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Bombshells from my radiation onocologist

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Posted 2/4/2009 3:42 PM (GMT 0)
Wow, just when I thought I had all the info, I went to a radiation onocologist today.  He feels that with a Gleason 7, nerve sparing surgery is not a good idea.  He also feels that brachy "seeds" are yesterday, HDR temporary implants are the way to go.  But, and this is a big but, he says even with the implants, I would need external beam treatments also, again due to that stupid Gleason 7.

Anyone with a "7" have nerve sparing robotic LDR?  How about HDR with additional external beam?  Results?  Complications?

Thanks,

Tony

Posted 2/4/2009 3:51 PM (GMT 0)
TOny,
I'm no doctor, but what you said would make me want a new opinion(s) from someone else. There's lots here with Gleason 7, nerve sparing and non nervesparing that have had both robotic and open surgery with good sucess. Most wouldn't do "seeds" with you initial specs, so not surprised there. Is there anything else going on that you didn't mention here that would complicate surgery?

David
Posted 2/4/2009 3:52 PM (GMT 0)
 

...ah, yeah....many of us have. I'd say keep  looking and researching. I'm gonna' go out on a limb here and say hang on, I have a feeling you'll have many more posters coming along real soon......

  My stuff is working pretty fair at 6-7 months out...

Posted 2/4/2009 4:34 PM (GMT 0)
Bluenose, looks like you are coming around fine and all areas, good for you.
Posted 2/4/2009 4:39 PM (GMT 0)
Godfather a tip from the syndicate of brotherhood of patients with PCa tells me:

Docs can be biased even if they are experts, docs sometimes have a protocol or even agenda that suits there liking. So get another opinion, I doubt that Dattaloi or RCOG would say that seeds are yesterday and others and that HDR seeds are the only way to go.

I seldom mention multiple opinions (LOL_LOL)

Z-Bob
Posted 2/4/2009 4:46 PM (GMT 0)

My biopsy indicated a Gleason 6. The actual pathology after robotic surgery showed a Gleason 4+3=7. The cancer was contained.  Based on your radiation oncologist what should I have done? You see, there is no easy answer.

Sam

Posted 2/4/2009 5:55 PM (GMT 0)
Sam,

Your case is what can make it hard. You had presurgery Gleason 6, but post surgery Gleason 7, and a 4+3 instead of a 3+4, conventional wisdom would say that surgery was the best course of action. I am not against watchful waiting, but there is a gamble going all the time, is the PC low grade, non agressive, and slow moving - like some Gleason 6's, or by waiting, are you giving a more aggressive cancer the chance to grow and spread. With a G7 ahead of time, waiting isn't usally considered wise, but with a G6, between a rock and a hard place. So in your case, in my opinion, you did the right thing by moving ahead with your surgery.

David in SC
Posted 2/4/2009 5:59 PM (GMT 0)
David:

Yeah, there are other things which complicate surgery. Weight 260 lbs, coronary artery disease and retroperitineal fibrosis. Other than those and prostate cancer, my health is just great (lol).

Still have Patel@Florida Hospital and Pow-Sang@Moffitt, both robotic surgeons, to see. Dr. Eastham at Sloan Kettering has agreed to review my stuff and give me a phone consultation, so the research continues. I keep you posted. Thanks all for the input.

Tony
Posted 2/4/2009 6:02 PM (GMT 0)
TOny, your weight could be a problem depending on your height with robotics, I have read that some surgeons are reluctant at a certain ratio. Your other health issues, don't know enough to know how they factor in. Your prostate size is on the small side based on your stats, so that part would make it easier for either robotics or open.

David
Posted 2/4/2009 6:22 PM (GMT 0)
I know that Dr. Menon (Henry Ford Hosp.) has parameters for weight issues on their LRRP, I heard it from a patient whom did do the weight drop to get his posterior into the program., He dropped like 50 lbs. prior to appointment scheduled down the road.
Posted 2/4/2009 6:26 PM (GMT 0)
Well Tony...as you can tell by now, finding the right treatment plan for yourself is gonna be long and difficult. Surgeons want to do surgery with their specialty, radiation oncologist will want to do radiation with their specialty and the list goes on and on. Each one you talk to will either scare the dickens out of you, or maybe even promise results that sound like miracles. Keep reading and doing your research...but also take some time off to absorb what you have been advised up to this point...otherwise the information is going to get confusing and scattered... it's called information overload.

Ever tried buying a house and making up your mind after seeing dozens and dozens of different homes. Eventually you will go back and review some of them again. So just take what is told to you now as the beginning of gathering information. Don't put too much into any one treatment plan until you have had the chance to look at all of them. Then go back for a second look before deciding.

Good luck and just know that we are here to help you when you do decide what is best or have a question about what you are told.
Posted 2/4/2009 6:30 PM (GMT 0)

Hi Tony:

Your case is another illustration of the complexities of this darn disease.  Every patient is different and we get different suggestions from different practitioners.  Here are some thoughts:

1.  It's obviously a good idea that you are talking with surgeons.  There are plenty of patients with Gleason 7 who have had both open and robotic surgeries with success, including nerve sparing.  But, it's not just the 7 that counts, it's obvously the whole collection of stats including your other health issues.

2.  With your weight issue, brachytherapy is likely a good choice...can't say whether traditional or HDR is right but...just google "brachytherapy overweight" and you will get some good evidence that suggests this protocol is a good option for overweight men.

3.  Seeds may be yesterday for your particular doc, but not so with many...including mine.  Zufus preaches multiple opinions and I think he is right.  You are near Dattoli, why not go there and get another opinion.  They are well thought of.

4.  With your combined stats, the radiation docs will probably suggest exteral radiation in addtional to brachytherapy either with traditional seeds or HDR.  It's not just the 7, but a combination of things that are considered with that recommendation indluding the % of nodes positive, PSA velocity and the fact that something was felt on the DRE.  That means the tumor(s) are likely closer to the edge of the prostate, lessening the chances that brachytherapy alone will do the trick...hence the need for additional radiation.

Hope this helps...please let us know how you progress.

Tudpock

Posted 2/4/2009 8:44 PM (GMT 0)
I had a clinical staging of T2b, a Gleason Score of 4+3=7, and a PSA of 37.95, when I met with my urological oncologist/surgeon the first time. This was against the recommendation of my urologist who wanted me to wait a few more months for the surgeon he works with.

I asked for da Vinci (he has done well over a 1000), but he refused saying that with my numbers he needed tactile feedback, which robotics currently cannot give, to determine if the surgery was feasible once inside, and what could and could not be saved. He also stated that if my PSA had been over 40 he would not consider surgery. In spite of the fact that my PSA rose above 40 over the next six days, he went ahead and performed a non-nerve sparing Laparoscopic radical prostatectomy (he has done well over a 1000 as well). I was out of the hospital within 24 hours. My pathologic stage came back T3b N0 MX, with a Gleason Score of 4+5=9. I am now on hormone therapy and discussing radiation.

The point is, if the doctor cannot defend his recommendations in a scientific manner that wins your trust and confidence, then talk to another doctor. You have to be happy with your decisions, not him. It's your life and health.

On a side note, my surgeon stated that if the patient is heavier he will only perform robotic or open, as laparoscopic becomes too difficult.

Shawn
Posted 2/4/2009 9:11 PM (GMT 0)
Shawn...is there a robotic procedure other than laproscopic? I know that there is robotic assisted laproscopic which I had...but I didn't know of any other robotic assisted procedure besides that one. Can you elaborate more...is this a new technique?
Posted 2/4/2009 10:33 PM (GMT 0)
GodFather, I'm a gleason 7 ( 3+4) and had nerve sparing prostatectomy with the robot in August. My urologist thought the robot was the best option for me. My doc is part of a large group of urologists with specialists is all of the major procedures. I felt I could trust his opinion based on that rather than feeling I was being sold the option he practiced. My So far so good.
Posted 2/4/2009 10:47 PM (GMT 0)
LV-TX,
I believe that Shawn is referring to "manual laproscopic surgery" where the surgeon holds the "instrument rods" with his hands thus giving the surgeon some tactile feedback, as opposed to the DaVinci equipment where the surgeon at a console remotely controls the"instrument rods"
Bill
Posted 2/4/2009 11:27 PM (GMT 0)
coxjajb:

Looks like you had a great result - congratulations. Where did you have it done?

My stage is T2c, 4+3 and I tip the scales at 260 lbs. So, I'm not optimistic at this point that I'll have the same result as you. I am consulting with 3 world class surgeons, between them having well over 5000 procedures, so we'll see how it goes.

Thanks for the input - it really helps as we muddle through this...

Tony
Posted 2/5/2009 12:35 AM (GMT 0)
Hi Godfather

I was a 7 and my first urologist told me the cancer was out of the prostate. I got another opinion and got rid of it all with open surgery. PSA's for the last 1.5 years have been less than zero. It will not hurt you to lose a few pounds. I was the guys who lost 50lbs. It was tough but I was determined to get the cancer out of me. Got to MSNBC and search health and look at the video about weight and PSA. The cute lady is my wife of 35 years.

Mika
Posted 2/5/2009 6:13 AM (GMT 0)
Mika,
I can't find the video...Can you put the link out?

Peace, buddy! Nice to see you again...

Tony
Posted 2/5/2009 1:21 PM (GMT 0)
Godfather, my husband had nerve-sparing robotic surgery and his Gleason was 7 (3+4) plus they knew from the biopsy that there was perineural invasion and that one sample was very close to the outer edge of the gland (the path report confirmed that he had a miniscule extension into but not through the prostate capsule). Our urologist said that both radiation and surgery were viable options for hubby - we chose the surgery because (1) we wanted the cancer out of him, (2) the pathology report would give us a definitive diagnosis, and (3) we wanted to keep radiation as a back-up in case the surgery did not do its job. Surgery was in March of 2008 and PSAs have been 0.0 since then.

I second what others have said - get a second opinion. I've heard of successful surgery being done for more advanced cases than yours. Good luck and please let us know what you decide to do.
Posted 2/5/2009 1:37 PM (GMT 0)
Sephie:

Your note nails it. Those are exactly my reasons for wanting surgery. What were his PCa pre-op stats? Age, weight? Where did he have his done? How long was the cath in? Any urinary or ED complications?

Congratulations on such a good result. Notes like yours gives us all a little more hope.

Thanks,

Tony
Posted 2/5/2009 2:03 PM (GMT 0)
Sephie, your husbands story/stats were very similar to mine. Your approach to his PC is along the same lines of thinking that I did, and very similar path. Gleason 7 usually very good target for surgery, and as you said, still leaves Radiation as a back up if the PC ever comes back. And yes, with surgery, the point is to get the cancer out with a good surgeon, and yes, once they have all the removed tissue, the pathology work is much more meaningful, and tells a more complete story. People forget that a biopsy pathology report is at at best, like my dr. said, an estimate of what is going on inside, but not a complete picture. Once inside, it may be better (fewer cases), might be worse (seems more common), or might be right on target. Glad your husband is still pulling zeros.

David in SC
Posted 2/5/2009 7:48 PM (GMT 0)
Godfather,
You will note from my signature below that my situation was similar to yours. I had 8 of 10 cores positive and a gleason 7 with perineural invasion shown. My original plan was radiation, but it involved External beam, seeds, and harmones. I decided to have the thing taken out via DiVinci. My skilled DiVinci doctor told me upfront he would cut a wider path than complete nerve sparing - which he did.

You will note I had no extraprostatic invasion on the pathology. This of course with negative margins was my number 1 goal and hope. Reference the nerve sparing part I can only say at 8 + months out I am using Cialis and Trimix with success. Even better, I have had some activity (although not sufficient yet) down south with just the Cialis - this means to me that even without total nerve sparing I may someday recover to pre-surgery form. My surgeon told me that regarding ED it is never all or nothing. The bottom line for me is that I would do the same thing all over again. I wish you well as you determine what is best for you.
Posted 2/5/2009 7:51 PM (GMT 0)
Godfather:

I saw 3 different doctors (all uro-surgeons) and they all told me that Robotic RP was the GOLD STANDARD for a man my age. I started with a Gleason 7 and eventually graded out at a 9.

I am 39 weeks post op. I still wear one pad a day for accidental drips. Still working on the ED part, but making progress. A lot of guys have recovered faster and more fully than I have, and right now I think I would be considered behind the power curve, but I can't complain. I'll start complaining if I'm still at this stage one year post op.

Good luck,
kcragman
Posted 2/6/2009 12:38 AM (GMT 0)
Your radiologist sounds like an idiot.  Brachytherapy has an extremely good cure rate.  Especially when they are treating people based on a biopsy gleason score that most of the time is higher then what they think it is.  Surgery gets you a better idea of how extensive your cancer is.  Look at the cure rates for brachy.  Whatever gleason score they are treating and curing are most always higher then what they state it is.  There is a place in Atlanta that says they get a 98% cure rate at 10 years for Gleason 6 cancers, which you know a lot of them are probably Gleason 7 cancers due to the fact that theses scores are based only on biopsies...I did RP, but would do Brachy next time.  I think it is very comporable to surgery for success rates if not slightly better.

Post Edited (ChrisR) : 2/5/2009 5:41:59 PM (GMT-7)

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