DRs Disagree? & Neo-Adjuvant Chemo + HT

edited in hopes of getting a response:

My parents visited both the Cleveland Clinic and OSU this week. They had two great visits, finding both very informative and helpful. They liked both doctors that they met with and were impressed with the overall facilities at both locations. Nevertheless, they have come away with two very different opinions on next steps.

Doc 1 - suggested two treatement options that he said could can be weighted equally in terms of likelyhood of being effective in treating my dad's cancer:

1. Surgery, get a full path report, any evidence it has spread, do radiation. Go from there if need be.
2. HT + Radiation

(based on my research/understanding this are the pretty standard approaches for a GS 8,
no clinical evidence cancer having spread)

Doc 2 - wants ANOTHER bone biopsy (the surgery kind). Is hoping that comes back benign, and if so, recommends a clinical trial. He is encouraging a clinicial trial with neo-adjuvant docetaxel AND ADT prior to radical prostatectomy vs JUST radical prostectomy.

The second bone biopsy is to conclusively determine whether the spots in his arm are/are NOT bone mets. This is necessary to qualify my dad for the trial as its only for high risk, clinicially localized patients.

Given this current state of affairs, my questions are as follows:
1. Can anyone describe the experience of getting a surgical bone biopsy? My dad is reaching his limit of getting poked and prodded for diagnosis sake, is this additional step a difficult one?
2. Does anyone have experience with a clincial trial similar to the one that is being recommended as an option? I can do much of my own research about docetaxel / Taxotere in general, but i'm specifically curious about its role as a neo-adjuvant therapy, particularly in combo with HT.
3. Given these somewhat conflicting opinions, would the recommendation be to consult with a 3rd doc to break the tie? Or could that just overwhelm my parents even more?

Thanks again for all your help and advice! As we work through the pros and cons
of all of their options, i'm sure I will come up with more questions to ask!

Thanks southern comfort! You raise a really good point about not being able to receive HT in the clinical trial. I'll have my mom follow up on that.

Moderators, I edited my post to remove the actual name of the CT as i read the posting rules and thought maybe that was not allowed. If i need to do more editing, please let me know.

I'm still interested in getting questions #1 and #3 answered so i can remove the detailed ref regarding the CT if need be.

Thanks!

I will add his age to my signature.

He is 60 and in good health (no other serious health issues).

He has been on 50mg of casodex (the generic version) since Dec 19th (when they thought it had metasisized to his bones and were prepping for HT), and yesterday he got a new PSA reading of 2.6. (which is good news and i'd take that as some small signal that his cancer will hopefully react well to HT when the time comes). I dont know his PSA progression history though I can gather that his GP has been watching it for at least a few months. THe second it got above 4 he ordered the biopsy.

The doctors are pretty convinced now that the spots in his arm are NOT a bone met, but instead a non-cancerous cyst (talk about a lucky break). So i would be comfortable to conclude that the evidence to date suggests that it hasn't spread past his prostate (low PSA, neg DRE, clean CT scan). The extra biopsy by Doc 2 is to get him qualified for the clinical trial.

I do understand that radiation + HT is just as effective as surgery (+radiation if need be). But as many of the individuals on this site can attest to, there is something to be said about getting that tumor out of your body, and getting a complete pathology report and knowing EXACTLY what you are dealing with. Knowing my dad, I think that is likely to be influencing his decision. He also seems to prefer the risk of side effects related to surgery compared to the side effects he reads about related to HT. This may not be completely rational, but at the end of the day, he has to be at peace with his decision, and I can accept either route.

I just read a review of an academic paper that was published in Jan 2011 that came to this general conclusion:
"Therefore, a reasonable conclusion is that there may be no significant differences between EBRT + ADT (radiation+HT) and RRP (surgery) for the treatment of high-risk prostate cancer for any of the outcomes the Boorjian et al study measured. This conclusion may be the most important point, which is that RRP(surgery) does provide an effective treatment option for patients with high-risk disease, although with the caveat that it rarely results in “cure” (meaning radiation is often needed after surgery given pathology report results). Thus, it is important for clinicians to continue to explore multimodal options for the treatment of high-risk prostate cancer (like the clinical trial being suggested to my dad)".

The study they cite is:
Boorjian SA, Karnes RJ, Viterbo R, et al. Long-term survival after radical prostatectomy versus external-beam radiotherapy for patients with high-risk prostate cancer. Cancer. 2011; 117: 2883-2891.

Now I understand that everything must be taken with some degree of skepticism. this could have been written by all surgeons that want to convince the field that surgery is still a good option for high risk patients. That said, this isn't necessarily inconsistent with a lot of other things i've read, or information my parents have received from their doctors.

Thanks for the insight!

Very glad to hear that there likely are no bone mets!

Another advantage to surgery is the ability remove a large number of lymph nodes. This increases significantly the chance of discovering any spread to the lymph nodes, and removing undetectable mets. Of course, this also entails more risk, as well post-surgery drainage issues. But recent studies have found that with higher risk cases, it is advisable to go after the pelvic lymph nodes when performing a RRP.

Wishing you the best.
Nellie

Medved - great suggestion abuot asking Doc 2 what he would recommend BESIDES the clinical trial! And i truly do appreciate the advice about letting my dad make his own decision. I absolutely agree. Luckily, the DRs are conveying information to him that i find consistent with everything i've read, and honestly, I will be completely content with whatever decision he makes at this point. The one thing I have focused on is providing him with the realistic expectation that given the details of his case, he can "HOPE" for a clean post-surgery pathology report, but he has to be somewhat mentally prepared for surgery being step 1 of at least a 2 step process. I just don't want him saying "i wish i had known x y z, because i would have made a different decision then"

Riviere - we were pretty shocked/excited too re the biopys results! you make an excellent point about the added benefit (as well as risks) of removing lymphnodes with surgery. I will point that out and make sure the details gets noted in the "plus" and "minus" columns of his decision making worksheets :)

tarhoosier - thanks for your insight. i have scoured the boards here and elsewhere and can find almost NO other instances of individuals having to have bone biopsies in general, or the surgical kind specifically. it raised at least a small red flag in my mind. i under the better safe than sorry approach (heck, that's what got us to ask for the bone biopsy in the first place), but given that they did find evidence of a benign cyst (and not just "clean" tissue) i'm confident they got the right spot the first time. i'm also somewhat unimpressed with the little research that is out there on neo-adjuvant chemo. but that's why its under a clinical trial. . . to try to find that magic combo for those that fall in the high risk category. this trial is a bit different timeline/combo than previous studies so it may be "the answer". That said, I'm still undecided whether my dad would be the right fit for such an approach.


the really good news is that my parents absolutely loved one of the drs they visited with, and as tarhoosier points out, having that level of trust and confidence is extremely important at this step in the process. he even said that my dad's loving, detail oriented, very concerned children (me) could email him any time I had any questions. he's also willing ot work with my dad's local dr to ensure my dad gets the best treatement in the most convienent means possible.

i am so appreciative to everyone on this site. it has been a really helpful avenue for me to use my energy to try to help my parents best i can from across the country. Best to you all!

I had a neo-adjuvant clinical trial. I also had a G8 at biopsy and a much higher PSA than your dad. The theory went that if there are micro-mets (that cause the high PSA) these would not be addressed by surgery or radiation alone. I was offered two different stage 2 trials (which means there was no control leg, so I would be guaranteed the treatment). One at Duke for Taxotere and Avastin, the other at Sloan Kettering for Taxotere and ADT. I chose Duke because I wanted to know whether the treatment succeeded or failed as soon as possible (right after the surgery). With ADT you would need to wait until T came back - as long as six months.

My tumor and the PSA have dropped by about 50% over the course of chemo and PSA was zero after the surgery. PSA came back eight months later and I had an SRT and ADT treatment. So far, so good.

Incidentally, the trail has been deemed a failure, as it did not produce statistically significant evidence of improvement in outcomes.

I was told that the other trial (Taxotere and ADT) has in some cases eradicated any evidence of the disease. They could not see any cancer cells on pathology slides. That certainly suggests that if the disease was gone in the protected prostate capsule, it is even more likely to be gone elsewhere. So, I would consider it, if it were a high risk case.

However, I don't see high risk features in your dad's case, other than G8. Alone, it does not suggest that the cancer has spread. Conversly, the PSA suggests a good likelihood of a cancer being contained in the capsule. I would recommend going with the conventional treatment and skip the clinical trail.

Remember, I am not a doctor and this is just one man's opinion and experience.

Best of luck!