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So based on the NE Journal Med study, what would you have done?

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Prostate Cancer
Would you have also chosen surgery if you were me, knowing my pathology.
Yes, you had an aggressive cancer needing to be removed. - 87.5% - 14 votes
No, as the study shows, there is no clear benefit for the price you paid. - 0.0% - 0 votes
Not certain what the answer is, that's the problem with this disease. - 12.5% - 2 votes
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Posted 7/19/2012 1:55 PM (GMT 0)

How do I decide if the price I am paying was worth it?

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"The study, which focused on cancers still confined to the prostate.."

"And because the average age of the 731 men who participated in the trial was 67, with only 10% under age 60, the implications for younger men who have more potential years ahead of them are less certain, experts noted."

"For high-risk men, "surgery clearly has been shown to be beneficial over watchful waiting," said study coauthor Dr. William Aronson, a urologist at the VA Greater Los Angeles Healthcare System."

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SO, two years ago - @ 51, robot removed G 4+3 with Tertiary pattern Grade 5 also present, tumor occupies 75% of the total gland, involves both lobes with focal extraprostativ extension, perineural invasion is present,  tumor is present in bladder neck and extends to inked surface...high grade prostatic interaepithelial neoplasta, chronic inflamation. Pathologic stage pt 3.

 

After radiation I have been 1 year of "undetectable".

 

SO, if you were me, knowing what I KNOW NOW.. would you have gone for surgery and then radiation?

 

Thanks in advance...

Posted 7/19/2012 2:07 PM (GMT 0)
Of course you needed aggressive treatment, thus my vote
Posted 7/19/2012 2:30 PM (GMT 0)
I don't believe any less aggressive treatment would have been wise.
Posted 7/19/2012 3:46 PM (GMT 0)
Bob,
You definately needed aggressive treatment, and your post op pathology indicated you needed salvage radiation. The real question is would have radiation as a primary treatment combined with 6 months of HT produced similar results with less permanant side effects. I believe the answer to that is yes.
Posted 7/19/2012 3:52 PM (GMT 0)
BobCape,

I've posted this description of low-risk PC in several previous posts:

The NCCN, the National Comprehensive Cancer Network (they are the organization that develops treatment protocols which doctors follow) updated it's Prostate Cancer Guidelines to more clearly define both "low risk" and a new category called "very low risk" PC.  Im going to just copy/paste from an article:

Patients in the low-risk category are those with a stage T1-T2a tumor, a Gleason score of 2-6, and a PSA level less than 10 ng/mL, whereas very-low-risk patients are those with a stage T1a tumor, a Gleason score of 6 or less, a PSA level less than 10 ng/mL, fewer than three positive biopsy cores with no more than 50% cancer in each, and a PSA density below 0.15 ng/mL per gram.

 

These case characteristics help to more fully define those who should consider AS.

You said that the NEJM study focused on confined PC cases, and probably (although I don't believe I've seen this specific article) "low-risk" cases...so perhaps this definition helps.

Posted 7/19/2012 4:36 PM (GMT 0)
Thank you for your considered answers..

John T - So my 75% involved prostate was going to be blasted with seeds for inside the prostate, radiation beam for outside & HT . . and what remained of my prostate gland just left dangling. assuming they could tell "which" regions were cancerous?

And I understand I invited you to look with the benefit of hindsight, but my drs had assumed it was contained in (psa 4.0) the prostate.

Had I then done seeds with HT and found them to fail because the pca had indeed escaped, I would then have had beamed radiation, the combination of which would have made surgery to remove the prostate a moot point...

I dunno, i'm not sure I agree with you that we can say your route would have given the same result with less damge.

Maybe.
Posted 7/19/2012 6:22 PM (GMT 0)
I would have chosen aggressive treatment too. Patient choice is often missing in a lot of those studies. Some of these authors write like there on the panel with final say. Let's pray we don't lose our choice on these decisions.
Posted 7/20/2012 1:55 AM (GMT 0)
Bob,
I agree that hindsight is 20-20. What was done is done and there is no looking back. This is for others that face what you faced. Why would a doctor assume that it is contained when there are many methods to confirm this fact BEFORE surgery? An MRIS or multiparametic MRI or even a color doppler ultrasound would have identified the large volume of tumor and most likely the extracapsular extension and the bladder neck involvement all which are indicative of a high probability of surgical failure.
Knowing what I know today there is no way I would undergo surgery before having a PAP test and at least one of the above scans to confirm that surgery would have a high probability of success. These are easy and inexpensive tests and could easily reduce surgical failures by 80% or more.
Posted 7/20/2012 2:24 AM (GMT 0)
Bob,
As futher explaination: I was faced with pretty much what you were faced with, a G4+3, but my psa was much higher. I was considering surgery, but a CDU, confirmed by a 3T MRI, identified a large tumor involving the nerves and the Apex. The probability of a surgical cure was very low and came with certain impotance and a high probability of incontinance. The location of the tumor dictated the treatment and radiation was the best treatment for this particular circumstance and was very successful in both cure and side effects.
My surgeon wanted to operate without any futher tests. My 2nd opinion doctor said we don't have enough information in order to make a life changing decision like this and ordered up more scans and tests. Thank god I had much better information in which to base a decision thanks to him. I strongly recommend that everyone get second opinions and further staging than simply a biopsy and a gleason score. These are important decisions and the more info you have the better probability for a favorable outcome.
Posted 7/20/2012 11:41 AM (GMT 0)
I appreciate your points John, thank you.

My decision ultimately was with a doctor whio was a second opinion. But prior to surgery I had more xrays, bone scans, mri's than I can remember.

I was having trouble going the bathroom... ends up prostate was 75% cancer.,. so it had to go either way.

Do we know how much radiation one would have to endure to actually remove an entire prostate?

And what happens with the plumbing when you remove it simply using radiation?

And if they could actually see it had escaped the prostate, would poisoning me with high doses of radiation in a specific region for what may no longer be a local disease be prudent?

I was 51 with a psa of 4.0.

I guess i'm wondering, if they can so easily detect the cancer having escaped the prostate, why do we rely so much on pathology reports and positive margins?
Posted 7/20/2012 12:52 PM (GMT 0)
Bob, using 20-20 hindsight and since you asked...I agree that agressive treament was warranted and I don't beleive the NE Journal Study would suggest otherwise.  However, personally I would have picked a combination therapy of brachy + IMRT with perhaps a short course of HT.  IMHO, that's the most optimal treatment in your case to be both curative and to lessen the chances of onerous SE's.

Jim

Posted 7/20/2012 2:19 PM (GMT 0)
John, Jim, you almost have me convinced.

But how would those treatments resolve the fact that I had a decaying gland that was attached to plumbing and bodily functions be resolved without surgery?

Anotherwords, forget that it was prostate cancer.. assume I had somehow bruised, impaled, lack of blood or some other issue with the prostate gland that wasnt cancer, and needed to be removed?

I guess i'm wondering if indeed there arent two seperate issues involved. 1. Treating the instant problem of needing to remove a decaying gland. 2. treating the cancer in a way to stop it from spreading.

If all we were concerned with was #2, then I agree, in hindsight, that your suggestions might be the preferred route.

Let me ask you this, if you had to remove a prostate for ANY reason, would you still suggest rad & ht? Curious.

My case was complicated by scarring from a previous emergency apendectomy as well as a broken pelvis.

I do continue to appreciate the honest discussion.
Posted 7/20/2012 2:44 PM (GMT 0)
Bob, this is now above my pay grade!  I was referring primarily to your #2.  I am far from competent to comment on the other issues you raised...

Jim

Posted 7/20/2012 4:38 PM (GMT 0)
Bob,
I certaintly don't completely understand what you mean by a decaying prostate. Never heard of that; so I can't comment.
In general radiation does not remove the prostate. Radiation releases very small energy particles that in very large doses kills all cells, but in small regulated doses affects the DNA of only cancer cells and keeps them from dividing. If they can't divide they can't grow and they die off. Normal cells are usually unaffected and keep replicating. So your prostate's normal cells still function to a lesser extent, and certain cells like nerves, ureatha ect. which are more resistant to radiation continue to function as normal.
The advantage that radiation has is that it treats the entire prostate and also about 15mm into the prostate bed where most positive margins occur. It can also treat the nerves and seminal vessicles without damaging them. You don't have to know exactly where the cancer is as the entire area is treated. After radiation you still have an intact prostate with living normal prostate cells this is why radiation patients never have a psa that goes to zero.
If a patient has other issues, such as strictures, or an overly enlarged prostate or other issues that affect the urinary tract then surgery would be the preferred treatment as it would resolve these isssues whereas radiation could make them worse.
Where radiation sometimes goes wrong is that if not properly applied some areas like the bladder and rectum get more dose than they should and normal cells in those organs are killed. The newer forms of radiation strive to limit the dose to these areas, but about 5% of the time these areas are damaged.
Salvage radiation is used to clean up areas that surgery had missed; these areas are usually around the nerves or in the apex where it is difficult for a surgeon to remove all prostate tissue and for those instances where the tumor has extended into the prostate bed and the surgeon could not identify where the microscopic cancer cells stopped. Salvage radiation is very effective in these instances as it treats a wide area and kills the microscopic cells. This is why I always make the point that if salvage radiation was effective than primary radiation would also have been effective.
Hope this lends some clearity to the discussion.
JohnT
Posted 8/2/2012 6:33 PM (GMT 0)
Bob,

Was there any concerns with all that tumor that your psa was only 4 ? I just had my surgary and had a very large tumor involving 25% of 88 gram prostate Gleason 3 +4 . My doc was not worried about it . Just sent off my slides to John Hopkins to see if the path is wrong.

Moose
Posted 8/2/2012 6:52 PM (GMT 0)
Hi Moose.

Not sure what you are asking..

My 1st psa test ever was 4, so the urologist actually said 'ok, come back in a year'... but then said "while your here, might as well have a DRE"..

And he immediately said "that changes everything" apparently it was bulging on one side..

Then the biopsy showned 3+4 Gleason.. and they assume with the psa that it might be contained in the prostate.

Since that uro was here on Cape Cod and dealt mostly with men older than myself, and since they didnt have the robot if I wanted, I went to Boston Medical Center, where that uro felt it was likely contained and "lets get it out"... well after it was out we found out it had already escaped the prostate (pos margins)... so the rise in psa afterwards was not unexpected, and radiation was warrented (in my/our opinion), which I had in Feb 2011 - then tested in March 2011 Undetectable, Dec 2011 Undetectable, and June 2012 Undetectable.

Dont now if that addresses your quesry.. happy to try again if it didn.t

Hope you get well.. and soon!
Posted 8/2/2012 6:57 PM (GMT 0)
I guess my question was with a large % of tumor you said 75%
And only a psa of 4 was there concern that your tumor was not putting off much psa which makes it more agressive.
Posted 8/2/2012 7:07 PM (GMT 0)
I spoke with several uros and radiation oncologists throughout, and none of them indicated to me that they were surprised that with my ultimate dx (inc G4+3 with some 5) that my psa was only 4.

The uro who did my surgery said he was very surprised it had escaped the prostate, but none along the chain ever suggested to me that they expected a correlation between the psa and the agressiveness of the disease.

*Because it was found during my 1st psa test ever, there was no trend to analyze. So I guess that could mean it was slowly growing in there for along time, gaining mass. Or, it was really agressive and I happened to catch it quickly.

Wish I could offer you more insight.
Posted 8/2/2012 8:22 PM (GMT 0)
New Guy here

John T   it is my understanding that radiation what ever type, kills all the cells in the gland, good and bad

and you still have a PSA because it doenst get them all to save the urethra.

Posted 8/2/2012 9:07 PM (GMT 0)
GBYtech,
As I undestand there are still live nomal cells in the prostate that give of psa. It is also said that the prostate becomes "fallow" which means that the DNA of the remaining cells become resistant to any other PC.
Posted 8/2/2012 11:20 PM (GMT 0)
Going by your stats, I think you made the right decision. If I clock over into Gleason 7 or even much more Gleason 6, I'll be in for surgery.
Posted 8/3/2012 12:26 AM (GMT 0)
My uro-surgeon would not operate because of the very high probability of failure due to my high risk status. Another uro and my med-onc agreed. My uro would not subject me to the risks and side effects of surgery if he wasn't convinced it would be curative.

Numerous studies have shown that brachytherapy and IMRT are more effective then surgery and with less side effects in intermediate and high risk situations. I needed aggressive treatment and the HDR brachytherapy, IMRT and ADT3 is very aggressive treatment.
Posted 8/3/2012 12:52 AM (GMT 0)
Bob,
Yep! I would have done the same. In fact, I agree so much, I did the same at age 56. My PSA was 23 with a doubling time of 139 days and involvement was only up to 70%.
You do what you gotta do.
Jeff
Posted 9/3/2012 11:19 PM (GMT 0)
Hi Bob,

Hope things are going ok for you and happy Monday.
I was wondering how large your prostate was ?
I'm still searching for more info on the relationship between
tumor volume, prostate size and psa. It looks like your tumor as well as mine
didn't produce much psa. I'm glad to hear that your medical team
wasnt concerned as neither was mine.
They thought I had way less cancer so they only did a pet- bone scan and an pelvic MRI. If they had done more tests they may have
not done surgary. I was lucky the ran any scans as they also found a small kidney mass which has since been removed. So far I'm lucky though still worried about large tumor with low psa.

Wishing you well

Moose

Age 53
5/21/12 Psa 4.1
Biopsy 6/6/12 9 of 12 cores Pos from 10to80%
Had Robot on 7/18/12
Path show 88 gram prostate with 25% involvment
Gleason 3 + 4 contained
Had path sent to John Hopkins for 2nd opinion by an expert
They called it Gleason 3 + 3 with tertiary 4
No one is concerned about big cancer and small psa
Posted 9/4/2012 2:26 AM (GMT 0)
My husband and I are new to this and do not know nearly as much as all of you guys, but we are trying to learn. When we met with a radiation oncologist about a week ago I asked the question - how can we know if the cancer is at the margins? His answer was that when it is at the margins it can be felt during the DRE. I suspect it can be at the margins and not felt on the DRE, especially if it is microscopic, but this was his answer to us. We met with three surgeons. One said that there is a value to operating even when margins are known to be positive, one said that it would be unethical. If I could know, ahead of time, that my husband has positive margins I would prefer that he go the radiation route.

John, you make an interesting point about the prostate cells becoming "fallow". One of the arguments that one of the surgeons made in favor of surgery was that if my husband chose radiation, a new cancer could arise in the remaining prostate cells.
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