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Just curious......brachy question for the young guys (or anyone else)

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Posted 4/14/2010 11:01 PM (GMT 0)
I'm just curious as to what the reasons were that made you go with surgery vs. brachytherapy.  From everything I've been reading, it looks as though the 10-15 year disease free survival is similar for both RP and Brachy, so I'm jus curious as to why more men don't choose this as a treatment option.....even the very young ones.  Obviously, many people aren't eligible because of their stage/grade.

Thanks for your input! 

Posted 4/14/2010 11:16 PM (GMT 0)

Read the fifth paragraph from the end of this article that IdahoSurvivor posted in another thread an hour or two ago:


www.pcf.org/site/c.leJRIROrEpH/b.5936977/k.FBA4/Is_robot_prostate_surgery_best_for_quality_of_life.htm

Zen9

Posted 4/15/2010 12:07 AM (GMT 0)
Wide consensus exists (although not universal consensus) that radiation therapy (any radiation) as first-line treatment for PC is a good choice for the older guys. Younger guys should recognize that their is a decent chance of having to deal with "latent issues" from the radiation in their lifetime if they go that route...and dealing with it later can be messy.
Posted 4/15/2010 12:39 AM (GMT 0)
Casey:

 

Rather than "consensus", I would personally characterize this as a paradigm espoused by surgeons and perhaps continued by robotic surgeons who are anxious to amortize their considerable investment in their new toys.  The current conventional wisdom on most current forms of radiation is that the side effects are likely to manifest themselves with the first 2-3 years and....those side effects are likely to be considerably less onerous than the side effects from either open or robotic surgery.  Of course their may be "latent" issues with both surgery and radiation but we should probably focus on the bulk of the curve.

 

One of the other reasons that people have given that promotes surgery for "younger" guys rather than "older" guys is that the cure statistics for modern brachytherapy only go back about 15 years vs. 20+ for surgery.  That argument was specious to me....in 5 more years brachy will "only" have 20 years while surgery will have 25...etc, etc, etc.

 

Finally, as JohnT has pointed out in numerous posts, the salvage options for brachytherapy are numerous and every bit as effective as the salvage options for surgery.  The fact that post seed surgery is not a particularly good option (IMHO) doesn't mean that there are not plenty of other choices as has been documented on this forum.

 

For me personally, the choice was fairly clear....but only after considerable study.  At the end of the day, the cure rates are similar and the SE's are considerably less.  Given that I had no psychological need to "get it out", the choice then became obvious.  I'm not saying it should be obvious to everyone but it sure was for me...

 

Tudpock

Posted 4/15/2010 12:50 AM (GMT 0)
I will tell you my line of thinking when I had a robotic prostatectomy at the age of 44. I was influenced by my doctor--my uro, although he did not really pressure me. I remember quite clearly when he told me that he would respect my decision and his office would provide the same level of professional courtesy and support afterwards for the long term, even if I went somewhere else and had something besides surgery.

My line of thinking (at the time, mind you) was that I was very young for prostate cancer, and I wanted something with a long, established track record. I was a little worried about the chance my PSA would rise later--if it did after surgery, I would have the option of radiation, but if I did radiation first, I knew that salvage prostatectomy, although done, was a very tricky surgery and there was a risk of very serious side effects. With decades ahead of me, I wanted to maximize my odds.

My PSA did rise after surgery. Would it have, after seeds? Maybe not, because the reason it went up was probably because of positive surgical margins. But who knows?

I had radiation, IMRT, as salvage. It was a walk in the park compared to my surgery, in terms of the experience itself and side effects. (I hated the recovery from surgery, especially the foley catheter. It was one of the worst weeks of my life. I know others have been through much worse, but still, for me, it really sucked) I have thought, since then, that if I knew then what I know now, I might have opted for some form of radiation as a primary treatment.

On the other hand, there was a recent study that showed an advantage to surgery for younger patients, in terms of PCa-specific survival: http://www.nature.com/nrurol/journal/v5/n1/full/ncponc1013.html

And, like the other poster wrote, any type of radiation confers some risk of secondary cancers. My IMRT has probably doubled my risk of bladder and colorectal cancer. The risk was very small, and still is, but still--I have decades for the effect of the collateral damage to cause me some other kind of cancer. When I met with a surgeon recently about a hernia repair (another fun leftover from prostatectomy) he suggested getting a colonoscopy sooner than later, because of my radiation treatments.

There are advantages and disadvantages to all the treatment options, and those pros and cons change with the age of the patient, IMHO.

Interesting discussion!
Posted 4/15/2010 12:52 AM (GMT 0)
I have been told by many doctors outside of the urology field that if there is a surgical alternative to radiation it is always prefered.  If you don't have to radiation in your body, don't do it.  I tend to agree with it.
Posted 4/15/2010 12:54 AM (GMT 0)
Well said Tud;
I think the reason that most patients have surgery is that the doctor that treats them first is a urologist with a bias towards surgery. The most recent data "The 2009 Prostate Cancer Study Group" composed of the top 25 doctors from all fields of treatments for PC reached the conculsion that Brachytherapy or a combination of Brachy and IMRT achieved better cure rates across all risk grades than surgery, cryosurgery and external beam only.
JT
Posted 4/15/2010 2:07 AM (GMT 0)
Hey, don't get me wrong, I think that brachytherapy is a good solution in the right situation, and when one generalizes it can be fair to say that there is no data which shows one treatment mode to be better than the other.  (Obviously, some patients evangelize their own personal choice.)

When you get past generalization, however, age is a factor which sways when radiation is or is not a superior choice...it's not the only factor, but it is one factor.

http://www.livestrong.com/article/52086-longterm-side-effects-prostate-radiation/

 

Posted 4/15/2010 2:22 AM (GMT 0)
I don't think there is a "consensus" on much of anything involving PC, either on this board or in the medical literature! There are statistics to back up almost any statement.

The problem is that few, if any, of the statistics currently available are worth much. That has been the conclusion of several recent meta-studies. It is a disgrace that a generation after the introduction of the PSA test, we still do not have multiple randomized double-blind studies that would answer at least some of the common questions.

The reason for this state of affairs is yet another thing as to which there is no consensus.

Zen9
Posted 4/15/2010 2:28 AM (GMT 0)
John T - Can you provide a link to the 2009 study/report you refer to?

Also, what research is out there on the incidence of secondary cancers among those who have radiation treatment?  I have seen references from time to time to increased risk for bladder, colorectal and certain other cancers, among men who have had radiation.  But I have not read studies evaluating this.  Anyone done this research?

 

Posted 4/15/2010 4:53 AM (GMT 0)
Hi MedVed,

I have a friend in his 70s, a practicing surgeon (ob-gyn) who I met with recently. He had also practiced with an oncologist as part of his medical staff. We were comparing notes, which I love to do, about our prostate cancer treatment experience in the last couple of years.

He chose radiation therapy because it was less invasive for a person of his age. He said radiation should give him enough years of remission where he would outlive any potential long-term side-effects or a biochemical recurrence.

He said if he were younger he would have chosen surgery for a good shot at a cure.

Barry
Posted 4/15/2010 1:19 PM (GMT 0)
kuls, As this thread nicely demonstrates, age is certainly a factor. You can see below what I chose at age 67 and for the same reasons as stated by others....similar cure rates to surgery, less onerous side effects, etc. If I had been 47 instead of 67, it might have been a tougher decision but I think I would still have chosen BT. Yes there is a risk of other cancers down the road....but there are risks associated with any major surgery also. If there was one thing my urologist made clear to me it was that a radical or robotic prostatectomy is major surgery. That said, I would never second-guess anyone's decision as long as they have done their due diligence before choosing a treatment....and it sounds like you are. Joe
Posted 4/15/2010 4:01 PM (GMT 0)

The Prostate Cancer Study Group 2009,

http://http://www.prostateseedinstitute.com/PCRSG_0409_Results.ppt#285,23,Slide 23

The summary of the study is posted on a seed site, but the original slide presentation was made at the PCRI Conference last year. You should be able to find the complete study on PUbMed.

It is very interesting to see who was on the study, Oppenhiemer, a pathologist, surgeons like Dr Carrol and oncologists. Pretty well spread out among all the treatment fields.

Secondary cancers and long term side affects are associated with the earlier forms of ERBT. These are extremely rare with Brachytherapy only, because the radiation effect is limited to about 1mm from the seed. There are exceptions in every case, but in general the short and long term side affects of Brachy are less than any other treatment, and in the majority of studies I have reviewed the long term survival rates are equal or superior across all risk catagories. There is a tendency to equate the affects of other radiation treatment to brachytherapy, but they are totally different. The radiation used is different and the delivery of the radiation is completely different. The above study points this out, but with the caution is that there will never be head to head blind studies and the best data we have is from retrospective studies where the pre treatment risk data is not well documented.

As Tony once pointed out, surgery combined with salvage radiation most likely has the same cure rates as Brachy or Brachy + IMRT. I calculate adding salvage radiation to surgery raises the cure rate by 6%. (20% reoccurrance rate X 30% success rate).

I can't help but thinking that if salvage radiation works in these patients with a reoccurrance after surgery then why would it have not worked better as a primary treatment as most likely the reoccurrance was in the bed or in left over prostate tissue that primary radiation would have easily killed.

A lot of the misconceptions about Brachy was the fact that there was no long term data and the earliest form or seed placements were crude. There is now good 15 year data and improvement of imaging has resulted in much more accurate seed placement and improved computer planning for the required dose and dispersion. There is still a misconception that brachy is not suited for higher risk cases, but all studies show that as long as the PC is contained in the prostate or in the bed it is very effective for high risk cases, and more effective for tumors in high risk locations such as the anterior or in the Apex which are problamatic for surgery.

JohnT

Posted 4/15/2010 4:46 PM (GMT 0)
At age 45 my decision to opt for surgery was based on long term , although I was confident that brachytherapy would give me the same 10 year outlook as surgery, I was for more then that. My father and two uncles have had PC so the genetics are against me. Although everybody was confident they could cure my cancer with seeds, no one could guarantee me that my normal prostate cells, which have the same genetic make up as the cells that have gone bad, would go bizerk and turn into cancer at 55+.

dx at 45
PSA 3.6
1 of 12 needle positive
gleason 6
T1C
RP 01/05/2010
Path report
gleason 6
tumour invloves both lobes, 35% of prostate
upgraded to T2C
cancer prostate confined,seminal vesicles neg, 1 focal margin
dry with no pads 8 weeks after surgery
progress on ED but still not there
Posted 4/15/2010 6:11 PM (GMT 0)
At 74 with zero medical issues other then PC (and a very large prostate) I chose the DaVinci robotic prostatectomy 2/10/10. Have not been sorry for a minute. While CT and bone scans found nothing 2 of 12 cores (biopsy) confirmed 30% and 70% / PSA 6.7 and Gleason 3+4=7 I didn't want to go through six to eight weeks of radiation which would have been more difficult for accuracy due to prostate size plus one area was near the urethra / bladder junction. While my nerve bundles and other associated components were saved, when the pathology report came back the cancer had made it to the outer surfaces of the prostate but not into the margins. Five week PSA was undetectable and I'm wearing no pads nights and mornings but do when I'm going to be gone for several hours for sneezes etc. Can also leak a tad if I pick something up over sixty or so pounds but day by day what little trouble I have with incontinence is improving even more. Cannot say enough about Henry Ford, their whole PC program and my surgeon Dr. Peabody.
Posted 4/18/2010 3:22 PM (GMT 0)

Thanks for all your input....definitely some great feedback!  It just goes to show what a nightmare this disease is as far as having to make decisions.  My husband had been leaning strongly toward having surgery, but is now seeming to heavily favor brachy as his treatment of choice.  He's repeating his PSA on the 28th, and we're meeting again with the Rad. Onc. on the 29th.

Initially, I didn't feel that Brachy was a good option for him at his young age.  I work in the field, but admittedly, I hadn't kept up with all the research for the last few years after going from full-time to casual, and after being off with knee operations for a couple of years.  After doing some reading, and discussing brachy with the Rad. Onc., my thinking has changed.  Here are some points that seem to be coming through in the most current literature that are making me feel that Brachy is a valid option.  I encourage and welcome any comments (pro or con)!

- There is virtually NO increased risk of developing secondary cancers post-brachy (one study quoted 1 in 300).  The dose fall-off from the seeds is very short, and improved treatment planning and intraoperative seed placement has greatly decreased the dose to the bladder and rectum (the two main areas for concern), while increasing the dose to the prostate with improved accuracy in seed distribution.

-If the 10 year survival is similar as that for surgery, it stands to reason that any PSA recurrence after that time is likely to be caused from disease that was already beyond the prostate and in the blood stream initially (as with surgery).  Also, they are able to implant seeds around the capsule for a margin of approx. 5mm, thus treating ECE that may already be present.

- The risk of local, persistent disease or local recurrent disease is extremely low, so the argument from the uros that you can't have surgery after brachy is a bit of a moot point.  Of course there are exceptions, but the risk is small.

- The side effects (especially ED) seem to be less disturbing for brachy....at least initially.  It also seems that ED that develops over the course of time with brachy responds better to meds (Viagra, Levitra) than in some patients who undergo surgery. 

As I've said, no decision has been made yet with regard to treatment, but I can't help but feel that the BIGGEST advantage of surgery over brachy in some instances is psychological (i.e. "get it out of there!").  The other obvious advantages are that you can rely on your PSA readings to monitor your treatment immediately after surgery, and you also get a full post-op path. report. 

With brachy, you have to be emotionally strong enough to deal with potential PSA "bounces", and a slower reduction of PSA to a point where it is once again a valuable monitoring too.  I can't really see any long-term risk associated with leaving an essentially "dead", non-functioning organ in place. 

Again, I welcome any discussion!!

 

Posted 4/18/2010 6:46 PM (GMT 0)
Brachytherapy is a very good choice, and the results are good.  It sounds like the things your radiation oncologist told you are the "expected" things one would want to hear from a radiation oncologist.  I would have probably done brachytherapy if I had been 5 or 10 years older. 

 

My case characteristics were, however, worse than your husband's.  If I've got this right, he has a PSA less than 4; no DRE findings; 10 biopsy samples with no cancer found in any portion of 8 samples, and only 5% in one and less than 5% in the other; and basically the lowest of any practical reported Gleason scores of 3+3.

 

I gotta ask...what's the hurry?

 

Unless there is some other important factors you haven't included, doctors these days who aren't "selling" any specific treatments would look at those case characteristics and say..."Maybe we should wait and see what it's going to do."  From everything you reported, your husband has what is called a "low risk" case, and may not need aggressive treatment.  What's the rush?

Posted 4/18/2010 6:53 PM (GMT 0)

Casey59 said...
Brachytherapy is a very good choice, and the results are good.  It sounds like the things your radiation oncologist told you are the "expected" things one would want to hear from a radiation oncologist.  I would have probably done brachytherapy if I had been 5 or 10 years older. 

 

My case characteristics were, however, worse than your husband's.  If I've got this right, he has a PSA less than 4; no DRE findings; 10 biopsy samples with no cancer found in any portion of 8 samples, and only 5% in one and less than 5% in the other; and basically the lowest of any practical reported Gleason scores of 3+3.

 

I gotta ask...what's the hurry?

 

Unless there is some other important factors you haven't included, doctors these days who aren't "selling" any specific treatments would look at those case characteristics and say..."Maybe we should wait and see what it's going to do."  From everything you reported, your husband has what is called a "low risk" case, and may not need aggressive treatment.  What's the rush?

Casey, you're correct with the stats.  The Rad. Onc. didn't say there's any rush (contrary to one of the uros we saw).  We were considering AS, but the last PSA had jumped to 4.63 in a little over 3 months.  We're repeating it on the 28th, and will see what happens.  The Rad. onc. was the one who was going to monitor my husband for AS, but he just said that if my husband's PSAs are erratic, they won't be as reliable for monitoring as for someone whose PSAs are more stable.  He's all for AS, but won't fool around if my husband's PSAs are, in fact, rising quickly.  Having said that, we think it's a good idea to have our "ducks in a row" as far as to what treatment my husband will ultimately have.  The RO said to think of it more as "deferred treatment" as opposed to AS.  We know full well that he will at some point have to be treated, so it's nice not to have to make a panicked decision when the time comes.

Posted 4/18/2010 7:17 PM (GMT 0)
Hello Kuls:

I must say that I think you have done an excellent job of thinking this through and your logic is sound, IMHO. 

A few additional comments:

1.  It's not only the 10 years stats that are equal to surgery but 15 years as well.  This only reinforces your conclusions.

2.  Re ED, my radiation oncologist showed me his personal stats (over 1000 procedures) that showed, by and large, if a man did not have ED problems pre-procedure he was unlikely to have such problems post-procedure....even long term.  I have not seen other long term studies re that issue but I pass this along FYI.

3.  Once I decided I needed treatment (my stats were worse than your hubby's) I also scheduled both robotic and brachy with the intent of cancelling one of them.  That took some of the time pressure off and gave me more opportunity to think....

4.  I understand what you are saying re being emotionally strong enought to withstand no "zeros" and PSA bounces.  For me being 1 1/2 years out I am still yet to hit my nadir and haven't yet had the "bounce" experience.  However, I'm not sure this is any more emotionally draining than what the surgery guys go through in their post-surgery PSA anxiety.  If you read many of the posts on this forum you can see than slight changes in post-surgery PSA cause serious angst in many surgery patients.

5.  Finally, there are other surgical issues that crop up tha you didn't discuss but may be aware.  Obviously there is the incontinence and recuperation time from a major operation.  But there is also loss of ejaculate, the ejaculation of urine that occurs in some patients and the shorter penis that are items that should also be considered when making the treatment decision.

In any case, good luck and please keep us posted.

Tudpock

 

Posted 4/18/2010 7:32 PM (GMT 0)
Thanks Tudpock! You raise several issues that I've also read PLENTY about, including the results of the 15 year studies. I can't even begin to tell you how many hours I've spent researching......being careful, of course to focus on valid, current studies, rather than "advertising" or biased results from individual treatment center sites. If I wrote down here all the issues/thoughts/concerns/conflicting info that I've encountered in the last couple of months, I'd be writing a novel!! :)

All in all, I would be OK with whatever route my husband chooses....I've simply done as much research as possible and coordinated consults for him. We did the same thing as you.....Robotic Sx booked for July 8th, and Brachy booked for July 20th. One will be cancelled, depending which option he prefers, and the other may even be postponed, depending on the outcome of the next PSA. Regardless, having both options "booked" allowed both of us to have a better sleep than any we've had since prior to Dx!!

As my husband says....."Just because I'm 45 and married with 2 kids doesn't mean I'm done USING it!!". :)
Posted 4/18/2010 8:43 PM (GMT 0)
Kuls,
You certaintly have done your research and I can't think of anything that wasn't discussed. As long as you are still considering AS as a deferred treatment option I can't fault your logic.
JT
Posted 4/18/2010 8:52 PM (GMT 0)

kuls said...

...The RO said to think of it more as "deferred treatment" as opposed to AS...

That's an excellent way of looking at it.

If your husband is willing to adopt some of the lifestyle changes which could keep the PC permanently in-check, the deferal might be for a long time or forever.  No reason to think of it in absolute terms of needing treatment.  A lot of people, however, have too much "inertia" in their lives to understand and undertake the changes in diet, exercise, etc.  Change is difficult.

 

Posted 4/19/2010 4:41 PM (GMT 0)
kuls,

I didn't read all of the responses, so this may have been covered.

Ask the doctor what the treatment options will be IF the cancer re-occurs in 10 or so years. As you can see, I had brachytherapy and 10 years later it re-occured. From a personal standpoint, I wasn't comfortable with salvage radiation and chose salvage prostatectomy. The pathology report showed the cancer was contained and removed; however, the damage internally due to radiation 10 years prior resulted in reconstructive surgery and other issues.

Just ask the doctor. I didn't. If I had, I think I would have chosen the surgery the first time around.

Wigs
Posted 4/19/2010 10:21 PM (GMT 0)

Wigs....I'm really sorry to read of your outcome with the brachy.  Do you happen to know what your prostate volume (size) was from the first biopsy that was taken, and also, how many seeds were implanted??  I'm wondering what the total dose was to your prostate.  Things have evolved substantially with brachy techiques and doses.....as I've said, ten years ago I would not even have considered brachy to be a viable treatment option. 

I sincerely hope that with all you've been through, your cancer is GONE!!  I can't even imagine what a difficult road it's been for you!!  :(

Posted 4/20/2010 7:09 PM (GMT 0)
I was DX on Dec 2, 2009. In the weeks that followed, I set out to learn all I could about PCa and the options.
I interviewed a local radiation oncologist and 4 surgeons (3 local and one 2 hours away).

The radiation oncologist stated that he could and would treat me if that was what I wanted. Further he expected a very good outcome. But he stated quite clearly, that if it were him at age 55, he would have surgery. He stated that the data on the outcomes of the various radiation therapies have a "time horizon" of about 20 years. Meaning they simply cannot predict if the radiation solution to this probelm will last beyond 20 years. A man in good health at 55 could expect to live well beyond 75 and possibly have to deal with this again at that later age.

I must add that as an engineer I was influenced by the "data" that is made avaliable once the prostate is removed.
A final pathology that will give you good information on extent of the cancer, its location, its true gleason score, etc.

Also the PSA test is an excellent and immediate (within 4-5 weeks of surgery) indicator of the presence of any remaining cancer cells and the need for any follow up therapy.

With radiation the "nadir" can be many months in developing (as much as 59 months on some cases). Once this nadir is achieved then further increases in PSA indicate cancer cell growth. In that long period of waiting for the nadir, the cancer could well be growing and expanding far beyond the prostate.

Lastly, everything I have learned tells me that radiation before surgery will eliminate surgery as a salvage therapy. While it is possible to have salvage surgery after radiation, as a practical matter, it is rarely attempted and by only a very few surgeons.

These reasons influenced my thinking. Thus for me, surgery was my first choice and if necessary, I will have follow up radiation therapy.

Rick
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