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PC in my 40s - What treatment to choose?

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Posted 1/31/2010 7:13 PM (GMT 0)
My doctor mentioned "analysis paralysis" when doing research and it can be a dizzying, winding road of info. Every day since DX my opinions have changed. One thing this thread has taught me is that BT as a first choice and surgery as a simple fallback option is not as reasonable as I had thought.

On the subject of BT, I have yet to understand the definition of a true "cure." Is BT "cure" defined as 10 years post radiation with average psa levels consistenly .02 or below? And is it conceivable that you could go a good 3 or 4 years of low PSAs after BT and then suddenly PSAs rise as the beast rears its ugly head once again?

I guess the larger question is does BT give you a sort of "life sentence" whereby the threat is always out there as opposed to removal where the potential for closure seems more clearcut?

Thanks
Posted 1/31/2010 8:26 PM (GMT 0)
Truth be told, the threat is out there for all of this, no mater what treatment choice we make.

If a couple of cells make it outside of the prostate, and go set up house somewhere else, you can get adenocarcinoma. technically not prostate cancer I guess.

A cure is expressed as no reocurrence in 10 or 15 years. For most of us older duffers, that is getting close to life expectancy.

It is a wicked little disease. But there are no guarantees as far as no cancer.

Take your time, find an option you are comforatable with , and go for it. Truly, all of the treatment options are pretty equal in curative terms. Side effects are a potential for all options, but BT has some of the fewest immediately after the treatment. There is a lot of discussion about long term effects, but like surgery, some have it , some don't.

Good luck. My advice is to find an option, go for it , and don't look back.

Goodlife
Posted 1/31/2010 9:14 PM (GMT 0)
You've got the idea Scully! Any recurrence is a drawn out demise. In my instance I chose to get rid of the source and hope that path report was clean, but it had a small smudge on it, so I did rad. Hopefully that's the last time I ever hear from those prostate cells that lost the programming to die off to make room for new cells, again.
Posted 1/31/2010 10:12 PM (GMT 0)

Hi Scott:

I will try to answer a couple of your questions and comment on your last post...JohnT may also come along with some BT specifics that you may find helpful.

1.  With ANY treatment, BT, surgery or whatever, the beast may rear its ugly head years later.  There are no guarantees, only statistics and probabilites,  With your stats both BT and surgery SHOULD cure you...but you will never truly know.  That is I don't think the "life sentence" is different with any treatment...you hope you have it cured but you keep testing over time to be sure.

2.  The .02 figure you mention with BT is not relevant.  With BT each man is different and each of us is expected to reach a nadir (low point) for our PSA.  It may be near zero or somewhat higher...after all, we still have prostates so it is not surprising to have a PSA score.  The cancer is deemed to recur when you get 3 straight increases in PSA level.  At that point, salvage treatment is probably recommended.

3.  Don't worry at this point about being paralyzed by your analysis.  If you were diagnosed on 1/10 then you are new very new to the process.  You most likely have plenty of time.  After I did most of my research I booked both surgery and BT, then took a month in Florida to relax and reflect...then cancelled the surgery when BT became my choice.

4. You mentioned doctor...in the singular.  If you have not visitied a radiation oncologist and prostate oncologist in addition to your uro-surgeon you have not done your homework yet...IMHO.

5.  If you want to get some good BT info, I can suggest www.dattoli.com.  They are a well known and experienced radiation center and their web site can help answer a number of your radiation qustions.  I understand that they also have considerable experience treating PCa in younger men.

Hope this helps.

Tudpock

Posted 2/1/2010 12:09 AM (GMT 0)
Scott,
The American Society of Radiation Oncology (ASTRO) sets the standard for determining a relapse after initial treatment using any form of radiation for prostate cancer as the lowest PSA after initial therapy plus a rise of 2.0 points. If this occurs, the disease progression is backdated to the first PSA test that started the upward trend after treatment. Some radiation oncologists will decide a relapse has taken place after 3 consecutive rises in post treatment PSA tests.

This is as opposed to post surgery definition which uses the ASCO/AUA standard(American Society of Clinical Oncology/American Urological Association) where relapse is defined as PSA equal to or greater than 0.1 on the standard PSA tests , or if using ultra fine PSA tests, three consecutive rises above post treatment if PSA has not risen to 0.1 yet.

Most oncologists agree that the sooner you treat prostate cancer after relapse, the better the survivability. Scientific studies lack sufficient data to prove this correct or incorrect. More long term data, over longer periods than current studies use, is needed. Cryo-therapy and HIFU centers typically use the ASTRO definition for defining a relapse. Not surprising since most HIFU/Cryo doctors are radiologists.

Tony
Posted 2/1/2010 2:24 AM (GMT 0)
Hi Scott,

I had my laproscopic robotic surgery on 1/6/10 to remove my prostate. I chose this because the way it was explained to me from doctors in Boston ma. was that a guy my age 43 jf I was to do radiation and needed later in life to take care of the situation again that the scar tissue from radiation could make it very difficult for prostate removal. As far as ED as far as the doctor says radiation you start off as normal and it works down to lets say 80%. Removal starts off a 0% and works its way to 80% so they start off at opposite ends of the spectrum and end up at the same place. I am only 3 weeks out and I do get feelings so I am very optimistic. I got my catheter out on 1/19/10 I am finding good results 12 days post catheter from 5 or 6 pads a day to currently 2 per day. A positive attitude I believe helps and kegel exercise help also. As far as watching and waiting I just could not in my mind wake up every morning and wonder what the cancer was doing. I wanted to take care of it while I am young and healthy. My 1st and 2nd opinions agreed with each other so I got it done.

Thanks Ron

Age: 43
GLEASON 3+3=6
P.S.A. 3.9
Biopsy 1 out of 14 positive (left quarter)
pathology report came back negative
2/11/10 getting P.S.A. numbers
Posted 2/1/2010 5:11 AM (GMT 0)
Ron,
For the record, you would not have qualified for watching and waiting by recent guidelines. I understand why they agreed on it. I was age 44 when I was diagnosed. But my numbers indicated I needed to do something far more definitively.

Welcome to the site. We look forward to your strong recovery.

Tony
Posted 2/1/2010 5:37 PM (GMT 0)
Scott, Read my threads which are fairly short or Tudpock's for much more detail to get a good sense on BT. I'm "young" too compared to many here but no where near as young as you. I went all over the map when first diagnosed but eventually locked into BT and, so far so good though it's very early. It sounds like your numbers are somewhat similar to mine (one core, 3+3 etc.) so you certainly owe it to yourself to talk to more than just uro surgeons. No one can sensibly tell you FOR SURE what to do but immerse yourself in research, talk to your loved ones, don't rush and go with your gut.
Peace and feel free to email me off the list if you want any more info.
Jay
Posted 2/1/2010 6:48 PM (GMT 0)
Scott -

I am also a recent BT guy like Klatts and have held off on commenting on this thread since I'm a whole lot older than you (and I do think your age makes a difference on what you decide is important  to you) and the fact that I can't add much to the advice and comments you have already received......except for this: be ready for the fact that a urologist will lean toward surgery (Rad or robotic) and a radiologist will lean toward BT, RT or Proton therapy depending on his/her affiliation. If they are really good, they will tell you that you should explore other options with your stats. (My urologist was honest enough to tell me that if I chose robotic surgery, he would recommend me to someone else....he preferred doing open for a number of reasons which he shared with me.)

You may want to talk to at least one (or more) oncologist who might be more objective. I confess that I did not do that....it only occured to me after spending some time on this site. That said, I am very comfortable with my choice after thinking about all the options, their ramifications and side effects. In the end, that's where you will end up....doing what feels right for you based on what you have learned.

Joe 

 

Posted 2/1/2010 6:50 PM (GMT 0)
Scott- Sorry -forgot to add my stats. _________________________ Age -67 PSA - 4.5 Biopsy   (9/4/09) - Positive in 5 of 8 cores. In those 5 cores, 5 of 11 samples were positive. Gleason 3+3=6. Stage – T1C   Ct and Bone scans negative   BT performed on 12/11/09. 84 seeds of Palladium 103. Surgery at 7:30 - Home at 12:30 same day with no catheter. Side effects as expected -  some burning, frequency, urgency. (Blood in urine stopped after 1 week).   Resumed daily   1 ½ mile walk after 3 days.   BT will be followed with 25 IGRT treatments beginning Feb 8.   
Posted 2/2/2010 10:43 PM (GMT 0)
Scott,
There is more to just a cure in searching for a treatment option. Side affects and quality of life are also part of the decision and to what extent depends on your personal outlook. All the data out there shows that for low risk PC all treatments result in the same cure rate. Surgery has some longer term studies, but that's just becasue it has been around longer; not necessarily because it is more effective.
The side affects of Brachy both short and long term are much less severe than surgery. If cure rates are the same, then to me it's a no brainer to pick the treatment with the least amount of side affects.
The chance of a reoccurrance is small with low risk pc and if it does reoccur the chance of it killing you is very rare.(only 2% of patients with low risk PC ever die of it and these are usually varients that manifest quickly). You cannot control the chance of a reoccurrance with the treatment option you choose; you can only control the side affects and the quality of the doctor you choose. The skill of the doctor will have much more impact than the treatment option.
You will hear a lot of opinions, but the facts on low risk PC are very clear and should not be mistaken with other forms of PC which require more agressive treatment and corresponding worry about reoccurrances.
JT
Posted 2/2/2010 11:53 PM (GMT 0)
Thanks for the insight, John. Everyday I think I have the answer and then I keep digging for info and something else will surface.

My thought of late was because of my age (43), I stand the best chance for recovery from removal with minimal side effects in the short and long term. Granted, everyone is different. I keep having this nagging feeling of going the BT route and stressing a new psa test every 3 months for the rest of my life...i.e. "Is this gonna be the one that doubles?" And, then my options for surgery have been drastically compromised from the radiation.

My doctor made the analogy: You're buying life. Do you want to pay by cash (removal) or credit (radiation). With credit, you never know when the interst rates will rise and you always have that debt hanging over your head.

As I said, I've ping-ponged the past 10 days between BT to Prostatectomy back to BT and have been on Prosta for the past 4 days in a row. I realize I have low-grade PC, but I still don't want to take it lightly.

Still crunching data. Thanks for taking the time to opine.
Posted 2/3/2010 12:35 AM (GMT 0)
Sully66: I know you are fighting the mind battle as to which choice is best for you. Looks like you are doing your homework. You will come to a decision and when you do you can never look back. Best wises. All of us have had that same battle with our Dx. The good part is that with you 3+3 you have some time to make the decision.

Do keep us posted.

Jeff T
Posted 2/3/2010 12:35 AM (GMT 0)
Scott:

Sorry to be blunt. But I hate to break the news to you, you’re going to be stressing over PSA tests from here on out. Mine are every six months, not three by the way. Once again, sorry to be blunt, but if my Uro had hit me with an overt emotional pitch like:

“You're buying life. Do you want to pay by cash (removal) or credit (radiation). With credit, you never know when the interst (sic) rates will rise and you always have that debt hanging over your head.”,

I’d have run for the door. Oddly, my Uro (who would have been my surgeon) said he’d opt for radiation if he had stats like mine (see below).

Best of luck with whatever path you choose.


Paralleli
Posted 2/4/2010 2:26 AM (GMT 0)
Scott,

Take your time and meet with each Dr for each possible procedure. My initial urologist couldn't wait to get me in the following week and cut me open. He attempted to scare me (and wife) into the 'if you don't do it now, it may be too late' thinking. We made an agreement (the wife and I) that we would take 6 months to research and meet the Drs. I went to MD Anderson to discuss radiation types. Spoke to another Urologist about a prostecmy. Went to the leading Dr on cryotechology (who happens to be in FL) and spoke to a new urologist about the robotic surgery. I then made a list of the pros and cons of each. One thing that may be true or not is if an area in the body is radiated, it is difficult to have surgery as the cells may not heal and could cause major complications.

I finally decided on the robotic. There is a great Dr here who treated me well and continues to do so. The expert in robotic surgery moved his research and practice from OSU to FL last year. (he didn't do my surgery, but trained the Dr that did)

You have to decide what is right for you and your family. If you get a chance, read "It's not about the bike" by Lance Armstrong.

Best wishes

Aaron
Posted 2/4/2010 4:47 AM (GMT 0)
Scott,

I haven't posted in awhile, but your similar stats compelled me to chime in. You have gotten some very good advice here. I ultimately chose robotic surgery, but had I to do it all over again, I would have:

1) investigated color doppler imaging to get a better understanding of the staging.

2) considered proton radiation more seriously

3) studied the TRUE statistics about continence after surgery. You will have to do some searching, but there were some recent sobering statistics from us surgery guys on side effects such as leaking. Ask your surgeon HOW he defines continence. No pads? Three pads a day? etc.

4) not been in such a rush to do the surgery quickly. Although I waited the recommended time after the biopsy to do the surgery, the prostate turned out to be still inflamed, which complicated matters.

That said, I had a tremendous outcome which I attribute to a top-notch surgeon, relatively young age, good health, and a bit of luck. Other than the "dry" orgasm (which is a natural result of having the prostate removed or destroyed by radiation) I wouldn't even know anything about my body had changed. If anything, orgasms are longer, and I "bounce back" after sex quicker.

I would also recommend that you honestly consider your personality in chosing a treatment. For me, getting the final pathology of a surgically removed prostate was important.

CaPCa

Posted 2/4/2010 2:12 PM (GMT 0)

Scott...you keep mentioning "doctor" in the singular.  It is natural that your uro-surgeon will push you toward surgery with that cash vs. credit nonsense.  You have to make the decision, of course, but IMHO you are shorting yourself if you do not consult a radiation oncologist, a prostate oncologist and get a color doppler assessment.

Tudpock

Posted 2/4/2010 2:56 PM (GMT 0)
I agree with Tud, at the very least, aside from talking with your uro or uro/surgeon which is often the combiniation, at least talk to a good radiation oncologist and get the entire take of radiation as a possibility in your case, including regular RT, Seeding, w/ and w/o additional IMRT. You owe it to yourself if your stats and criteria would meed a less invasive primary treatment.

David in SC
Posted 2/4/2010 6:02 PM (GMT 0)
Actually, I have consulted now with a radiologist and oncologist who both, to my surprise, said that at my age and fitness level surgery would be their reccommendation.

BT success really only maps a relatively recent timeframe of about 15 years. And since so much of the statistics for BT focus on men at least 10, usually 20 years my senior, there's really no empiracle data I can find that says, if 43 years old and treating with BT, you have an X% chance of living without prostate-related cancer reoccurrance for 25 years. So to say that BT shows a high percentage for a 15-year success cycle sounds fine if you're 60> but a little scary and short-sighted if you're looking a good 40 years of clean health.

It has also been enlightening reading the posts of the early 40-somethings on this board (thanks to CaPCA, Aaron, Woodguy5 and the rest for your insightful takes). More research to come, but I'm strongly leaning toward prostatecomy every day and feel that my age and force of will (I was the editor of Hustler, ironically, for many years so I have quite the stimulation practice) will help me quickly overcome the short-term SEs.

Also being a more A-type person, I hate clutter and jobs half finished. BT feels that way to me, and I would rather remove the demon, pay the piper in the short term for what hopefully will be long-term positive results. With any luck, I hope to know before my 60th B-Day that I have kicked this ******'s ass.

Please keep sharing. I really appreciate everyone's help.
Posted 2/4/2010 11:09 PM (GMT 0)
Hi Scully,
I'm a little surprised by your radiologists recommendation, but not entirely. Most RO's won't be completely forthright about these things about treatment modality history. I believe what your RO told you is correct and he has done a great service to you. What he has told you has been my mantra for two years. I had to talk to many RO's, surgeons, and oncologists to arrive at what I suspected, however. All treatment modalities can have a success rate. And radiation is great for the median age of 64 in most prostate cancer cases (exception is the high risk cases). I was 44 when I set out on this journey, and I had a radiologist at a multi-faceted treatment center tell me the same thing. Younger guys usually recover better from surgery, have excellent long term results, and have a better fallback plan if it ever becomes needed. Unfortunately I needed those fallback plans, but I had a pretty good idea of than when I set out with a PSA near 20, Gleason 7 cancer. And even with an advanced case I have continued to string the zeros.

But you are only halfway there. If you finalize your decision with surgery, your next decision is critical. Don't choose a doctor because he is convenient. Choose the best one you can get. Don't worry as much about robotic versus open. My surgeon was well known and very good. Everything works, even after the additional treatments. There are no guarantees with any doctor, but heavily improve your chances of success with the top surgeons...Community doctors can be good, but you will have a hard time telling the difference between the great ones and the average. Good luck on this. Where are you located?

Peace,

Tony
Posted 2/4/2010 11:57 PM (GMT 0)
Thanks Tony. I'm in Los Angeles, CA.
Posted 2/5/2010 4:59 AM (GMT 0)
I had my surgery in the area. I didn't like my options in the vegas area, I have lot's of family down near Laguna Beach. My choice was the City of Hope. Kawachi and Wilson (my surgeon) are terrific. But UCLA and USC both have great surgeons as well. I also head good things about the head of UCI in Irvine.

Good luck in your call, you should stop in one of these sites...

Tony
Posted 2/5/2010 6:18 AM (GMT 0)
Since you are in Los Angeles, I would recommend you get a Color Doppler ultrasound test because there are a couple of doctors who are very proficient at doing the test in your area. Learning just how aggressive your cancer is will certainly help you in determining how quickly you should seek treatment. Keep researching and keep your mind open to all options.

Best of luck.
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