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Young man just diagnosed weighing brachytherapy or da Vinci surgery

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Posted 12/15/2012 9:01 PM (GMT 0)
Tudpock,

Squirm said...
Why is surgery more often considered in younger men, then say brachy or external beam?

Was his question wicked or was it wicked of me to try to answer it? I identified my response as coming from "the conventional wisdom" without saying whether I believe it or not. That is beside the point. The question was "why is brachy/radiation recommended less often for younger men?" So, I'll put it back to you: I'm pretty sure that many practitioners shy away from radiation for younger men. Without insulting me, or them, or blaming it on some sort of vast conspiracy of willful ignorance, why do you suppose that is?
Posted 12/15/2012 10:06 PM (GMT 0)
Guys, let's not argue on a thread started by a newbie looking for help.  Posting facts, studies, reports is what this young man needs - and 'opinions' from us yes - but let us not get so engrossed in our own stances to let that overshadow what we are trying to do, myself included if I am being honest with myself. 

To that end the gold standard used to be surgery, hands down, particularly because radiation therapy 10 years ago had not quite yet evolved to where it is today nor were long term data available - in 2013 that is no longer the case.  Is surgery still a good, viable option - absolutely yes.  Is it the best?  That depends - primarily on the patients PCa statistics as well as what is most important to each of us.

PeterDA I'll step in and answer the "why is brachy/radiation recommended less often for younger men?" by sharing some of the research results I found during that part of my own journey (bold and underlines added)

"Louis Potters, MD, chairman of radiation medicine at North Shore University Hospital and LIJ Medical Center, and his colleagues said in the paper published in The Journal of Urology that the urological community generally refers younger patients for radical prostatectomy -- the surgical removal of the prostate -- over radiation or no therapy at all. However, better screening and detection methods are discovering prostate cancer earlier in men. Knowing the long-term outcomes for each of the available treatments across the mid-to-late lifespan is vital. “It is even more important to understand treatment options and associated outcomes for younger patients diagnosed with prostate cancer.”

"In a study of 2,119 patients in different clinical stages of the disease, scientists looked at the five and 10-year so-called “freedom from progression” (FFP).   At five years, 90 percent of those who underwent the seed implant were treated successfully; and at 10 years, 86 percent had successful outcomes. Those rates did not change when the population was stratified into two groups – under 60 years old and over." 

“It appears that a prostate implant, when performed well, is an effective treatment option for younger patients,” Dr. Potters said. “Therefore, patient age should not bias one’s options.”
 
"Is surgery best for younger patients? Is prostate brachytherapy as effective as surgery in reducing the risk of disease progression and death over a five-to-10-year period? And what are the benefits of seed implantation versus directing radiation beams at the tumor?"

“There is no gold standard for outcomes in younger men with prostate cancer,” said Dr. Potters. According to the new findings, he said, “Outcomes are impacted by disease-related risk factors but not by age.”
 
"He added that the advantage to brachytherapy is that the risk for incontinence is small, and impotence is not nearly as common as it is following prostate surgery."

And here's more:

"Myth: Young men should have surgery."
 
"Fact: Published data (cite 1-2,4,7 below) has demonstrated brachytherapy to be an excellent and equal or better treatment option for younger patients. There is no scientific data to suggest younger patients have better cure rates with surgery. This has long been a misconception on the part of some physicians."

 

"A recent study showed that the 8 yr control rates for younger (<60 y/o) men were 92% vs 88% for > 60 y/o. In fact, there are numerous studies that show that there are no differences in cure rates with young patients (age 62 or less) versus older patients (cite 1-2,4,7 below).  Another recent study concluded that of patients with prostate cancer and treated with single (brachy, surgery or EBRT) approach, better urinary continence was exhibited in those who underwent radiation-based therapies. Furthermore, higher sexual function scores were seen in men who selected Brachytherapy (cite 3 below). Bottom line is that if you are a younger man you should explore all the options."

1.Ho, AY et al. Young Men have Equivalent Biochemical Outcomes Compared to Older Men After Treatment With Prostate Brachytherapy Volume 69, Issue 3, Supplement, Pages S90-S91 (1 November 2007)

2.Merrick, GS et al. Brachytherapy in men age less than or equal to 54 years with clinically localized prostate cancer. BJU Int'l (98), 324-328, 2006.

3.Frank SJ, et al. An assessment of quality of life following radical prostatectomy, high dose external beam radiation therapy and brachytherapy iodine implantation as monotherapies for localized prostate cancer. J Urol, Jun 177(6), 2151-6, 2007.

4.Sharkey J, et al. 103Pd brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer: a 12-year experience from a single group practice. Brachytherapy, 4(1): 34-44, 2005.

5.Ganswindt U, et al. Adjuvant radiotherapy for patients with locally advanced prostate cancer-a new standard? Eur Urol, Jun 23, 2008

6.Stone et al Int. . Radiation Oncology Biol. Phys. 76: p355-360 2010

7.Burri, R et al. Young Men have equivalent Biochemical outcomes compared with older me after treatment with Brachytherapy for PCa Int. J. Rad Onc. Biol Phys 2009 (article in press)

There are many more studies and reports available, including the "Grimm et al" report published just this year that includes 15 year results that echo the above - but I'll conclude my rather long post with the comments being made 'currently' in the medical profession including above:

Bottom line is that if you are a younger man you should explore all the options.

Aachen and all - I am NOT preaching one treatment over another, that is a decision that is far too personal for anyone to push on anyone else - however I also can't stand in the background with facts and data that need to be presented when some of these threads start drifting too far towards our own passions.

Peace. . . .

Posted 12/15/2012 10:43 PM (GMT 0)
Yooper,

Thank you for your very well stated and researched post. You are truly wiser than your years. You are so right we do not need at any time in this forum attack any other member for their passionate opinions. nono

We all need to remember that unless you are a medical professional none of us are experts on PC or its treatments, so any information we present is strictly opinion based on our own experiences and research.. scool

Terry

Posted 12/15/2012 10:50 PM (GMT 0)
That's a great post Yooper. I've been thinking that radiation would be more effective since it can treat the margins around the prostate too.

Also what I don't understand about surgery is the notion that if it fails radiation can be done. Why not just do radiation as the initial treatment and spare the side effects of surgery?
Posted 12/15/2012 10:53 PM (GMT 0)
Has seed treatment improved in the past 10 years or so?
Posted 12/16/2012 1:43 AM (GMT 0)
Terry and Squirm - thanks for the replies.  Again, I hope I didn't come across as too "pro-Brachy" - not my intent but I also wanted to make sure that the issues were clear. 

To be sure there are also strong arguments in favor of surgery - such as knowing the post surgery pathology of precisely what your stage of cancer is.  I just wanted to be sure Aachen and other newbies that will unfortunately join us understand that they need to do their own research, be aware of what the statistics are, be their OWN advocate with respect to the medical community as well as those of us out here - in order to be in the best position to make their own very, very personal and life changing decisions.

Again, Peace - we are all brothers (and sisters) in this together. . . .

Posted 12/16/2012 2:05 AM (GMT 0)
Squirm,
Seeding made a major breakthrough in the late 1990s due to better imaging and new templets to insure the proper dispersion. Imaging has gotten progressively better, allowing newer technologies such as High Dose Brachy to be introduced as mainstream. There has also been a lot more research on the doses necessary to kill higher grade cancers. With older radiation higher doses caused morbidity and lower doses caused reoccurrances. It took years to find the optimum dose to balance effectiveness to side effects. The better the imaging the more acccurrately the proper dose can be delivered to where it needs to go. The major issue with Brachy prior to templets was the problems of "hot spots", where too many seeds were placed together and "cold spots" where seeds were not placed.
Yooper,
Thanks for posting that. There are tons of myths about radiation that keep appearing. These originated 20-30 years ago when there was some truth to them, but modern radiation is far different than your father's radiation. Dattoli published 10 myths of Brachy in his book "Brachytherapy and IMRT".
You can expect unknolwedgable patients posting some of these myths, but it galls me to have doctors that should know better constantly repeating them to thier patients.
Posted 12/16/2012 3:27 AM (GMT 0)
Aachen,
I'm pretty much in the same boat as you, looking for answers and getting ready to make some hard decisions. I've read this entire post twice but you appear to be overlooking the statistic that's most important to me; What treatment option offers the best long term probability the cancer will not come back.

The reason most young, early stage people like you and I opt for surgery is because the data supports this is your best treatment option for long term survival but if you put your ability to achieve an erection above your life then Radiation might be the way to go.

If anyone has data that proves otherwise please post the links. My first post I don't want to seem like a know it all, in fact I would appreciate it if someone could prove me wrong.
Posted 12/16/2012 4:14 AM (GMT 0)
Welcome Bob Fisherman, sorry you have to join our fraternity but certainly welcome from us all. Thanks for sharing your PCa stats, actually very similar to my own - and that will help us, hopefully help you.

You stated "The reason most young, early stage people like you (Aachen) and I opt for surgery is because the data supports this is your best treatment option for long term survival" - and I have to respectfully correct you, that's simply old news. Please refer to my earlier posts (as well as JohnT's above) for more details, and, if you would like a copy of the "Grimm et al" report that will show you these actual statistics of the various treatment approaches please send an email my way and I'll reply with a copy of that report. I can't post a link to it because it was a report that I had to purchase, but their "terms and conditions" do allow me to share it with those that are "affected" as you, and Aachen, and all of us are.

With this being your first post, I would encourage you to join in, certainly, but please be carefull of making statements unless you have the medical studies / data to back that up.

Again, I am neither an "expert" nor do I have a medical degree - but I have comitted the past several months of my life, several hours a day - every darn day - to understanding this beast and the various treatment options. I attempt to share what I have learned to help others on their own journey.

Again, Peace and best to you.
Posted 12/16/2012 4:44 AM (GMT 0)
By all means please prove me wrong! I have not done anything yet so my options are still open but all the data I've seen so far suggests otherwise. When I plug my data into the calculator posted above http://nomograms.mskcc.org/Prostate/PreTreatment.aspx, I'm much more likely to have it come back if I choose radiation, try it yourself and tell me if I'm misreading the results.

Post Edited (Bob Fisherman) : 12/15/2012 10:08:40 PM (GMT-7)

Posted 12/16/2012 6:07 AM (GMT 0)
Peterdisabled, I get that you are anti-brachytherapy-anti-radiation and that's fine. We are all entitled to our opinions on this forum. But when you post things like implying that 50% of men will suffer some sort of long term radiological effects you are far outside of the conventional wisdom of modern medicine.

I believe that Yooper has posted an excellent answer to the question you posed and that is not unlike comments that JT or I have posted in the past. So, I won't be repetitive.

So, when you post comments that are wildly inaccurate, please don't be surprised when I react strongly.

Jim
Posted 12/16/2012 4:02 PM (GMT 0)
Bob Fisherman:

On the namongram choose details.  You will need a copy of the biopsy.

I struggled with this section quite a bit.  I did well on math and

conversions at one time in my life, not this time.  Have someone double

check, and triple check your data before entering.  It could possibly

change the percentages, when all the data is entered "correctly".

Posted 12/16/2012 6:37 PM (GMT 0)
Tudpock18,

Actually I am neither anti-brachytherapy nor anti-radiation. I considered brachytherapy for my primary treatment and wound up regretfully abandoning the option because the unusual size of my prostate would have required either an extended pre-treatment with ADT to shrink the organ down to a size that could conveniently be treated, or the application of so many seeds that I would singlehandedly deplete the available radioisotope inventory for the southeast US. As it turns out I have been unable to avoid the ADT (*sigh*) but on the other hand, since the grade and location of my cancer changed markedly with my post-op pathology report I would not have been as good a candidate for brachytherapy as I at that time believed myself to be.

I do believe that one of the things one must bear in mind with any radiation therapy (such as the adjuvant IMRT I just finished) is the possibility of late toxicities which tend to be more of a factor with radiation than they are with surgery (where the toxicities are mostly acute and immediate). The risk of late toxicity with brachytherapy are less than with external beam treatments and both are less now that they were ten years ago. But late toxicity is still a concern and they do affect young men more than older men because they have more time to experience them.

In my thought-experiment with the 2% per year 50% in thirty years figures I was just trying to show how a late toxicity with a low per-year probability per year could be affected by the age of the patient. The two percent figure I used was an example that struck me as reassuringly low to illustrate the point. I did not mean to imply that it applied to anything in particular. I have done a quick review of recent results in PubMed and the 2% figure may be a bit high.

Here's a recent study for instance:

www.ncbi.nlm.nih.gov/pubmed/23046084

They find, in part,

The incidence rate per 1000 patients for 0-2 years, 2-5 years and 5-10 years following radiation for rectal bleeding is 14.3, 15.9 and 6.5, respectively; for haematuria, 14.0, 8.2 and 1.3, respectively; and for ED, 82.4, 48.2 and 42.2, respectively. •  Just 5% of rectal bleeding occurs after 5 years from radiation vs 18% of haematuria cases and 22% of ED. •  On multivariate analysis, time to first onset of rectal bleeding was affected by the addition of EBRT only whereas the time to onset of haematuria was affected by the biological effective dose of the radiation and the addition of EBRT. •  The only factor on multivariate analysis to affect time to onset of ED was the age of the patient at treatment, independent of radiation dose or technique.
I think those figures can be added up.

Rectal bleeding: 14.3 + 15.9 + 6.5 = 36.7
Haematuria: 14.0 + 8.2 + 1.3 = 23.5
ED: 82.4 + 48.2 + 42.2 = 172.8

Ignoring ED (which they don't think is an effect of the treatment) we get 60.2 incidents per 1000 men in the first 10 years. That's 6 % in ten years. They suggest that rectal bleeding rolls off pretty sharply with time but haematurea is a more long lasting problem. That's not enough guidance to guess at a 30 year figure but I might be tempted to swag it at 9%. So, my thought experiment was high, at least compared to the study I quoted.

I'm not sure exactly how I got so wrong-footed with the Brachytherapy guys on the forum.
Posted 12/17/2012 12:06 AM (GMT 0)
  Quote from A Yooper - "With this being your first post, I would encourage you to join in"   Thank you, I will.   Quote from A Yooper - "but please be carefull of making statements unless you have the medical studies / data to back that up...."   "In a study of 2,119 patients in different clinical stages of the disease, scientists looked at the five and 10-year so-called “freedom from progression” (FFP).   At five years, 90 percent of those who underwent the seed implant were treated successfully; and at 10 years, 86 percent had successful outcomes. Those rates did not change when the population was stratified into two groups – under 60 years old and over."    I'm just comparing the data from the "medical studies / data" you posted above with the results I get from Nomogram calculator with my stats. With RP my chances of being "progression free" at five years is 97% and at ten years is 95% plus there is data that indicates a 99% probability of survival at both 10 and 15 years.  I also ran Aachen's stats and they are almost identical.  The Nomogram calculator doesn't offer the long term survival stats for radiation.   This is consistent with all three of the Urologists who I have consulted with thus far.  One was a general Urologist, one was a RRP surgeon, and one was with JHU's multidisciplinary practice who does both RRP and Radiation therapies.  They each told me my probability of not having a re-occurrence will 3 - 5x better with RP over Radiation and suggested that as my best treatment option.       
Posted 12/17/2012 12:52 AM (GMT 0)
Bob F and Aachen - please accept my very heartfelt apologies if I came across as trying to tell you what to do. Bob F - you selectively quoted me which is all good, but please don't ignore the parts where I say that this decision is up to each of us.

You challenge me to prove you wrong - that's not what this site nor I am about. My strong push back was to simply refute erroneous statements being made - and if I came across otherwise again I will absolutely apologize. We are all in this together as brothers against the beast - not against each other.

Now, with respect to your nomogram - you are correct. Nomograms are predictive tools that should indeed be used as part of your journey to make YOUR best decision. Please continue to do your research across all avenues, hopefully you will get to the point of "paralysis by analysis" - which is o.k.!

Indeed use the nomogram as the predictive tool that it is as part of your journey. I would also again encourage you to e-mail me so that I can share with you the "Grimm et al" study that reports facts on actual treatments - in this report you will see that after actual treatments LDR Brachytherapy / Monotherapy has better long term (15 years concluding with this report published in January 2012) than ANY other treatment approach.

I do understand your frustration, anger and all of the rest that comes with "you have prostate cancer" - and I am truly sorry if I did anything to make that worse.

Peace, and my very best to you both.

Jeff
Posted 12/17/2012 3:52 AM (GMT 0)
I didn't get the feeling you were trying to tell me what to do so no apology necessary there.  You have a lot of knowledge about radiation therapy so I think it's good that you are willing to share.   I hope my post didn't come across as being angry, I didn’t intend for it to come out that way.   Maybe a little frustrated but that has more to do with the situation that I'm in and the choices I need to make so please don’t take it personally.     The thing that got my attention here is you were quick to accuse me of making a statement without being able to back it up so I just don’t understand why you are referencing something that isn’t publicly available.   I'll send you my email address..                           Post Edited (Bob Fisherman) : 12/16/2012 8:55:34 PM (GMT-7)
Posted 12/17/2012 9:32 AM (GMT 0)
Bob,

The abbreviated "Grimm" study referenced by Yooper is publicly available. It is just that Yooper has purchased the entire study and has been kind enough to offer it and some other information to those trying to make a decision. I was 46 at diagnosis and it was key in helping me make my decision. Good luck with yours.

Greg
Posted 12/18/2012 4:56 PM (GMT 0)
Brachy-Wife chiming in.   My husband was 44 when diagnosed with a 3.74 PSA - we chose Brachytherapy.  Now, seven years out - he's doing great.  I can tell you that we used "stranded" seeding so the seeds were stranded together like pearls for less chance of migration - there was zero migration, relatively little side effects (other than fatigue) and he's doing very well.

If you are looking for a more detailed description - from diagnosis to (almost) current updates, please see my previous post - JustJulie's Brachytherapy Journey.

Best wishes in your decision.

Posted 12/18/2012 4:59 PM (GMT 0)
JustJulie,

Glad to see you chiming in on this topic. I'm sooo glad to see that your husband is doing great at 7 years out ! That gives me very much hope. I've wanted to contact you, but your email wasn't in your profile.

thanks again.

Post Edited (powellst) : 12/18/2012 10:06:28 AM (GMT-7)

Posted 12/18/2012 5:05 PM (GMT 0)
Glad to be chiming in (and even more glad to report we're now SEVEN years out).  I sent you an email with my home address but if anyone has any other questions regarding Brachy that they want answered, I'm certainly not shy so ask away.

So blessed my husband is in good health, especially at this time of year - Lord knows seven years ago our Christmas was not so Merry.

Blessings to all ...

JustJulie

 

Posted 12/18/2012 6:31 PM (GMT 0)
Hey Julie, glad to hear from you guys again and also great to hear things continue to go so well! Here's to the next 7 years of health and so on and so on - and best wishes to you for the upcoming holidays.

Best,
Posted 12/18/2012 8:33 PM (GMT 0)
Hey All:

I'm never really that far away :)

Wishing all of you a very Merry Christmas.  We are thrilled to be seven years post-brachy now with little to no side effects so for those of you looking for someone who has reached "long-term" goals, I guess maybe we're it at this point.  I'm not sure if there is anyone with a longer post-brachy experience but I can tell you my husband made his decision and never looked back ...

 

Posted 1/25/2013 2:12 PM (GMT 0)
Folks:

Aachen again.

Ok, that's not my real name. That's my dog's name.

Anyway, somehow I didn't click on the option to get email notices of posts here, so I didn't realize there were any.

Since my initial post I sought a second opinion at Johns Hopkins.

I went to the all day thing, where a whole roomful of people look at your slides, etc.

They ended up reclassifying me, from a Gleason 6 to a to a Gleason 7 (3+4).

I saw both surgeons and radiation guys.

All recommended surgery.

Primarily because of my age and the 10 to 15 percent chance that over my lifetime the cancer will come back.

If I have radiation first then from what they say surgery isn't a realistic option, so the treatment on reoccurrence would be basically hormones.

Not a fun thought.

The radiation guys actually said they didn't want me to have any type of radiation without four months of hormones right off the bat.

I already have partial ED so I assume my pecker isn't going to be happy either way I go.

I'm already resigned to having probably the injections to resume any sort of decent sexual activity. Speaking of that, does anyone out there have experience with that post treatment, after having had some ED prior to treatment.

Also I've noticed a general lack of interest in sex and such for the past year or so anyway. I initially went in for a checkup thinking I had low testosterone.

Since prostate cancer feeds on testosterone is it possible that even though I'm testing in the normal range for testosterone, that the cancer is basically eating it up and giving me symptoms like lack of sex drive, tiredness, lack of motivation, etc?

Any additional input anyone has is much appreciated.

And I personally don't mind those with very strong opinions one way or another posting. As long as it's valid info it's all good to hear. But I have seen some sortof crazy information out there and have spent a fair amount of time chasing down faulty data.
Posted 1/25/2013 2:42 PM (GMT 0)
Aachen,

I had very similar numbers as yours but I had NO loss of libido before my surgery and ED was a problem for me as well because of my high BP and the meds I take to control it. I used Viagra for 3 to 4 years before PC. I am not an expert, but even though the PC is fed by Testosterone I do not think it "eats"  enough to have any effect on the libido issue. My URO told me to not have high expectations on the ED side effect as I had ED going into surgery.  But I will tell you the weeks leading up to my surgery I used up all my Viagra and my prostate was returned with an empty tank and flat tires. smilewinkgrin

I am some what curious as to why the radiation guys told you to do the surgery?  Was there an issue with a large prostate or the size of the tumor?

Good luck as you now start your journey.

Terry

Posted 1/25/2013 2:58 PM (GMT 0)
Aachen,

I chose to be treated with surgery (DaVinci); however, my first choice probably would have been brachy except for the fact that the doctor would not have done the brachy unless I had undergone a around of HT to shrink the prostate. I was with Kaiser (in Denver) and the only two options that they offered me were surgery and brach. The surgeon was a relative rookie.

Results have been pretty good. PSA has stayed undetectable; I was immediately continent; and ED is handled with pills and/or injections. One of the benefits of the removal of my prostate was that it cleared up problems I had urinating. I no longer had to get up several times a night and instead of taking several minutes I could go in a jiffy ... as James C. once described, I could now move the deodorant puck in the urinal.

Concerning injections, I recommendf you get a copy of Dr. John Mulhall's book, "Saving Your Sex Life". Its a guide for guys undergoing prostate cancer treatment and focuses on "Penile Rehab". Or, google his name and the subject matter and you can hear him speak to the topic. Anyhow, I've done injections (Trimix) and they are great; for me, there is no pain, they are quick (quicker than waiting for a pill to kick in), and they last. The part about them lasting is important ... too high of a dose can lead to trip to the ER. Work with your doctors when starting injections. I found the Kaiser doctors/nurses very helpful.

Best of luck as you go forward with your decisions .... you only get one crack at deciding your initial treatment.
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