Posted 4/2/2012 7:20 PM (GMT -7)
First of all, many thanks to all of you who have shaped my approach to confront the new challenge in my life and I wish the best outcomes for everyone seeking support via this site. According to Mayan Calendar - ending in 2012- this year could be an end of the World… For me, it has already ended in the way I knew it before being diagnosed with prostate cancer, just before last Christmas. Following is my path to reach a decision for the cancer treatment (I intentionally avoid calling it my cancer – no, as I do not think at all that I ever wanted to have or keep it…). Diagnosis Until last October 2011, I considered myself in pretty good health status, mainly having only routine physical medical exams. I am pretty active, running during week days, having a good blood pressure for my age (115/65) and with no treatment or medication for any condition.
One of the routine blood tests done after crossing the 50 years mark was PSA, but I paid not attention to it at all. That changed on last day of October 2011, when my primary care doctor called me saying that I need to undergo a biopsy of my prostate, and that he will refer me to a urologist. As I was in a work meeting when I answered the call, I had no comment. At that time, I hoped that the alarm could be false; however, thoughts were put in motion… I never paid attention to my prostate before, and anatomically I knew nothing about it. Following are my PSA results since I have known them: Aug-09 Routine PSA 2.8 Sep-10 Routine PSA 3.4 Oct-11 Routine PSA 4.2 Facing the perspective of a biopsy, I started reading information from reliable sources on the internet and found that beyond the PSA another test may be more reliable, the PCA3, which has a good correlation with the probability of cancer if it is above 40. I also read that a free PSA/total PSA ratio below 15% may also indicate presence of cancer. For my age, a PSA in excess of 3.5 could mean either an enlarged prostate ( benign prostatic hyperplasia – BPH), or cancer. So, I could still hope for a better outcome. The November trip to New Orleans was filled with fun, but my thoughts were magnetized by the cancer perspective. We cut short our trip and I went in to see the urologist. Right away, he recommended to have a biopsy. I tried to resist and I did ask if he would do any other tests before biopsy, such as any imagining technology. He told me that there are no nonintrusive tests which can detect intra-prostate cancer (which is partially true – if the cancer is microscopic, 3 Tesla MRI cannot detect it; a larger size, when coupled with spectroscopy is a better tool to detect mm size cancer). I have asked if the biopsy can detect it 100% reliable and the doctor said no; then, I added that I would like to get the procedure referral, but I will do it only after I get to repeat the PSA test, this time free and total, and the PCA3. I should also mention that I had no symptoms at all, and the urologist, similar to my family doctor, did not detect anything suspicious during the digital rectal exam (DRE normal).
Following are the results:
Repeat of PSA (Mayo lab):
After I read some publications about the probability of PCA3 to detect cancer, its value of 40.6 convinced me to schedule the biopsy. However, I should have studied better what are the side effects and potential risk of infection (after the fact, I found out that there are quite a few articles describing the relatively high incidence of infections). Specifically, I should have thought how many samples (cores) should be taken to increase the confidence in the grade/risk of the cancer, should it be detected. Although, just before the doctor did the biopsy, I asked him why only 12 - are they sufficient? He told me that they have done 18 core samples before but they found that 12 was the optimum (?). Actually, after undergoing this "barbaric" procedure, I have read about the saturation biopsy (usually, in excess of two dozen cores, depending on the prostate size); I would have submitted to it, since repeated biopsies are no fun at all and it never crossed my mind about having another one again.
After the nurse has used the gel anesthetic, a student came in trying to deliver it to me again… is that good communication or what? Just a reminder that once in the medical system we need to ask often if the right procedure is done for us… On a lighter side, afterwards, I asked the nurse to show me the biopsy samples, strings of "my material"… I told to the nurse that I felt lighter (meaning I weigh less); she thought that I was fainting, and she hurried up to bring me some sweetened water, but I explained to her what I meant… Although I did not develop any infection, some urethra burning due to inflammation and some stinging under the pubic bone set in, and persisted for a few good weeks. I can say that, because I felt perfectly normal before. Unfortunately, short of biopsy, currently, there is no other reliable and widely available test to confirm the presence of cancer and its aggressiveness. Since the biopsy samples represent a small percentage of the prostate (which depends on the prostate size and of the cores/needles used), and may have targeting errors due to prostate movement or the skill of the doctor, it is considered to detect cancer only in about 75% cases.
Following are the results of my 12 core biopsy guided by endorectal ultrasound:
Biopsy performed by Dr. J. W.;
prostate ultrasound estimated size: 44.6 cc (revised later to 35 cm by the more accurate MRI estimation)
Results: T1c - low risk cancer : 2 positive cores of 12
core 7 "Left Lat Apex": 1.2 cm tan core "<5% Gleason: 6 (3+3)"
core 8 "Left Med Apex": 1.2 cm tan core "5% Gleason: 6 (3+3)"
No perineural invasion present. Note: Gleason scale is 1 to 5; currently, 3 to 5 are considered to be the true cancer patterns (with the 5 being the less differentiated type of cells). Gleason score is the sum of the predominant pattern of cells and of the secondary pattern of cells (i.e. 7=4+3, which is more aggressive than 7=3+4). Based on the Gleason score and depending on the presence of metastasis, the prostate cancer it is classified four grades (1-4). Dr. J.W. called me around 8 pm on 12/20/11, and told me that I have the lowest Gleason score 6=3+3, which represents the low risk cancer, T1c (definition: Gleason score 6, PSA<10, less than 50% of core positive, normal DRE).
Luckily, I have the stage 1, the low risk; unfortunately, I still have cancer. He mentioned that he will refer me to a surgeon at the University hospital that evening; I reacted, saying that I may want to see an oncologist, and he replied that the surgeon is an oncologist, too. Probably he meant that he is an urologist, and not a medical oncologist. He also mentioned that I may not need to do anything, wait and monitor the cancer for awhile. It is unfortunate that most urologists are surgeons and probably biased towards surgery. I said that I want to talk to a radiation oncologist as well, and Dr. J.W. said that I can try to schedule them together. Being the Christmas vacation time, I was not able to schedule anything until January. In the mean time, I requested my family physician to recommend another potential doctor to consult; he told me that if he would be in my situation, he would go for surgery. The shock was severe, as I hoped until the last moment that I would not have cancer. So, my 2011 Christmas holiday was subdued because of the anxiety and the absence of a clear direction on my options. I felt blessed having a warm family and true friends who were there for me, when my spirits were low. Diagnostic Lesson Learned: Do not assume that your urologist has a crystal ball or is able to direct us to the most advanced and less intrusive tests to conclude that high PSA means cancer, or if it is confirmed by biopsy, how aggressive it is.
Treatment Now what? To treat or not to treat? I could not discuss my treatment options with any doctor until the 9 th of January. I reached to others who went through similar experiences, and I found out that most of us are affected by some anxiety. Probably our primary care doctors, due to their professional deformation, are immune to such a situation and think that time will resolve this. But the sleepless nights can take a toll on the patient… I did consult the web references mentioned above about what could be my options. And little by little, I got to understand the details of the following treatments for my low-risk (judged as confined to the prostate). ·
Robotic Surgery (nerve sparring) ·
Radiation – external: o photon-based intensity modulated radiation therapy (IMRT), image guided radiation therapy (IGRT) and CyberKnife o proton –based (not yet available in my state, but I looked into it, as the distance and cost were not decision factors); the latest data did not show significantly less side effects than the current IMRT. ·
Radiation – internal: o brachytherapy (BT)– high dosage rate (HDR) o low dosage rate (LDR) with radioactive seed implants. ·
High intensity focused ultrasound (HIFU, available in Toronto ) ·
Cryotherapy · Hyperthermia (available in Europe ) I should note that for cancer grades 2 - 4 these treatments are typically combined with hormone and chemo therapies. The prostate cancer growth is stimulated by the dihydrotestosterone; since most of doctors avoid hormone therapies (mostly to protect the patients from undesirable side effects) for the stage T1c, I did not spent too much time diving into it, or into chemotherapy.
I formulated my goals which guided me towards making a treatment decision, before I completely eliminated the active surveillance:
A) understand the aggressiveness and spread of the disease;
B) choose a treatment that has good chances to cure the cancer;
C) minimize all other side effects, knowing that there will be some undesired consequence with each type of treatment:
o maintain urinary continence
o avoid rectal problems
o preserve potency
o manage risk of secondary organ cancer.
For T1c cancer the doctors are reticent to prescribe more aggressive tests (bone scans), as they say that, statistically, there are few chances for cancer spread (metastases to bones- most common, or lungs – very rarely). I was able to get an MRI which identified a suspicious larger area on the left side, but it created additional concern. The doctor assured me that this does not change the grade and the prognosis for cure. However, I believe that the MRI was done too soon (6 weeks after biopsy), and inflammation may have tinted the results. The accuracy of MRI test increases significantly after 8 weeks, but each individual is different, so generalizations may not work. I did investigate Color Doppler Ultrasound (CDU), but it was offered to me in conjunction with another biopsy (which did not appeal to me). Bottom line, I could not say with 100% confidence that there are no other more aggressive cells lurking in my system trying to root somewhere else. However the statistics are on my side, based on the nomograms developed by reputable cancer centers. In parallel, at the beginning of January, I eliminated milk and its by byproducts, increased the meals with fish and maintained my high consumption of fresh fruit and vegetables.
I supplemented it with Vitamin D, fish oil, pomegranate extract, lyc opene, saw palmetto and selenium. Interestingly enough, all along my life, I have always liked and ate similar to the diet prescribed to enhance resistance against this cancer, cruciferous vegetables, garlic, cumin, hot peeper, fish, etc. Unfortunately, that was not enough to keep it at bay… As I ate right, did not smoke or drink, and have been pretty active, what else could have triggered it? Who knows? Some genetic traits and stress probably could be blamed for it… So, after so many years, my body could not remain infallible against this scoundrel. To comprehend the treatments, I consulted my local library and, one by one, I have read the following books: · Patrick Walsh (urologist/surgeon) – "Guide to Surviving Prostate Cancer", a good book, by an outstanding surgeon who cannot escape the bias and defines the surgery as the "gold" standard; the 2007 edition is more balanced than the 2001 edition, by including a radiation oncologist (subdued) point of view, and recognizing radiation as a true alternative to the still "gold" surgery. ·
Peter Scardino (urologist/surgeon) – "Prostate Book", 2010 edition. An excellent book, still biased towards surgery, but recognizing on page 234 "Why would a rational person go through painstaking biopsy to find a cancer and then choose not to treat it? In fact, this often make sense, and I've become a strong advocate of deferred therapy for many patients. Every once in a while – about 1 in 100 case – we perform a radical prostatectomy and find no cancer at all!! Far more often – 1 in 4 cases - the cancer turns out to be so tiny and insignificant when examined under the microscope that I question whether it was worth removing" ·
Eric Klein (urologist/surgeon) – "The Cleveland Clinic Guide to Prostate Cancer", 2010. Brief, easy to read, less biased. · Mark Scholtz (prostate medical oncologist) – " Invasion of the Prostate Snatchers", 2011. Major statement: for the more than 50,000 prostactectomies (surgical removal of the prostate), 40,000 are probably unnecessary, low risk cases. Radiation is a true alternative. · Michael Dattolli (radiation oncologist) – "Surviving Prostate Cancer without Surgery", 2005. An Introduction statement: "If you received advice from a surgeon, then you should do yourself a favor of seeking an opinion from a radiation oncologist, and vice versa." Biased towards radiation.
After reading these books, I realized that the prostate cancer is not a death sentence. According to the National Cancer Institute, the estimated new cases and deaths from prostate cancer in the United States in 2012 are: new cases - 241,740; deaths - 28,170. Among men, from all cancers, the prostate cancer has the highest incidence and it is the second cause of cancer-related death. Having an HMO selected for my health care, before knowing about this cancer, knowingly I did not want to limit my treatment options and I considered therapies out of state or out of the country (proton, cryo, HIFU, I decided that cost I may incur should be no decision factor in my treatment options). In the process of narrowing down the treatment options, I considered the statistical finding (based on post-surgery biopsies): most of the time, the prostate cancer is multifocal . Therefore, even after contacting a focal cryotherapy center in Denver , I rationed that a focal treatment may ne not be the right path for me, specifically when the second interpretation of the biopsy (from Dr. Jonathan Epstein at John Hopkins) showed that abnormal cells (potentially precursor of the cancer) were present on the right side as well. As for total prostate cryotherapy, I eliminated it based on available studies showing that its urinary and ED toxicity is greater than that of internal radiation. Also, the HIFU, after looking at its side effects and chance of cure , it did not remain in my cards. Following is the timeline of my doctor appointments that I had, trying to understand the remaining treatment options. Virtually, all doctors said that Active Surveillance (AS) is an option for me; some of them think that the unknown could be greater than the known, and a more radical treatment would be better, giving my age, health status and life expectancy in the absence of this cancer.
My conclusion after talking to all doctors was that no one can guarantee that there are no pockets of more aggressive cells which can evolve faster and a more radical treatment will be necessary, inclusive the potential of the cancer to migrate and root in other organs. What I start thinking was to trade a few more side effect-free years vs. the potential of more pain later. This is an individual choice, which no one else, but only the patient can make. Although, virtually all doctors mentioned that I am a candidate for active surveillance (AS), most of the protocols involve periodical biopsies, which is not a painless route. Also, my personality is of such nature that when I know of an issue, I cannot detach myself from thinking about it until I attempt a definitive solution. I have also looked at some of the useful monograms for the treatment decision process. ·
I did look at the national clinical trials available for my stage of cancer. Unfortunately, for stage T1c there were only a couple of clinical studies, one being at the medical center that I belong to, dealing with hypofractioned external radiation, Calypso-guided. I considered it before seeing the radiation oncologist; not anymore, after I found out about the increased dosage and the doctor replied that she would wait, when I asked her what she would do if she would be in my situation. Finally, I organized the remaining (six, inclusive of applicable combinations) treatment options into one Excel spreadsheet where I rated the side effects (urinary, bowel, potency) via their typical percentage incidence for each type of procedure; for further consideration, I have also added the options for the second treatment, or salvage therapy, hopefully, that it will be unnecessary. Based on what is important for me as an individual, I have added the weighting factors for the cure and for the side effects. The generated score is supposed to be a predictor of the outcome according to my priorities.
Yes, it may not be perfect, but overall, the score showed the LDR and HDR brachytherapies as being the top runners for me , in line with what my thoughts were in the absence of a score. In the realm of prostate cancer treatment, there is no "gold" standard, as there is no perfect solution… Before making the final decision, I had the PSA test redone (March 2012), both locally and at the Mayo clinic: ·
Total PSA: 4.2 –same as on October 2011 (done at the local University). ·
Total & Free PSA: 3.3 & 0.4 vs. 3.4/ & 0.8 in November 2011 (done at Mayo Labs).
Interestingly, both tests did not indicate a growing tumor, but this time I followed recommendations I did not know about before. I was intrigued by the big difference between the results from different medical centers from the same blood sample (3.3 vs. 4.2). It was explained to me that it is due to the test methodology difference. The problem is that, most of the times, the PSA is the only basis on which a doctor may refer someone for biopsy when PSA value is above a certain threshold (which varies from 2.5 to 4, depending on doctor's understanding of the patient's risk factors). It was not easy to decide between LDR and HDR, but finally the rationale was that low rate is less toxic to the normal cells (similar to getting the same amount of heat transfer to my arm via a low heating pad over an hour versus putting my arm in a fire for a few seconds…). Both doctors performing LDR and HDR brachytherapy are experts in their fields, so that was not a decision factor. Moreover, both went the extra mile, answering my questions and concerns via email
Regardless of the treatment alternative (surgery, radiation, cryotherapy), every specialist in the field recommends that, for reduced toxicity, we should search for a doctor who routinely performs the procedure and has at least 300 of them done already, preferably more than 1000; medical team's experience and skill are of paramount importance . Of course, with the high incidence of the prostate cancer, not everybody will have that opportunity, if someone cannot travel or wait long enough for availability, but at least it should be considered as a treatment planning goal. For years, I paid attention to news reporting successes in the fight against cancer. I called on the drug companies hoping to get into a clinical trial to extend my father life, diagnosed with multiple myeloma, in August, 2005. My brother, a doctor himself, said that our father's cancer could be fought for about five years - so did the oncologist who treated him; unfortunately, our body's ability to beat the cancer with a proper treatment is not the same, and our father passed away in January 2006, less than five months after the diagnosis.
One goal of my remaining life is to help those who will encounter a similar challenge with cancer. I do not know exactly how that will be shaped, but I will do my best. I believe that the future looks bright, as more research is happening today targeted to suppress genes that assist tumor cell growth and to develop non-intrusive detection and treatment options. Although they may not help my situation, I would be extremely happy to see it happening during my lifetime, such that the ones next in line to battle this disease would not have to worry once diagnosed. And the good news continues to come on… Every day is a good day - my glass is half full!
Edited 4/8/12: added March/2012 PSA test.
pdate: 5/6/12 Following, I detail my experience with the treatment so far via periodical updates Preparation Three days in advance of the brachytherapy, I started the usage of 0.4 mg tamsulosin (Flowmax). I was advised not to take any medication (aspirin, ibuprofen, etc) that may have a blood thinning effect, a week before. I had no food or liquid intake from the evening before the procedure, and had an enema about 1.5 hours before checking in at the hospital outpatient building (9:30 am). A week before, I asked Dr. P.M. (the doctor who has done my brachytherapy) who will do the needle insertion and the radioactive seed drop off. He genuinely answered that he will do all seed positioning, and the resident will insert half of the needle, as it will be easier; in the end, the doctor has offered to do all the needle insertion and seed drop off. Dr. P.M. emailed me a few of his medical journal publications for brachytherapy and I became familiar with details of the procedure, but I have also understood that the skill and experience in operating room are important. The Brachytherapy & After During my treatment search, I developed a deep trust and respect for Dr. P.M., to the point that I had no worries of any kind when I entered the hospital on Monday (4/30/12). I checked in, had the vitals done and I met with the anesthesiologist and urologist. I was explained that I will be sedated and will have an anesthesia. The urologist mentioned that the catheter will be inserted after I am sedated and will be out before I wake up. That happened around 10:30 am and the next thing I remember it was being in the recovery room around 1:30 pm. I had 90 I125 seeds for an MRI-determined prostate volume of 35 cc. Hospital pharmacy delivered a 7-day supply of ciprofloxacin and, after I was able to urinate, I was discharged around 2 pm. Once at home, I was able to go to the bathroom without problem. I was recommended to have plenty of fluids until there is no blood in the urine. I drank clear juices, water and herbal teas, and after the third time, the urine looked clear and normal. Overall I felt OK and normal with the exception of some burning and pain in the needle insertion area. I have used two Tylenols when I got home and two more before getting to bed (10 pm). On Tuesday, I stayed around the house, had no pain medication until going to bed when I took two Tylenols, more for ensuring better rest. Wednesday morning I woke up without any pain drove to a couple of places, connected to work via phone and email, directed some work around the house and finished the day without taking pain medication. Urinary side effects were so far quite minor: some burning and I had to wake up for it at night (nonexistent before): first night I woke up twice (as I drank a lot of liquids till late evening), once the next one, none after that.
Today is the sixth day after the brachytherapy and the side effects are almost non-existent: no urinary urgency or increased frequency, just a faint burning at the start; no bowel changes, and in the E department no deterioration. Overall, in my case, it seems that the side effects are no worse than the biopsy. Based on Jim’s (tudpock18) suggestion, I will consolidate current and future updates into the opening comments to more easily share my experience with the newly diagnosed (that’s what my pseudonym NewDiag stands for). I consider that this is necessary because the treatment options advanced by different doctors are sometime biased and confusing; I was biased towards surgery at the beginning, but when I analyzed the risks and various side effects, the toxicity of brachytherapy for T1c cancer iseems lower than that of the surgery, while providing at least the same cure rates . So far, I can summarize that I am pleasantly surprised with the procedure and recovery J . I will be waiting to see the PSA outcome along with the side effects evolution, but I am conscious that, for the rest of the life, I will be on a monitoring status (my mind accepted it, as being necessary regardless of the kind of treatment).
Update 6/03/2012 – One month after brachytherapy Although I had no real side effects the first week after brachytherapy, during the second week the urinary stream progressively got weaker but manageable with tamsulosin (the comparison is with a 100% normal function I had before). No real urgency issues or frequency (zero wakeups at night, just like before treatment). No bowel or rectal issues. As for E function, it worked almost as before treatment (some impact because of trauma, similar to that after biopsy). On the 15 th day after the brachytherapy, I had a CT scan, an MRI and X-rays for coverage and dosimetry calculation/assessment and I have seen the doctor. After their evaluation, the doctor emailed me saying that there is no need for any correction and there is good margin coverage all around prostate capsule (cover the uncertainty of any microscopic tumor cells that may have penetrated the capsule). He said that from cancer side I should be all set, and we need to manage the side effect symptoms in the next few weeks as he expects to peak between fourth week and fourth months (for Iodine 125 isotope recovery lasts longer than Palladium 103 isotope). He will see me after 6 months and have the PSA test just before that. During the fourth week the urinary restriction stabilized, but I still use the tamsulosin, and the doctor continues to check on me to see how I am doing, via email; I find this communication very expeditious, eliminating any potential misunderstanding through medical staff intermediaries. I knew from the very beginning that I will have to deal with certain side-effects and the doctor said that this urinary restriction due to swollen prostate is acute and not a chronic issue, reversible after a few months (the prostate size before and 15 days after brachytherapy being almost the same indicates that the internal swelling is partially restricting the urethral passage). Overall, I am quite satisfied with the brachytherapy treatment and I returned to my normal, wholesome life, including running again… P.S. More than a week ago, the US Preventive Task Force (USPTF) issued the recommendation (grade D) to stop all routine PSA testing. After being diagnosed via biopsy (without having any symptoms) I had the same opinion when I found out through my own experience that there is no uniform medical advice/approach in dealing with this cancer, and many opinions are rather biased; detecting cancer as early as possible is not bad, what is unfortunate is that there is no non-invasive test (like a blood test) having high accuracy to diagnose the prostate cancer and to predict which low grade clinical cancer (T1c) has chances to become aggressive instead of being indolent (not a life threat). I feel that the biopsy is a barbaric procedure, which should be avoided as much as possible. When I started to consult with doctors, I felt that somehow I was on my own; after reading the “Prostate Snatchers” I asked at the University hospital I belong to if there is any medical oncologist who specializes in prostate cancer; I was told that there are two… but that they deal only with advanced cancer cases; I felt that the medical system has failed me. I do recognize the needs of the advanced cancer patients and I sincerely sympathize with their suffering. What I was looking from a medical oncologist was a non-biased opinion, since the first urologist/surgeon I have seen was ready to schedule the surgery on the spot, and told me that I should not consult with more than two doctors, as it will be very confusing; yes, I did not consult two doctors, but six… Since most of the diagnosed prostate cancers are low grade cancers (about 90%), the USPTF underlines the harms that the low grade cancer patients are exposed to due to two main causes: lack of reliable noninvasive testing and overdiagnosis (treating what it may not be necessary); therefore, waiting and monitoria via non-intrusive tests is a viable and solid option for many patients who can cope with it.
There is no debate with respect to the treatment of the high grade cancers - they need to be treated aggressively. In mathematics and logic we are using the necessary and sufficient conditions to demonstrate a truth. For a person, being born in the US is a necessary and sufficient condition to be a potential Presidential candidate (oh, I fail this, but I am still happy of being a naturalized citizen…). In my dealing with this cancer I emphasized to my doctors that I do not want to betray my body – I want only the amount of treatment that is necessary and sufficient to get rid of of cancer (which is much easier said than done…). So far, so good for my choice. Doctor Visits Notes You may want to prepare a set of questions for your appointment, as it would be more difficult to get answers after you leave the doctor's office. Probably is even better if you have a family member or friend with you and write down the doctor's answers. Following are potential questions (I got inspired from other sources) that you may want have with you to write down doctor's answers for further reference:
Dr. X,what are the treatment options and what would you recommend?
Are there additional tests that we can do to gain the most complete understanding of the stage, spread and aggressiveness of my cancer (CAT or bone scan, CTC)?
Can you do a spectroscopic MRI and a Color Doppler Ultrasound?
Do you think there is any seminal vesicle involvement or lymph nodes? (Partin tables)
What is the probability of my cancer recurring with the treatment you propose after 10 years (%)?
What would be the potential salvage therapies?
What is the duration of the treatment procedure?
How many procedures of the treatment you propose have you performed (total and yearly)?
Or how many years have you done them? Do you recommend dutasteride - Avodart?
If radiation or cryo - do you recommend that we initiate androgen deprivation therapy ("hormone therapy") before the treatment? Why or why not?
If I select surgery, would you recommend nerve sparing for me (unilat/bilat)?
What dose of radiation will you be using and how/why did you select that dose of radiation; how many seeds, what isotope for LDR BT/how many times, at what interval for HDR BT?
If cryotherapy, is it focal therapy?
How is the saturation biopsy done and how can risks be contained?
If surgery - what are the positive margins (area adjacent to prostate with remaining cancer cells) for your patients? What level of failure have you had in preserving urinary continence at 1 year (%)?
Are there other urinary or bowel side effects that I should be concerned about at 6 months and 1 year?
What is the level of failure in preserving potency in your patients following the proposed therapy (after 1 yr)?
What can I expect following the procedure in terms of recovery time?
How long will it be before I can return to my normal activities?
Would you recommend active surveillance (AS)?
What is the AS protocol at your institution?
Are any clinical trials that you may suggest?
Are there dietary or lifestyle changes that I can make that can slow prostate cancer growth or that may allow my body to be more healthy to fight this prostate cancer?