Choosing surgery because of salvage radiation option.

I keep reading posts on this site that state the main reason for choosing surgery was if it didn't work you could always go to salvage radiation. For some reason I just don't get this logic.

There are many good reasons to choose surgery and this is a very good option for many, but choosing it because you can get salvage radiation as a back up is not one of them.

The cure rate for reoccurances is about 30% which is very low.

If you have a reoccurance it is either local or systemic. If you have a high gleason the probability of it being systemic is high and beyond the reach of both surgery or radiation.

If the reoccurance is local it can only be because you have a positive margin somewhere or the surgery was botched and they left some prostate tissue. Getting the best surgeon will reduce botched surgeries.

One can reduce the possibility of positive margins through imaging

such as MRIS, or color doppler. If it shows that the PC has penetrated the capsule or if it is near something else that is hard to get to then surgery is not the best option. Radiation can get better margins in these cases.

If radiation is done correctly it should kill all the cancer in the prostate and give wider margins and kill cancer near the ureatha and seminal vessels where it is difficult to get clear margins. You can also radiate the pelvic bed to kill any stray cells and kill suspected PC in the pelvic lymp nodes.

Stacking multiple treatments with their own side affects is not very appealing to me. I would rather have one that get's the job done the first time.

Seed implants and cryo surgery and even radical surgery are salvage options in radiation if it is local. None are great options and this means that the initial dose given was not sufficient and can be eliminated by going to a top radiologist.

I would like to hear other opinions on this or have someone point out what I'm missing.

JohnT

 

John,
I don't know if it is us you are trying to convince or yourself that radiation is the best treatment for you. Results indicate radiation is not superior, but is on a par with surgery. However figures indicate that surgery has a slight edge as the years pass post treatment. If "radiation kills cancer in the prostate as well as killing cells in a wide margin together with eliminating Pca in the seminal vesicles as well as the pelvic lymph nodes" then local occurrence following radiation would be very, very low compared to surgery. This clearly is not the case as figures indicate. It is a fallacy to declare that if it fails to do so then that must be because it was not done correctly and by an incompetent doctor . Equally it is incorrect to state that local occurrence following surgery is purely indicative of the skill of the surgeon. In addition, the best scans today still are not foolproof which is why a great many choose surgery...............post surgery you can be reasonably sure of where you stand locally. Radiation also involves its own particular set of risks and side effects. Very few surgery patients have bowel complications ( which to me would be much worse than bladder problems) which can a d do occur with radiation patients. Heavy internal scarring following radiation is not unusual and is often the cause of disastrous complications with post radiation surgery. All in all I would assume that most who elect surgery do so on the basis of
(1) Psychologically I want that out of my body
(2) I want to know the true extent and grade of the cancer
(3) Should there be a local re occurrence I want another bite at the cherry.
Most members weighted up what they felt was important to them and based their treatment selection on those criteria.
Bill

Hi John T,

I think you may be over-thinking this. The first physician a patient talks to about his confirmed prostate cancer is a urologist. One of the arguments given to advance the surgical option in lieu of others is the ability to perform other salvage operations in case of recurrence.

Full RP rather than robotic is defended by the fact that all tissue is open to hands-on inspection including lymph nodes and seminal vesicles.

Many of these assertions may seem to be an exaggeration to some but I am sure the urologist is convinced he is advising the patient for what he considers to be the best option.

Salvage surgery is much more difficult than salvage radiation and requires no special talents.

It seems reasonable to me that a patient might repeat the urologists logic when defending his treatment option.

Dave

There are still very sound reasons and a whole lot of case histories to justify why having surgery as the primary and the most frequent treatment method of all times thus far as the "gold standard". It gets the prostate out of the man, it still the best way we have of knowing the extent, quantity, staging of the cancer in the prostate itself, as well if there is any extension to lymph nodes, seminal vessels etc

I think in the future, some of this 3D mapping, color dopler imaging will take some of the pre-surgery guess work out of the formula, and may eliminate surgeries for ultra low level PC cases.

But learning that salvage surgery is a bad alternative to a failed radiation treatment is good knowledge and needs to be factored into one's treatment choice. A person needs to know that. Again, I go back to saying that radiation as a first choice treatment can still be an excellent solution for low grade PC. Gleason 6 or less, low PSA velocity, PSA well under 4.0. That's the range where the cure rate for radiation is so good.

But for the rest of us, I think it is important to know the sequence of treatment options, not just the option itself. The order can be just as critical as the choice in the event of reaccurance.

Despite having surgery for my PC, I am not pro-surgery only. In my previous cancer bouts, it required mutiple surgeries, some unneeded after the fact, but there was no other way of knowing at the time without removal of suspected tissues, and extensive rounds of radiation. So it took both to "cure" those cancers.
Made it to the ten year mark, and only now, my original oncologist thinks I am safe.

We still all agree, there is no one cure package fits all, too many variables, and some of it is subjective and by the choice of the patient, and some of it, call it providence, or the blind luck, just a good call.

David in SC

Don't get me wrong here. Although I too had surgery I am neither an advocate for surgery as THE treatment nor do I think that radiation is any better or worse a treatment. What is best for each of us depends on pathology, grade and stage and the patient's personality. What tipped my decision was the scans available today cannot detail accurately enough (for me) the extent of the tumour and this was important to me. In hindsight my only regret is being swayed in selecting robotic by the blurbs of the advantages of its whiz-bang technology.
Bill

So in my case, if my PSA rises I have 30% chance of the cancer being completly destroyed by Salvage radiaition? I thought the #'s were higher.

Do those #'s matter based on your Gleason Score and months PSA free?

Are there any other alternatives after surgery other then this and Hormone treatment?

Thanks.

SHU93,

The 30% number is the cure rate for all salvage treatments. I would assume that if your pre stats were low and the reoccurrance is local the cure rate could be higher, but I really am only guessing.
If all the margins were clear and if all the prostate tissue was removed it is unlikely that the reoccurance would be local; in that event ADT3 is the appropriate treatment.
I think the most difficult thing in any reoccurance is determining if it is local or systemic. You have to know where the PC is before you can treat it effectively. If I ever had a reoccurance I would get every scan available and biopsies to locate the source. If I couldn't determine if it was local I would go to ADT3 without wasting time and incurring the side afffects of any salvage treatment.
The other salvage treatments are seeds directly to the tumor area and cryo surgery. These can be done for both surgical and radiation failures. Salvage surgery for radiation failure is not a very good option. IRMT for a localized surgical failure is a good option.
I disagree with Billy Mac because I think that today's imaging technology can give you a good idea of tumor location; it's not perfect but nothing is. Color doppler identified the location and size of my tumor and a telsa 3 MRI confirmed it exactly. MRIS missed it altogether (I was told later that it was a telsa 1.5 machine) Newer imaging technology that fuses MRIS, Color doppler, DEC MRI, and diffusion MRI can give you a pretty good idea of tumor location and size and posssibly agressiveness; then there is always 3D saturation mapping. Before I want anyone cutting on me I want to know if the cutting is going to get it all. If not then I'm going to something else that will. It's just common sense. I'm forunate I found a doctor that willing used all the newer scanning technology. All my previous docs weren't aware that it even existed and never gave me that option and I know now that the recommended surgery would have been a failure.
JohnT

Dear JT:

This is an interesting thread but, your post on another thread about cognitive dissonance should make you realize that most of us will rationalize our treatment decisions including the relative importance of post surgical radiation as a backup plan for surgery patients...

Having said that, I'll still weign in on this with my commentary.  My primary point is that psychological reasons can be a powerful motivator in making a treatment choice.  I do not believe, as you postulate, that having the radiation option available after surgery is invalid reasoning.  However, I do believe that the relative weighting of that can be vastly different in different men.

Let's take an example.  Say we have a 60 year old man with early stage cancer.  PSA is 5, nothing found on DRE, Gleason 3 +3, normal sized prostate and a couple of core samples with 25% or so cancerous.  That man has pretty much the full range of treatment options available.  So, what factors does he consider when making his choice?

1. Cure rate of treatment.

2. Short and long term urinary issues.

3. Short and long term ED issues.

4. Invasiveness of procedure.

5. Potential bowel issues.

6. Need to have a "backup plan" if primary treatment doesn't work.

7. Need to "get it out" of his body (the cancer that is).

8. Need to see pathology immediately after procedure.

I think both rad and surgery guys would agree that "cure rate" is number one with all of us.  After that the similarities diverge based on the psyche of the particular individual.  Now I will generalize a bit…the surgery guys seem to place a high degree of importance on items like “getting it out”, seeing the pathology and having a backup plan.  The radiation guys appear to weigh low invasiveness and fewer immediate side effects as higher motivators than backup plan or the other surgery motivators.  For me personally, I felt that there was a very high likelihood of cure so I didn’t worry too much about backup plans.  I figure that, if I had either surgery or seeds and either didn’t work, I would probably end up on HT eventually anyway, so I didn’t weight the loss of the option of having post-surgery radiation as very important.

I guess my point is that, while I do believe that the surgery guys’ point about an extra backup plan is valid, it’s not that important to me (and I’m guessing not to you) because of the weighting I personally give to some of the other factors listed above.

I’m sure I didn’t solve anything here, but this hopefully adds another perspective to this thread.

Tudpock

I would be willing to bet....that a vast majority of decisions for treatment were actually performed by the doctor that made the recommendation initially. A very very small percentage of men will actually research treatment methods before making their decision. I only base this on the number of newly diagnosed men that have had treatment and then post on a board...either this one or any other forums. And due to the number of senior men that are not savvy to the computer...I would bet even more that this is the case. The internet is a powerful resource...but only has grown in popularity in the last 10 to 15 years if that much.

So I don't know how much thought is really put into the treatment selection by most men. Albeit it is getting better with the word of mouth and the media attention of late for prostate cancer.

David...I agree it was generalizing at best, but in the emails and phone visits I have had with many men...most of the time not alot of research was done before making their decision. It comes from the attitude (including me) that your doctor knows what is best for your individual health. With my knee surgeries, skin cancer and including my lung problems, I had always followed the advice given by the doctor including any referals by doctors. It wasn't until the prostate cancer and having my sister with breast cancer at the same time that I even began searching for info. It started with the searching for breast cancer and the possibility of genetic association that I stumbled on the sites dealing with the complexity of prostate cancer. You don't have so much discussion or treatment options with other cancers as I know you are very aware of in dealing with your own multiple cancers. So yes...it is generalizing...but I think it was relevent to the discussion here.

Decisions are as unique as the person making them I think. Paul for instance; he wasn't a radiology candidate so that narrowed his options. He would likely have chosen surgery as a first option saving radiation for a rainy day if need be but, who knows? His age played a significant role in his choice as did the clinical pathology. Having so many treatment choices does make decisions more complicated.....

swim

David...part of where alot of this was from some news concerning a husband of one of my wife's friends at her work. He is young, 48 with PCa and followed his urologists recommendation for surgery without giving it anymore thought than that. He even followed the urologists recommendation at what hospital to go to. I am trying to get more info, but it appears that during the surgery, robotic I think, his colon and bladder were damaged. He has add at least 2 additional surgeries to repair the damage and is scheduled for another one in a week or so. According to my wife his stats were better than mine at the time of his original diagnosis. I don't have the full story, so there is more to this than what I have said, but the point was, he made a decision without researching the doctor, the hospital or the procedure and is now suffering terrible side effects. His wife is just now starting to ask questions...after the fact. Sometimes we men, tend to try to keep private our health issues and won't discuss it much with anyone especially strangers.

All I know, is if I had just followed my GP's recommendation for the urologist he referred me to...I probably would not have had the good outcome I had. My GP is new to the area and did not know about the reputation of the local hospital or the urologist he referred me to. Thank goodness I did know and I researched before making a decision.