Befuddled First Post: surgery vs. radiation in low risk case?

Hello all. Really great forum you have here! Been reading a couple of months since my biopsy results came in (Gleason 3+3=6, 1 of 12 cores positive, 5-10% of tissue involved, latest PSA 2.4, DRE normal, T1c, father had PC, overall good health, age 56).

I've been trying to cram into my brain enough info to make a thoughtful and reasonable decision about what treatment option is best for me. I average a couple of hours a day reading about treatments and outcomes and probabilities and trials and studies. I've talked to some really smart doctors, surgeons, medical oncologists, and radiation oncologists, with a few more scheduled next week. I seem to be a "great candidate" for virtually every treatment anyone has ever thought of, including active surveillance. And rather than really good advice, I seem to get doctors who either just advocate for their speciality, or those with less of an obvious bias who just say all of the options are good. So, here I am - someone who knew and cared very little about PC two months ago - trying to become some type of medical scholar overnight to make a decision that will potentially have a HUGE impact on me and my family for the rest of my life. It is befuddling, and disappointing, to me that the medical profession is not more helpful with this! On the other hand, maybe it is just me, with a skewed and unrealistic perception of things...

Anyway, a basic question that I have still not resolved is the surgery vs. radiation choice, assuming that I do not choose AS. I'm having trouble figuring out the long term differences between the two for a T1c type of case. For those of you that had a case like this, and were healthy enough to be able to choose either, and who have a life expectancy of 20+ years, what made the difference in your decision making?

It seems like both have a high chance of successfully treating the PC without it reappearing later. It seems like both have likely unwanted side effects regarding urination and ED. And it seems like it is impossible to predict in advance with any real certainty what the particular side effects will be in your case.

I'm obviously still working to figure these things out, and may not have all my facts straight. I may be missing something obvious. But what others found to be important in their decision making would be of great interest to me.

Thanks for your help and for all the great information on these boards!

Mac

Welcome Mac

It's the $64,000 question for almost all of us.
My response is thus not a recommendation merely an explanation of how I saw it and see it.

My first uro's concern was my age at diagnosis (48) the problem being: what treatment will give this guy as many more years as possible (and I agreed with him). Plus he was concerned about my quality of life during those extra years. (I agreed with that too)

Put simply I decided that my goal had to be: to be a man of 70 (or older) with ED - after all my dad lived till he was 95. I did not want to find myself pegging out aged 59 thinking I could have done more

I thus ruled out AS on the basis of my age. ie there were too many years available for me for the PCa to get worse, and in the waiting game I felt that you could wait too long and find that at the point when you did act you had left it too late.(I could work out that my Gleason 6 was only going to get worse, not better, and that if it suddenly got much worse between two biopsies I'd be kicking myself.) I thus decided to act then.

The next bit of analysis about what treatment to choose was based around the idea in my head that people with cancer tend to have it come back, even if their initial treatment knocks it out. So I looked at a bridge that did not need to be crossed as well: ie what are the options available to tackle a recurrence.

If I started with surgery, then I could always have radiation therapy at some time in the future to deal with a recurrence. However if I had RT first then it would not be possible to have RT again and nor would it be possible to do surgery as the RT would scar the area too much to permit removal of the prostate.
I can't really say why I rejected seeds, I guess that right from the outset I was perhaps conditioned to think that cancer=surgery. (Lots of family & friends are doctors and/or surgeons)

Tackling the cancer was far more important for me than ED and continence. If I didn't deal with the cancer it would be there every second of every day. If I got ED, it wouldn't kill me and I would have to adapt my sexlife, use meds etc. If I ended up incontinent, then it would be a nuisance, but it wouldn't kill me.

So I opted for (robotic) surgery.
Was it the right choice?
Well the first issue that arose post surgery was that my post-op pathology was worse than my biopsy: Gleason 7 instead of 6 and seminal vesicle invasion. I don't have any stats, but a lot of guys have had a post-op pathology come back with a higher Gleason. It is this lab report that really tells you what is inside you and surgery is the only way of getting the prostate gland to the lab.
And then my first post-op PSA was not zero either(0.1).
Next, I didn't even get much of a chance to start PSA watching either as my next PSA was 0.4 and I was sent to a radiotherapist.

So a year after diagnosis in April 2009 when I worked out that I could have RT as a second option I was actually having it.

I will never know what might have happened if I had chosen seeds and RT first up, but the good news is that by September 2010 my PSA is <0.1 at last, and however big the "rest of my life" is I can now simply get on with living it.

Alf

Couple reasons I elected surgery was that radiation could be done later if needed and the 25 to 45 trips for radiation didn't appeal to me at all. Snip snip and you're done.

Hi MC,

Welcome to the forum. I see that a few surgery guys have tuned in and I'm sure the brachy guys will too. My husband went with surgery for the same reasons stated in the above answers. He wanted the cancer out and he wanted a plan B (radiation) if he needed it in the future. The one bit of advice I can give you is if you pick surgery to get the very best surgeon you can find-we traveled to Orlando( 2 hours away) but would have gone further is needed. My husband's surgeon had over 3500 Da Vincis and feels it was the surgeon's skill that gave him such a great outcome. Good luck.

Renee

Hi Mac, you have raised the age old question that has been debated and discussed on this forum many times but we are always happy to weigh in again for a new patient.  Like you I was in good health and had a long life expectancy.  I also consulted multiple doctors and researched this disease for untold hours.  At the end of the day for me it came down to logic and not emotion.  Here are the things I considered and it becomes clear why I chose radiation (brachytherapy for me):

1.  Cure.  In my case (and yours if I understand your stats correctly) the chances of cure were essentially the same for both options.

2.  The procedure itself.  Surgery was a big deal with potentially difficult recuperation.  Brachytherapy was an out-patient procedure where I was back to all of my normal activities in a couple of days.

3.  Urinary side effects.  Surgery gives incontinence for some time...potentially some incontinence for years.  Brachy gave me some urgency and frequency for a couple of months that was no big deal.

4.  Sexual side effects.  Surgery usually brings ED that may get better over time.  Brachy usually has no immediate ED but it may get worse after a couple of years.  Studies show the long term ED for surgery is worse.  Also surgery brings other sexual side effects that are not well publicized, e.g. shorter penis, no ejaculate, ejaculating urine.

5.  Backup plan.  With surgery there is the possibility of radiation later if the initial treatment fails.  With radiation surgery later is quite difficult.  This is true but only part of the story...and the part that urologists who want to sell surgery usually tell.  The truth is that there are backup plans with radiation that include re-seeding with another isotope, cyrotherapy, HIFU and surgery with a real expert.  "Cure" from a salvage treatment only results if the cancer is confined to the prostate.  And, the salvage results are generally the same for salvage after surgery or radiation.

6.  Knowing the final pathology.  This is a big "so what"?  Even with final pathology known after surgery most patients will do nothing until they get further evidence of cancer, e.g. rising PSA.  So the question is whether or not that knowledge is worth having surgery for.  In my case, the answer was clearly "no".

7.  What if the pathology indicated that my Gleason was higher?  Again, "so what?"  The radiation treatment is an effective as surgery with different G scores.

So, that was it for me.  Pure logic including the major fact that quality of life was important to me.  BTW, if you don't choose AS or one of the "usual" treatments, you could also consider something like targeted focal therapy which is showing great promise.

Good luck and keep us posted,

Tudpock (Jim)

Mac,

Lots of good feedback in the posts so far, but my first observation is that you pretty well nailed the "twilight zone" nature of PSA testa and PCa in general.

I had an initial biopsy that was positive in 9 of 12 cores, ranging from 4+3 to 4+4, up to 90%. That automatically eliminated AS. I wanted seeds, but was told by multiple clinics that I was too far along for that.

IGRT (45 sessions) offered me a 70% cure rate according to the Rad. oncologist, which did not give me a good feeling (in theory I could be around another 30 years or so).

When it is said that radiation "can not" be followed by surgery, it is a bit of an overstatement. It can be done, but you will find few surgeons who will attempt it. The difficulties presented, as I was told by my surgeon, make it extraordinarily hard to do.

So in the end I found a surgeon I felt good with, and did DaVinci. My Gleason came back 4+5, with EPE. I did IGRT afterwards.

ED is complete - side effect of the surgery, incontinence was getting better before radiation, but is static now.

 

Post Edited (142) : 10/6/2010 7:52:18 AM (GMT-6)

I chose surgery for the reasons already mentioned (especially the radiation as a back-up plan). I felt it gave me a second bullet (which unfortunately I may have to use).

I was not a candidate for AS, but also I think it takes a special kind of mentality to do that. Not for me!

In retrospect, another good reason for surgery is that you will get the complete pathology and know what's what. Many folks with a G3+3 end up getting upgraded to a G7.

Mel

This is a great article written by a very thoughtful reporter for the NY Times. I give him a lot of credit for presenting this because he is a perfect example of someone who likely would have been harmed by taking his prostate cancer lightly....he's one of those with a very aggressive cancer.

I had almost the same exact stats the original poster has. I was 45. I opted for proton radiation. Personally I believe that surgery is overkill for these stats. 18 months later, if I had the decision to make over again, I'd choose AS. Having said that, I never 2nd-guess my choice....most people here don't...nor should they.

http://well.blogs.nytimes.com/2010/08/30/a-rush-to-operating-rooms-that-alters-mens-lives/

I dont have much to add to the thoughtful comments of everyone that has already posted. 

It was less than 13 months ago that I was in a similar situation.  I spent hours a day reading everything I could on the alternatives.  Given my age, low PSA and G6 (which turned out to be 7 (3+4)) my uro and my readings told me I had a lot of options that would all work well.  My uro did not suggest an alternative(although I believe he was leaning to surgery) but was a great sounding board for me as I wrestled with my choice of action. Just when I thought I came to a decision , I found reasons to look in another direction. I was driving myself crazy.  I eventually chose surgery for many of the reasons given already - getting it out, having a backup plan etc.  The other reason that swung me towards surgery was when a radiologist suggested surgery as a first option given my age and the possibility of secondary cancer 15-20 years down the road from radiation treatment.  Although improvements in the focus of the instruments are constantly being made, he seemed to think that the possibility still existed.  Perhaps I am being presumptious , but i do plan to be around in 20 years and just didnt want to have to deal with that then.

As others have said, no matter what treatment you decide on , try to find the most experienced doctor that you can.  I am confident that the skill and experience of my doctor made a huge difference in my outcome and recovery.

Best of luck - remember we are all here for you - so dont hesitate to ask questions.  There are many experienced and caring folks here to help you however possible.

Ray

fairwind - dont fully agree with your good post. i feel strongly, it should always be cure, incontinence, ed, and in that order. shouldn't be based around anything but the best cure possible. i am old school that way.

mel - i should be the poster child for what can go wrong with salvage radiation. even when i was dx with pc, i was so afraid of having to go through radiation a second time in barely 10 years, and i let my drs know of that fear. i know what happened to me with radiation this time might be rare, but it happened, and now 7 operations later, i am in the condition that i am in, and still not sure if the radiation worked or not.
no one should go into it lightly.

david

"fairwind - dont fully agree with your good post. i feel strongly, it should always be cure, incontinence, ed, and in that order. shouldn't be based around anything but the best cure possible. i am old school that way."

I feel EXACTLY the same way Dave.. It's just that I feel his chances for a CURE are excellent with either surgery or radiation and if that's the case, side effects need to be considered carefully..

Expertly performed robotic surgery would STILL be MY choice, but I'm trying to keep the playing field level..JMHO...

Thanks for all the thoughtful posts!   It is very helpful to see that others have faced the same issues, and very insightful to hear about the decision making process that each person used for their own reasons.

Inwm, hope your surgery went great today.  Best of luck to you.

Alf, I agree totally with you on the AS thinking.  If I happen to live another 25 years, the odds are very high that my PC will progress eventually to a point that requires treatment. 

The harder question for me is thinking about AS for the short term, not long term.  What about monitoring things for, say 5 years, enjoying life w/o side effects for the time being, understanding that treatment will likely be sought then.  This idea also seems helpful in considering a "new" option like CyberKnife, which doesn't have a lot of long term data yet - and you would have more info to evaluate when making your treatment decision.  (I'd also be interested to see if real changes in your diet, re fat, red meat, dairy, etc, would have an obvious effect on PSA and disease progression.)

Speaking of CyberKnife, has anyone chosen to have it?  It seems to promise the benefits and cure rate of traditional radiation therapies with some likelihood of fewer side effects due to better targeting, technology, etc.   But again, as applied to prostate treatment, it seems a bit early to draw any firm conclusions.

Lots of good points about having a backup plan.  For those who chose surgery and have needed or are planning to use radiation as a salvage therapy, is there a standard radiation therapy used for this?  Is it targeted where the prostate was formerly located, thinking that the PC is still localized there?  Or is it a more broadly targeted treatment?

Jim, thanks for the explanation for your choice of brachy.   Is the expectation now that urgency and frequency issues are the main urinary issues, as opposed to blockages from scar tissue or bladder damage, etc.?  (My dad had some form of EBRT 20 years ago and did have periodic episodes where he would have to go to the ER to get help releasing urine.)  And with ED, how long out should those effects be apparent if they are going to appear?  Is your expectation that ED can be treated with pills, or will this likely require additional remedies?

Joe and JohnT, you each chose a form of BT.  What were your expectations going in as to likely urinary and ED problems that you might experience vs. those likely with surgery?  

bt, glad your procedure went well and hope that the 90 day numbers look good!

david in sc, your story is incredible.  Surely you are due to have something good happen in your treatment! 

thanks again to everyone.

Mac 

Mac,

Going in, my expectations regarding urinary issues were some short term (6-8 weeks) burning, urgency and frequency. Since I already had some frequency prior to the BT, these were not a big concern for me. I did not worry about incontinence based on what I was told by my uro and onc rad and by the fact that I don't think I have ever read anywhere on this site about a BT guy that had incontinence issues. And it worked out just like that....burning sensation, urgency, frequency which have all but disappeared....no incontinence. I do still take one flomax a day.

As to ED, I wasn't sure what to expect since each man is different. My docs told me that, as a general rule, most men have some initial ED which improves over time. That has been the case for me...and without any pills. I don't have ED but I also don't have as much desire/libido as I did before the BT/IGRT. To what degree that totally returns remains to be seen. I also understand that there can be a delayed ED effect with radiation after a couple of years....but I also had ED risk with surgery.

There are no guarantees in this game. That said, I feel that I got what I was looking for....a treatment with a 90+ cure rate chance with minimal side effects on my QOL.

Hope that helps....regards,

Joe

PS - Where are you in NC? I have family in Charlotte.