 3/17/2011 9:15 PM (GMT -6)   
Thanks for all these very helpful replies. And now I have to totally embarass myself and say, after talking to my partner, that I was wrong about the 25 surgeries. That was another doctor who we are no longer considering. Have not found out how many Dr Hernandez has done. But all the advice here is excellent. Believe me we are looking in every nook and cranny of any viable and proven therapy.

Viperguy
Regular Member


Date Joined Nov 2010
Total Posts : 259
   Posted 3/18/2011 8:45 AM (GMT -6)   
Don't risk it. You need someone that has done over 1,000 of these procedures.
2009 PSA 2.2
2010 PSA 3.2
Biopsy 24 cores 3 positive
Gleason 3 plus 3
Robotic Surgery March 3, 2011 @ 6 am
At home recovering
Cath removal scheduled 3/17/11
Pathological report confusing, no seminal invasion Gleason 6 but margins not completely clear.

Sancarlos
Regular Member


Date Joined Feb 2010
Total Posts : 242
   Posted 3/18/2011 10:35 AM (GMT -6)   
Bear in mind that if the cancer is not confined to the prostate surgery will not remove all of it, which means that down the road your partner will probably have to also do radiation therapy. In that scenario many people believe it makes more sense to do regular or high dosage brachytherapy followed by IMRT as this protocol is just as effective as surgery with less side effects.

Have a look at those calculator to determine the probability that your partner's cancer is confined to the prostate. http://www.bostwicklaboratories.com/uropredict/uropredict.aspx

When faced with prostate cancer the natural reaction of many men is "just cut it out." Unfortunately, if the cancer is not confined to the prostate it is usually not possible to eliminate it with surgery alone.

Sancarlos
Age 66, PC diagnosed 7/2009 at age 65
Stage: T2c, Gleason: 9 (4 + 5), 6 of 6 cores positive
Bone, CAT and MIR scans negative

Treatment: brachytherapy (103 palladium), 100 gy, 11/2009 + IMRT on Novalis, 45 gy, 3/2010 + ADT3 (Lupron + Casodex+Avodart)

PSA: 7/2009, At time of diagnosis -- 11.9
10/2009 -- 5.0 ; 12/2009 -- 0.56 ; 5/2010 -- 0.15
8/9/2010 -- 0.06 ; 11/2010 -- 0.013; 3/25/2011-- 0.005

Post Edited (Sancarlos) : 3/18/2011 12:37:05 PM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4227
   Posted 3/18/2011 10:38 AM (GMT -6)   
See Dr Carrol as you can't go wrong with his experience. Also look into combination seeds/IMRT as it may be more successful in your situation if it likes like you will be receiving salvage radiation.
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.

life partner
New Member


Date Joined Mar 2011
Total Posts : 5
   Posted 3/18/2011 3:53 PM (GMT -6)   
We've contacted Carroll's office and also a guy at Stanford. Waiting to hear back.

life partner
New Member


Date Joined Mar 2011
Total Posts : 5
   Posted 3/21/2011 11:07 PM (GMT -6)   
Great news. We have an appointment with Dr Carroll for a week from today.
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