Posted 9/12/2016 7:38 AM (GMT -6)
We first met with a nurse who completed their necessary medical history files. She thanked me for the comprehensive files I had left with them the week before. This kept the information session short.
Dr. M then came into the exam room. He explained that J (Nurse/navigator) had already alerted him that I am a highly informed patient and that I probably did not need any of the usual introductory discussion about the disease itself, the actual meaning of my diagnosis/pathology, survival rates, etc. We pretty much went directly to treatment options that he felt would be appropriate for me.
He asked me what modes of treatment I was considering. I told him that I had a particular interest in CyberKnife, but that I also wanted to know what treatments he felt would be appropriate for me. He agreed with my interest in radiation treatment and CyberKnife in particular. When I asked his success statistics for CK/prostate, he said that he measures it as 85-90% over the 8 years they have used CK for prostate cancer. He disagrees with some of the math used by other studies, and feels that their results are more realistically the same as his, not the 90% published. I did not press for details.
We discussed their treatment protocol. First, after qualification of the patient for CK (Gleason scores, organ size, co-morbidities, etc.) they implant 4 gold fiducials into the prostate. This is done through the perineum. When I questioned why they do not do them trans-rectally, he said that going through the perineum gives them better control of where the markers are placed into the prostate. I told him that I have a low pain threshold and a highly developed “startle” reflex, and asked what methods of pain control they used. I related to him the story of my prostate biopsy and my need for a nerve block. He said that they prescribe oral pain meds pre-op (Norco), and then use a topical that completely numbs the skin of the perineum. They will also consider prescribing valium for anxiety. They use no injected nerve block, stating that the actual insertion pain is only about what is felt when receiving a nerve block injection, so they just do the two insertions (two “threaded” fiducials per insertion) instead of two nerve blocks and then two more insertions. I guess I’ll have to deal with it.
Dr. M briefly discussed their CK protocol. They insert the fiducials, then perform imaging (usually MRI and CT, for me only CT) studies for treatment planning, which takes about two weeks to complete. After the plan is complete, treatment is scheduled for M-W-F; M-W. Five treatments over a two week period. They have both bowel and bladder prep instructions. I was aware of the bowel prep (enemas), but will have to wait to hear about bladder prep. I hope it does not require an overly full bladder for an hour-long session. During and after treatment the patient is monitored for side effects. They prescribe tamsulosin (FloMax) to minimize urinary issues before, during and after the treatment. The urinary toxicities they have noted are usually urinary frequency, urgency and sometimes some burning sensation upon urination. They have found thus far that bowel toxicities are manageable without prescription medications, and may consist of loose stool, urgency, etc. Dr. M said that typically any side effects last a month or less.
Dr. M also surprised me by asking if I had ever considered LD-Brachytherapy. I told him that this was originally my first choice but that Dr. F had indicated that LDBT has fallen out of favor and he rarely saw it done of late. Dr. M said that he does 70-80 cases annually with LDBT. He said that the reason he brought this up is that in a few cases, the CT scan alone is not clear enough to plan CK. He then said not to worry, that if for any reason CK was not possible for me he had a second plan that was equally viable.
Dr. M then said that LDBT would give about the same long term results for a lower risk case like mine, compared to CK. He mentioned that the urinary side effects would last longer (up to two months, rather than one), but that there were rarely any bowel side effects with LDBT. He mentioned that there are some other cautions, activity advice, etc., but that we would go into that if the need arises. Basically this treatment has the same efficacy as CK, one-day treatment (outpatient) rather than five days, but the side effects last longer.
After completion of treatment, they will monitor PSA and testosterone levels (why T if they aren’t going to do anything about it?) at their hospital lab. Tests are scheduled at 3 mo., 6 mo., 12 mo., and annually thereafter. I think he said that after 5 years they end their monitoring and return you to your own doctor (uro or internist).
Over-all, I was favorably impressed. I left the office with the feeling that Dr. M really does care and wants to treat the patient, not just the disease. He seems to regret he cannot offer me more help with the TRT issue, but he genuinely feels that my odds of beating this cancer are better without TRT. He, himself, is not comfortable dealing with the entire situation and would make referrals as needed. (I am afraid that I may have made him a bit uncomfortable by seeming so “needy” about this.)
Dr. M also helped me to feel better by having a backup plan should, for any reason, CK not be a viable option. I appreciated that he looked ahead and gave me the peace of mind to know that he identified a second path to follow that does not require 8-10 weeks of treatments or surgery.
So - one very good meeting with both Plan A and Plan B revealed. Next up is tomorrow's meeting with RO #2. After that, just book it and get it done!
Age 68 at Dx
PSA history: 2000-2012 0.9-1.2; 06/2012 started T replacement
2013-2015 3.0-3.3 (new normal)
Biopsy: 12-core biopsy 07/2016; 3 cores G3+3, 5% or less; 1 core 3+4, 15%; 1 core HGPIN; 2% of gland involved. Summary G3+4.