Surgery vs IMRT, is surgery the better option? Seems like IMRT is easier...what am i missing?

I think I, like a lot of guys, just wanted the cancer out of the body. I never even talked to the radiation oncologist. I felt that if the surgery didn't get it all, I had radiation as a back-up. This turned out to be the case. I ended up getting salvage radiation after open surgery. I keep thinking now, would I do it the same way all over again and I can't honestly answer the question. I've learned a lot more about PCa and treatments since my surgery and still find it to be one big confusing mess with no real winner as far as treatment goes. Everybody has their own opinion as to what is best, including all the doctors. All you can do is take your time, read a lot, talk to many doctors, and then decide for yourself what you feel is best for you. Squid.

I was told that surgery would be the best route if everything (psa, age, biopsy etc) indicated that the surgery would be completely successful in remove all the cancer. If there was any reason to believe that the surgery would not be successful, then go the radiation route because the trama of surgery can be pretty harsh on men...especially as they get older with other health issues involved.

Based on your stats...I think you are approaching this correctly and looking at the options of radiation vs. surgery. But that is my take.

BTW welcome to HealingWell

Hello a777. First, I agree with the suggestion that you get a "second opinion" on your biopsy slides, from an expert in prostate cancer pathology. The same 4 or 5 experts have been recommended dozens of times on this board, so you can easily find them, but if you need names or contact info, let us know and I or someone here will provide it. It is not very expensive, and you might be surprised by the substantial number of times the expert pathologist disagrees with the initial reading. You certainly want to be making decisions based on an accurate reading of your biopsy slides. The expert pathologists can also provide additional information that may be useful in evaluating how agressive the cancer is, such as a ploidy analysis. There are also some newer tests that purport to be able to evaluate how agressive a tumor is, and therefore help patients make treatment decisions. Here is one of them: http://www.aureon.com/ I have no view on whether this is useful or not, but maybe worth talking with your doctor. Second, there are some predictive tools you can use to evaluate the likelihood that your cancer is organ-confined. One of them is the Partin Tables. Another is a nomogram from MSK. Here are links:

http://urology.jhu.edu/prostate/partintables.php

http://www.mskcc.org/mskcc/html/10088.cfm

This information -- the odds that your cancer is organ confined -- might help you make the decision about which treatment. (There are other such tools too).

If you are considering radiation, a couple of things to discuss with the radiation oncologist: (1) should you use adjuvant HT before/during/after the radiation, and for how long; and (2) any benefit to using seeds + IMRT, and which first.

Very tough decision -- a close call and each doctor believe in and is biased in favor of his/her own speciality.

A medical oncologist might be more "neutral" -- so maybe go for a "third opinion." But if you do that, make sure its a medical oncologist with expertise in prostate cancer. Otherwise, it might not be very useful.

Best wishes,
Medved

JohnT,

In your radiation as the primary treatment methodology, which I understand why you feel that way, what do you really subscribe as a good salvage treatment if the radiation fails? Regardless of IMRT, Seeding, with or without HT added into the mix. What would you choose if your seeding ultimately failed?

To our new friend here, my official opinion is neutral in choice as it should be. But there is still a lot to be said for having the pathology of the entire prostate once its removed. Then, you are going to know more fully the real staging, Gleason, % of tumor, and locations of tumor(s) within
the gland itself. No way of knowing all that info without surgery. Plus, if there's a lot of cancer present, the "debulking" theory of removing the primary and most major source of the cancer has merit that surgery offers.

I don't have the stat in front of me, but surgery is still the overwhelming choice of primary treatment for PC, unless you got some to show that proves otherwise. Yes, there are plenty of uro/surgeons, regular surgeons, and not shortage of radiation centers. So there has to be another reason while surgery is still the number one choice in quantity.

What concerns me with our new friend in his stats, is the % of Gleason 7 found just in a low core biopsy. If it were upgraded, then it could even be more serious. I hold to the growing school, that Gleason 7 cases should be handled as if they were 8's or above in many cases. The Type 4 component is what makes the risk higher and more unpredictible to the patient. In my opinion, it leaves too much room for making a guess erroring away from treatment, or not having a treatment strong enough to make a difference on the first pass.

If ultimately my SRT does prove to be a failure, then the whole question of surgery vs. radiation as a primary becomes very mute to me, and the almost two years I have suffered with the effects of both surgery and radiation will to me, seem like an incredible waste of money and pain and suffering to have gone through for nothing in the end.

It is a tough choice, and there is no magic in making the decision, but I still come back to, with our new friend stats, I would want an independent review of the biopsy, and as you suggested, getting a neutral opinion from a good Medical Oncologist to help even out the surgical and radiation related opinions.

David in SC
Of course, the primary treatment needs to be the right one, and should be based on sound facts and opinions from the medical community, but a person still needs to have a good "backup" plan if the primary fails. Couldn't imagine anyone disagreeing with that logic.

A777, IMO radiation is a choice to strongly consider if it is very likely that your PCa is outside of the prostate, but still local. If you have surgery and they find that you have positve margins, or epe then they will probably want to irradiate after you recover from surgery. They may want to put you on HT during the recovery period. If you want to avoid both treatments and the related side effects, radiation may be the best choice. The question is, "what is your staging"? A second opinion and additional testing will help to get you to a place where you can decide.

David,
Accoriding to The Prostate Cancer Study Group:
The largest cause of surgical failure in low and indermediate risk PC is microscopic cancer cells left around the nerves. This happens about 15-20% of the time and can't be seen by the surgeon.
Radiation also can hit an area in the bed up to 15mm, far greater than a surgical margin.
If I had a reoccurrance the first thing I would do is to determine if it is local or systemic. I would get an MRIS or some other type of dye enhanced fusion MRI and the get a color doppler targeted biopsy of the suspected area. If it was determined to be a local reoccurrance I would look at cryosurgery, cyberknife, and HDR Brachy as local salvage treatments. If I could not absolutely determine that it was local I would not do any salvage therapy and go on intermittent HT.
JT

goodlife - i wondered the same thing, lol

johnt - i hear you, but why is surgery far more popular? and of course, when a prostate is removed, there is not little lights that light up showing the cancer or some dotted line that the surgeon follows. Also, there is no way of being 100% positive if it's local or systemic after a primary treatment failure, I thought that was a given. Since you couldn't absolutely know, wouldn't it still make sense to take a chance on a secondary treatment like many of us have done, even if the odds percentage wise aren't all that good? At least it would be a curative attempt, and one might make it into the good side of the numbers. The problem I see, is that with radiation first, if there is recurrance, the options are more vague and uncertain.

fairwind - even the skill of the surgeon/doctor isn't always enough, despite their stats and records. we have more than one man here that went to the best of the best, did all their due dilligence right, and still ended up with almost instant recurrance. each body is different, each PC case is different, you can still have two men with the exact same specs and age, and similar medical histories, and still end up with 2 different results from the same dr/surgeon.

As a i.c. sufferer radiation was ruled out for me as my bladder has already been compromised and the docs felt that zapping things in the area would not be a good idea. When you re hashing things out be sure to take the rest of your health in consideration. Good luck.

"Why would anyone choose surgery? Isn't IMRT easier and just as effective? Am I missing something?  Seems like a lot of people are going with surgery."

When I was first diagnosed, I (like so many others) began all means of study, and contacted anyone with an opinion.

One friend worked for what I thought was a Urologist, so I asked that she describe my situation and ask "What would YOU do?"

The predictable response was "Get Cut".  

The interesting fact was that the recommending doctor was a Professor in PC Radiation.

Cutters want to cut..  Rads want to Rad..  It's an industry..

For a Rad to say CUT        surely says a lot.

A time later I met this Professor at a semina on PC, and he was honest enough to admit that Radiation after surgery, was far better than considering surgery after radiation..    Once irradiated - your goose is cooked ? 

Is there something wrong with his thinking.

I had planned "Self-Cure" via diet and supplements (OPC), but many doctor friends warned me that only a few individuals get to write a book about DIY Cancer Survival, the  others are DEAD.

They also pointed out that it was far better to accept a 95% guarantee of cure, and then use DIY to ensure no re-occurrence.

Purgatory said...


johnt - i hear you, but why is surgery far more popular?

Dave,

Surgery is more popular for a very simple reasosn. The great majority of men are referred to a urologist after a high PSA, usually at the time of an annual physician with their primary physician. It is a urologist who does a DRE and biopsy, makes the diagnosis of PCa, schedules bone and CAT scans, and it is the urologist who makes the first recommendation for treatment. And as we have seen, urologists usually recommend surgery. And the reaction of most men is to believe that surgery will "get it out" and they will be done with the cancer, so trusting in the wisdom of the urologist they follow his/her advice.

I read an article somewhere that stated that about 90% of urologists recommend surgery over radiation. Does that not sound reasonable?

So I say whatever you do be skeptical of all advice, get a second and third opinion on the biopy and treatment, and educate yourself as best you can to the disease.

Sancarlos

PS My urologist recommended surgery. He insisted it was the only reasonable option for me.

Dear a777:

Well, you have initiated a well worn discussion/debate here at HW, i.e. which is better surgery or radiation? You will find no clear concensus here but I will wade in with an assessment of how I would logically look at your decision process, given your stats.

1.  Cure Rate.  To my knowledge there has been no long term, large scale randomized study of radiation vs. surgery.  However, there have been many, many separate and sometimes contradictory studies that detail the long term surgical and radiation cure rates.  Despite the confusion, my conclusion is clear...the long term cure rates for surgery and radiation are similar.  ADVANTAGE:  Neither.

2.   location of the Tumor.  According to you, there is some indication that your margins may be positive.  Reference the above posts by JohnTand BobCape...radiation has a better chance of curing you the first time than does surgery.  ADVANTAGE:  Radiation.

3.  Quality of Life.  With surgery you are likely to have immediate incontinence and ED.  The incontinence should lessen, the ED may not.  You will also likely have a shorter penis, no ejaculate and may ejaculate urine.  With radiation you are likely to have short term urgency and frequency that will lessen and may have longer term ED. There is also a small chance of rectal issues.  Overall, the long term side effects of sugery include higher rates of ED as compared to radiation.  Probably the best QOL comparision that I have seen was done by the New England Journal of Medicine a couple of years ago.  It showed much lower declines in sexual satisfaction from radiation patients than from surgery patients. BIG ADVANTAGE:  Radiation.

4.  Back up Plan.  Surgeons have been great at playing on patients fears about having a back up plan, i.e. you can have radiation after surgery but not surgery after radiation.  That only tells part of the story even though some posters even on this thread continue to preach that gospel.  The fact is that there are multiple salvage procedures for a failed radiation.  These include cyrosurgery, seeding with a different isotope, HDR Brachy and salvage HIFU.  The success rates for these salvage procedures are as high as for salvage surgery.  The bottom line is that you hope there is no need for a salvage treatment but ones are available for either choice.  ADVANTAGE:  Neither.

5. Knowing your Pathlogy.  If you have surgery you have an exact read on your pathology shortly after the operation.  With radiation you do not.  The real question is what will you do with the information once you have it?  There have been debates on other threads about the advantages of starting immediate post-surgery radiation or waiting for PSA rises.  If you are of a mind to wait, then having the information is interesting but not critical.  If you are of a mind to start immediate radiation if postive margins are noted, then the information is important.  ADVANTAGE:  Surgery.

6.  Psychology.  This is highly patient dependent.  If you are like me, my mindset was to "get it cured", so I was able to look at the facts fairly logically.  However, some men have a mindset to "get it out", in which case emotions rule over logic.  Only you can know which kind of guy you are.  ADVANTAGE:  Neither.

OK, so what would I recommend to you if you were my brother and knowing your stats?  I would encourage you to get your biopsy pathology read by a PCa expert, to seek an opinion from a prostate onlcologist, to get a color doppler and then to probably proceed with a combination of seeds and IMRT.

Good luck and please keep us posted,

Tudpock (Jim)

Great discussion laying out the pluses and minuses of different treatments.

The only ironic thing is that the bulk of what I have learned about PCa treatments was learned after I made my treatment decision, which seems kind of backwards. (BTW, I am still very happy with my treatment choice, though)

Dan