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Firmly on the fence. Surgery vs. Brachytherapy

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Posted 9/25/2009 8:06 PM (GMT 0)
Tony:

The side effects of surgery can be used for and against the procedure. The way I see it, you don't know what you are going to get after the surgery. In our group alone, we range from zero incontinence from the moment the cath is out, to men suffering two years later and needing mechanical devices. Same with ED, we have men with high tech - big name surgeon - both nerved saved operations with total ED a year or two later, and people like me, and others, with one nerve taken, one left damaged, and no ED whatsoever. That's where the biggest gamble is to me when weighing out surgery as a primary treatment. And I am saying that as a surgery guy.

The real issue is cancer removal, what is best for that patient. And with the more agressive stats, surgery is the only thing that makes sense. With the lower numbers and lack of aggressiveness, there is more time and more options.

I have noticed that some advocating radiation type treatment first, sometimes discount the salvage advantage that you get with surgery first. I don't find that a small matter to consider, its major. By having surgery first, you still have a major treatment option in the form of salvage radiation to fall back onto if needed. And lately, its seems more and more of us are reporting re-occurance issues that we didn't expect.

I like to have a Plan A and B and C with most things. I am getting ready to use up my Plan B, and its only 10 1/2 months since Plan A was executed. Disapointed, absolutley, mad? Perhaps, but not sure who at. But thankful to have a Plan B to go to, and knowing if even that ultimately fails, there is still a Plan C.

With PCa, I still agree with most surgeons priority list: Cancer first, then Incontinence, then ED. In my personal life, I can live with that order, other men may feel different.

David in SC
Posted 9/25/2009 10:10 PM (GMT 0)
Tony,
There is always a chance that PC will return; there is a chance that we will get hit by a truck tommorrow. I think that once a patient gets past 10 years without a biochemical relapse the chance of a relapse is small regardless of the treatment. We all have a much greater chance of developing another cancer or heart disease after 10 years. There is plenty of 10 and 12 year data showing no difference in cure rates among treatment options for localized PC. Even robotic doesn't have a 20 year history the only options that do are open surgery and ERBT and no one does 3D conformal ERBT anymore. In our world of changing technology it is unrealistic to wait 20 years to get good data on a procedure. I firmly believe that in 20 years from now surgery and radiation will be looked at as barbaric treatments for PC replaced by treatments that have way less than 20 years of data to back them up.
JT
Posted 9/26/2009 5:42 AM (GMT 0)
John,
I challenge you to a sushi off. Here in Vegas or there in SoCal...We'll settle this, I promise.

Peace my friend...

Tony
Posted 9/26/2009 1:57 PM (GMT 0)
Tony: No surprise to you, I'm sure, is the fact that I don't buy your argument implying that brachytherapy must be inferior since there are no definitive 20 year studies.  IMHO, that's like saying that 15 years after the first heart, liver or kidney transplants that patients should not undertake the procedure because of the lack of 20 year studies.  Or, 15 years after seat belts were required in autos, that there was not definitive proof that they saved lives because of the lack of 20 year studies.  Medical science moves quickly my friend and if we waited for 20 year "proof" on every medical advance we would still be in the stone age. There are plenty of 5, 10, 12 and 15 year studies that offer convincing evidence that brachytherapy provides equal cure rates to surgery.  Even the renowned uro-surgeons like Walsh understand and admit the equal effectiveness of this treatment. Again, IMHO, there are two valid reasons that an early stage PCa patient should choose surgery over seeds and/or radiation: 1.  Medical reasons.  That is a super large prostate, morbid obesity or physical condition a la David in SC that would prohibit the procedure. 2.  Phychological reasons.  That is the need to "get the cancer out". I think the other reasons often cited by uro-surgeons are a bit weak.  For example, having the opportunity for salvage radiation after a failed surgery.  As JohnT has pointed out numerous times on this forum, salvage radiation is only effective if the reoccurrance is local...and most are not.  That's why the success rate for salvage radiation alone is low.  And, if radiation had been selected as the primary treatment to begin with, there miight not have been any local recurrance. Modern radiation plans radiate in high dose the prostate bed and the entire prostate killing any stray cells in the bed or in hard to reach areas such as around the ureatha and seminal vessels. Radiologists believe this gives a better chance of eliminating positive margins and local reoccurrances. Anyway, I guess we will continue to agree to disagree.  Although I know we agree on one major point, i.e. that this sort of debate is healthy and probably helpful to the new patient. Tudpock
Posted 9/26/2009 2:39 PM (GMT 0)

Greetings, all.  I have tried my best to stay out of this but find I need to add my 2 cents worth.  That's probably all it's worth - afterall, as has been stated here I am nuts (as are all of us who chose surgery).  My friends and business colleagues have known that I am nuts for some time but it is good to have one of my brothers here confirm that so plainly for all of us.

There are several treatments options and I firmly believe they are all valid.  Different people should and will choose different treatment options for many, many different reasons.  If you do your research and then choose brachy, radiation in its many forms, surgery in one of its several forms, or even watchful waiting, you can find valid evidence to support your decision.  You make your decision and move forward with confidence. 

I chose surgery based on the recommendation of my urologist after we talked about the options.  Keep in mind my urologist is not a surgeon nor a radiation doc.  He told me upfront that whatever option I chose, he would have to refer me to someone else.  He told me that if we looked at the 10 year studies for all treatment options, they are basicaly the same.  However, when you go beyond 10 years they start to have differences.  I am aware that some of the other treatment options have not been available as long so that tends to skew the studies.  I factored that all in.  When I looked at everything, at my age I chose surgery. 

Even thought I firmly believe surgery was right for me, let me very clearly state that surgery is not right for everybody.  There are many guys that one of the other options is very appropriate for and that is what they should choose.  However, please take that advise with a grain of salt - afterall we all know that I am nuts!  yeah David

Posted 9/26/2009 2:51 PM (GMT 0)
Bro. Tud,
This kind of debate is always helpful to the new and the experienced, just needs to be kept on a civil tone like it is now. Not a "you are wrong and I am right" mind set.

You last post kind of made me feel bad, because you bring up some good points. I was not suitable candidate for seeding, though I originally wanted it. If I hadn't been so messed up by my 2000 radiation experience in my neck/throat, might have been willing to think through IMRT as an primarty treatment last year. So with my stats and PSA velocity, it was all too easy to get into the surgery mode.

In hind sight, a strong primary treatment of IMRT might have done a better job on me, and knowing that bothers me. Been through a hell of a time since surgery, won't repeat all that here, only to have my surgery fail in its prime purpose of eradicating the cancer, less than 6 months from surgery. Now I am having to do IMRT as salvage starting a week from now, and I am no fool, I know I am looking at best, a 40% chance of sucess, and that is if it still local, which is the great unknown. My new rad. oncl. is honest enough to level with me, that with my pre and post surgery psa velocity issues, this might not work.

If it doesnt, I will have been put through a lot of hell with major surgery, at least 3 corrective surgeries, and now radiation and its side effects all for nothing.

What you write, JohnT too, and some of the others, should be read and considered strongly by anyone new here, either pre-dx, or post dx, before they make that first critical desision.

As a closing note, I was told at the time that radiation probably wouldnt get it all, because of my stats/velocity issue, still might be true, but was told that by a surgeon, not a radiation oncologist.

Keep writing what you write. Can't help me, but still can help the endless line of new people that make their way here.

David in SC
Posted 9/26/2009 3:13 PM (GMT 0)

Dear CPA:

"Nuts" is what is known in the trade as exaggeration for effect.  I certainly did not mean it literally and apologize if it offended you.  I will re-state my position in a more politically correct yet no less controversial manner:  I personally believe that brachytherapy and/or a combination of brachy and other radiation is a better choice than surgery for early stage PCa patients who are eligible for either procedure.

When I first came to this forum, I felt it was a close call betweent the two and it was a close call when I made my choice.  After spending almost a year here and reading countless heartbreaking stories about the aftermath of surgery, I have hardened my position and believe it even more strongly.

David, of course you know I would never want you to feel bad from one of my posts.  I grieve for your situation like many of us here do.  You are one of the ones who really can't look back because your choices were limited from the get-go.  My commentary is aimed only at those who have unlimited choices...

Respectfully,

Tudpock

Posted 9/26/2009 4:09 PM (GMT 0)
Tony,
A sushi off would be great. Not very good sushi in Idaho this time of year (trout sushi is not my favoriate) so I'll be looking forward to some very expensive Toro, especially is someone else is footing the bill.
Tud, I'll start to put together resourses so we can have a standard Brachytherapy post for the new guys; I'll send it to you.
JT
Posted 9/26/2009 4:16 PM (GMT 0)
Tud, you didn''t make me feel bad, but the truth of your words did, perhaps more sad and bad. Being lt unemployed, limited to the confines of my wife's health insurance (thankful for that), living in smaller populated area - not a large urban area with more rescources, the choices aren't always equal for us all. No one can do anything about that part.

Trust me when I say this, I only want the truth in these situations, and it that hurts sometimes, or causes sadness or reflection, then so be it.

I pity more, the guys that come to us that are in full denial, or think they can tough their way out of PC, or wish it away. Knowledge does displace fear. Ignorance isn;t a crime, just means you don't know something, stupidity is when you are shown the truth, and you refuse to acknowledge it. Two different things.

Your original post was dead on, that's all that matters.

David in SC
Posted 9/28/2009 7:20 PM (GMT 0)
Klaats , I find myself in the boat over choosing between BT and Robotic Surgery.  In my case I leaning 80% BT versus 20% surgery. As I see it the "burden of proof" falls on surgery since it is the harsher of the two.   Surgery has immediate ED and incontinence side effects that may or may not improve over time.   So my thinking is that surgery has to have superior outcomes in order to be the preferred choice. However, I’m still not 100% sold on brachytherapy over surgery.   I can’t yet overcome the following issues: ·          Surgery is considered the gold standard for treating prostate cancer. ·          I hear that young patients should be treated by surgery. ·          It is said that surgery has a better cure rate because salvage radiation treatment is available. ·          I’ve read that there is no 20+ year brachytherapy data.   Thus surgery is best for patients with  20+ year life expectancies. ·          My urologist believes surgery has about a 5% higher cure rate. In addition, I don’t have a definitive answer concern whether surgery or brachytherapy has a lower long term sexual side effects.   I get different answers from various sources.   My urologist claims that while surgery is worst in the short, after five years, it has better ED results than brachytherapy. Klaats , what did you think about Dr Moran?  While my local BT team in Omaha is experienced, they do not specialize exclusively in BT.  I've contacted the Seattle Prostate Cancer Center, but Chicago is a lot closer to Omaha.  I'll travel for BT if I'm convinced the out of town guys are really better.
Posted 9/28/2009 7:29 PM (GMT 0)

Hey Everyone:

I've been busy settling my oldest at college but I've been lurking and I am more than happy to answer any questions directly related to Brachytherapy.  As you can see from my signature we chose it several years ago now - hard to believe - and never looked back.

For the couple with a small child - I understand your concerns but there are options.  You cannot have a child sit in your lap for extended periods of time but if you're overly concerned believe it or not your hospital should be able to lend you a pair of lead underwear - yes you read right - lead underwear.  They are worn over the regular underwear and provide an extra layer of radiation protection if you have or are around small children.  We borrowed them to be on the safe side and they're not as bad as you're imagining.

As many of you know, I fully support my husband's decision to choose Brachytherapy as his treatment of choice and the results have been solid for us and we're happy to be moving along and enjoying life again. 

If anyone has any specific questions, I'm more than willing to share our experiences - no holds barred.

JustJulie

Posted 9/28/2009 11:26 PM (GMT 0)
Nebraska Guy,
Let's take your points one by one:
Brachy Cure rate for low risk factors: Prostate Cancer Foundation of Chicago, 11 years; 96%
Cleveland Clinic, 11 years; 96%
MSK; " 5 year reoccurrance rates similar for surgery, Brachy and IMRT"
Seattle Prostate Institute; 10 years, 97%
Who says surgery is the "gold standard"? Urologists that are trained as surgeons. How can surgery be 5% better when the cure rate for seeds is 96+%. Your Uro is pulling numbers out of his hat.
Salvage radiation only works because of two reasons: 1, the surgeon didn't remove all of the prostate tissue (they can never get it all) and that tissue contains pc cells. 2. the PC has escaped the gland and is in the prostate bed. In both of these cases radiation does a better job at the margins. The typical radiation margin is 10mm to 15 mm to the bed and also gets all the PC at the difficult ureatha margin. What most people don't know is that a 2nd application of seeds of a different isotope for a salvage procedure can be performed if PC is still local. (Dattoli).
There is no 20 year data on Brachy; there is also no 20 year data on Robotic. Only open has 20 year data.
There are some experts that believe that surgery is more effective for younger patients, but no evidence to support it. The slight advantage, if any, is more than offset by quality of life issues.
Some other facts:
There has never been a recorded instance of hospitalization required for complications during the brachytherapy procedure. (Grimm)
For patients with no ED issues before procedures; Boston Study 36 months after (Normal, Intermediate, Poor).
Non Nerve sparing surgery: 6% 31% 63%
Nerve sparing surgery: 8% 28% 64%
Brachytherapy: 46% 35% 19%

There is a lot of information out there on Brachytherapy if one searches. Hope this helps in giving you more information. If you need the source data feel free to e mail me.
JohnT
Posted 9/28/2009 11:40 PM (GMT 0)
Nebraska Guy,
I was quite impressed by Dr. Moran. He's probably done as many BT as anyone in the country and he's good and he knows it. Almost TOO confident. Also impressed that he had me send my slides to NY for a new test procedure called Aureon that is so new that the really knowledgeable guys on this forum hadn't heard of it.
I'm feeling better and better about the seeds and I think deciding on ones route may be a good part of the battle. There is no sure cure and the success rate seems to be close on robotic and BT. I think doing a bunch a research and then feeling confident with what you choose and comfortable with your Dr. is maybe more important than the method itself.
Posted 9/28/2009 11:53 PM (GMT 0)
My oncologist who is neither a urologist or radiation oncologist says surgery is best. He is in line with Scardino, Myers, Walsh (he is a urologist), and others, who say that they believe that surgery is the best starting point for most PCa cases that can still realize a local cure.

"There is no 20 year data on Brachy; there is also no 20 year data on Robotic. Only open has 20 year data.
There are some experts that believe that surgery is more effective for younger patients, but no evidence to support it. The slight advantage, if any, is more than offset by quality of life issues."

Robotic devices have been used for over 20 years. Like brachytherapy they have improved greatly. Physician skill is more important than open or robotic. But an extracted prostate is what is done. Both do it equally as well with a great surgeon. On the "no evidence to support it" part, surgery is the ONLY local therapy that has successful 20 year data. There is no evidence to support radiation is better. But there is 20 year data on radiation. But we don't need to discuss it because 20 years ago EBRT had devastating results.

This debate can go on and on. Please start that thread that shows that brachytherapy is as good or better than surgery. I hope you will allow me to post counter point on it. On this thread, Klaats subjectively asked why someone would decide on surgery. My answer was very correct.

Tony
Posted 9/28/2009 11:59 PM (GMT 0)
Tony,

I think your point and the logic leading up to it is in the right direction. All 3 radiation oncologist I consulted with before making my decision for SRT had looked at the details of my case, and all of them agreed that surgery was the correct first step.

David in SC
Posted 9/29/2009 12:22 AM (GMT 0)

Dear Nebraska Guy:

At the risk of being labeled as over zealous re my advocacy of brachytherapy, I will keep this post short.  Needless to say, I agree with JohnT's most recent post on this.  I would also encourage you to scroll back through this thread to read my other postings on this subject.

The bottom line for me is that brachytherapy offers equal cure rates but with a huge advantage re quality of life.  As I stated before, I have hardened that view after reading the many heartbreaking stories on this forum about the aftermath of surgery.

And, Tony, master uro-surgeon Walsh also includes the following in his book when discussing cure, "...multiple studies have shown similar results for both brachytherapy and radical prostatectomy".  Also, JT and I will probably get that thread started in a week or so.  I'm travelling this week so won't have much time...

Tudpock


Posted 9/29/2009 1:32 AM (GMT 0)
I look forward to it. You guys know a lot about it and we need that thread...

I referenced the Walsh book just now, and I will finish that paragraph later...

Tony
Posted 9/29/2009 1:35 AM (GMT 0)
After reading the board for about 6 months now, I really wonder if the choices available confuse the issue and reinforce the "prostate cancer will not kill most people " argument.   They all seem to work, I don't see one as best. I think maybe we are splitting hairs on the 20 year rate.  So pick the one that after your research seems best for you.  I see it as a good thing to have options.

I am sure most of you like I have become the local expert for the housewives questions when their hubby comes in high PSA.   My advice has been, there are several good options available and if you act in good time you should have no problems.  Just don't ignore it.

Posted 9/29/2009 2:01 AM (GMT 0)
For the most part you are straight on. 20 year studies is something for the under the median age of 64 guys almost exclusively. This is the challenge I have been stuck with. Not being able to analyze data beyond the former standard study period of ten years. I don't believe that studies should ever end. With PSA screening bringing a host of younger patients, many advanced like myself, it shows a real need for extended data.

Tony
Posted 9/29/2009 2:11 AM (GMT 0)
Tony, I agree. In our own lil PC world here, look how many under 60 men we have and especially under 50 men. PC has been around a longtime, would love to see some longer study groups as well.

In my local area, I have met a man that was recently dx. with a strong gleason 8, PSA above 20, debating his limited choices right now as we speak. He is 36 years old. No family history of PC or any other cancer. A ten or even 20 year study of odds isn't as enticing when you are only his age.

David in SC
Posted 9/29/2009 5:05 PM (GMT 0)
I’ve been digging more into brachytherapy and doctors.   I am quickly finding out that not all BT procedures are the same.   Different techniques and technologies are use by various doctors improve the quality of seed implantations.   The goal is to assure the cancer gets nuked while avoiding collateral damage to the surrounding areas (rectum, urethra, neurovascular bundles, penile bulb).   Here’s a list of the techniques and technologies I am finding: ·          Pre-planning, intraoperative planning or interactive planning ·          Peripheral loading of seeds to reduce urinary symptoms ·          Different seed isotopes ( Iodine & Palladium). ·          Seeds connected together to prevent seed migration. ·          Advanced imagining technology to plan and guide seed implantation (color doppler & Prostascint/MRI image fusion) ·          Nerve Sparing Brachytherapy (what a marketing term) Now it looks like I have to wade through this stuff to find a superior doctor who can provide me the best odds for a successful outcome. BTW, if you Google Stephen W. Doggett MD you can read about much of the stuff I listed.
Posted 9/29/2009 5:56 PM (GMT 0)
If it helps any I can offer this information:

My husband participated in the "stranded" seeds - 91 of them - of the Iodine variety

Posted 9/29/2009 6:24 PM (GMT 0)

On the subject of BT, I found a contradictory statement in the “Johns Hopkins Health alerts Guide to Brachytherapy”.  They said “Because brachytherapy alone could be associated with a lower chance of a cure and a somewhat higher rate of complications than external beam radiation therapy, external beam is still considered the gold standard of radiation treatment for prostate cancer”.

I haven’t seen any other claim the external beam radiation therapy is clearly superior to BT.  The local radiation oncologist I consulted with recommends BT over beam.  He performs both BT and IMRT treatments.

Is John Hopkins wrong about this?

Posted 9/29/2009 6:29 PM (GMT 0)
We concur that Brachytherapy was suggested over external beam
Posted 9/29/2009 8:24 PM (GMT 0)
Many centers are now including IMRT to go along with BT, this is usually in high risk cases. There is no scientific data that says IMRT is better nor vice-versa. The philosophy is that because of high risk or suspected leakage, that BT will not work alone and radiation outside the interstitchal areas will improve results and take advantage of both therapies. You can find consistent information at multiple centers, including Proton centers, that adding the less precise IMRT has it's advantages.

Keyword: high risk

Tony
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