Thanks (I think) for your support. I'm getting a little confused by your use of pronouns - please feel free to address me directly in the second person, and to refer to yourself in the first person. My only "job" here is to support my peers. Sometimes that involves correcting what I see as "misinformation," sometimes that involves trying to get my peer to a more rational place. My "job" is not
to work within the patient's paradigm. You are free to agree with or disagree with anything I say -- it's your health, your life, your decision - and I am not a doctor. So feel free to ignore the rest of this post as it does not conform to the "job" you've inexplicably assigned me. I'm sure you can pay someone who won't challenge your misinformation or paradigms.
he will not have a Prostatectomy nor any form of Hormone Therapy
Does that preclude even short term hormone therapy adjuvant to radiation? And why is that?
The patient wants to know everything he can know about where the cancer may be before doing any thing.
In my opinion, that's a very poor strategy. Diagnostic tests are only valuable inasmuch as they have the ability to change treatment decisions. Knowledge for knowledge's sake is a waste of valuable time (when one is GS 9), and is apt to provoke more anxiety than it alleviates. It may also create a very false sense of security.
t would be helpful if he sequenced an imaging path
I did - start with a bone scan and CT. If money is no object, get a CellSearch CTC assay.
I want to clear the lymphs . If it is not in the lymphs, it is not in the bones because it had to pass through the lymphs to get to the bones.
Where on earth did you get that misinformation? Cancer can be found in lymph nodes, bone or viscera - any or all of those, and there are no rules about
where it will land first. Cancer can travel in the blood, the lymph, or even around nerves. Cancer can also be in the lymph without forming tumors in the lymph nodes.
The patient, perhaps erroneously , has concluded that if the cancer is out in the Lymph nodes, it has also parked in other places which may not now be discoverable, like the bones.
Not necessarily. The cancer may have moved only as far as the LNs so far. There is a big clinical trial (RTOG 0924) looking at whether treatment at this stage when LN invasion is suspected but not yet detectable can be curative. A previous study, RTOG 9413 found an advantage to hormone plus RT treatment at this stage. Even when cancer in the LNs is detectable, there is a survival advantage to treatment. One arm of the STAMPEDE study
looked at that subgroup and found a survival advantage in the first 2 years (will it be maintained? we don't know). Several database analyses seem to affirm this with 10 years of followup data (see ADT and radiation for first-line treatment of node-positive (N1) prostate cancer
The patient then says after we clear the lymphs , lets do our best imaging on the pelvic area
I suspect that you are confusing detectability with actual presence of cancer. They are not the same. Imaging, even the best available, can only detect macroscopic bits of cancer (say, down to 2 mm). So what we use instead are probabilities. Nomograms developed based on the experience of hundreds or thousands of men are useful for this purpose. GS 9s carry a high risk of local tissue invasion and LN invasion. Doctors treat areas of high suspicion for cancer even if they can't see it. Undoubtedly, some patients are overtreated with this strategy, but with GS 9s, that risk is small. What you can't see can still hurt you.