Just Diagnosed

Drowl, you asked "how does one make the initial choice between surgery and radiation". I can share with you my spouse's decision-making process. Good luck to you in making your decision!

First, he and I both started reading everything we could get our hands on after his first PSA result of 28. After the biopsy and official diagnosis by the 1st urologist/surgeon, we scheduled 2nd and 3rd opinion appointments with two more urologist/surgeons.
- The 1st urologist/surgeon recommended either open RP or brachtherapy to be done by her. She ordered a Prostascint scan, bone scan, pelvic MRI, and chest X-ray.
- The 2nd opinion urologist/surgeon (chairman of urological department) recommended open RP [period] to be done by him.
- The 3rd opinion urologist/surgeon agreed with 1st and 2nd that open RP was an option (and recommended the 2nd opinion urologist/surgeon as the best) but strongly encouraged my spouse to meet with a radiation oncologist before deciding. He also prescribed bicalutamide to put the PCa in the "deep freeze" (his words) to give my spouse time to research and decide.

We then scheduled an appointment with the 1st radiation oncologist (who was recommended by the 3rd opinion urologist/surgeon) who recommended a combination therapy of ADT + external beam radiation + brachytherapy, all to be done by him. He showed us slides from a study done by Dr. Peter Grimm (http://prostate-cancer.org/PDFs/Is14-2_p3-11.pdf).

Still confused, we sought the advice of a medical oncologist who specializes in PCa - Dr. Charles "Snuffy" Myers. Dr. Myers prescribed Avodart in addition to the bicalutamide, and referred him to Sand Lake Imaging for an MRI with Ferreheme contrast and F-18 PET bone scan. He recommended that we consult with another radiation oncologist - Dr. Michael Dattoli. We sent all medical records and then he met by phone with Dr. Dattoli who recommended a combination therapy of ADT + external beam radiation + brachytherapy, all to be done by him.

His goal was to choose the treatment he believed most likely to result in long-term cure. He scheduled open RP surgery in November but cancelled it to investigate the combination therapy more fully. In the end, he chose combination therapy of ADT + external beam radiation + brachytherapy. He chose Dr. Dattoli over the local radiation oncologist based on experience and peer-reviewed, published results. He has also made substantial lifestyle changes with regard to nutrition (following Dr. Myers' nutrition guidelines) and he is trying to exercise more. On a side note, his cholesterol dropped significantly after introducing the nutrition changes.

We don't know now and won't know for some time whether this treatment plan will result in long-term cure. He made the decision he felt most comfortable with and we are very hopeful. (It happened to be the one I was most comfortable with too but I backed him 100% whatever he chose). At this time, he doesn't have incontinence or erectile dysfunction. He does have some urinary burning and fatigue, which are expected side effects of the radiation.

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Age 49, PSA 28
9/11/2012 - Biopsy (blind)
9/17/2012 - Diagnosis
- 8 of 12 cores positive, high volume (all 80-95%), PNI, Gleason 4+3=7 (1st and 2nd opinions)
9/24-26/2012 - Prostascint, bone scan, MRI of pelvis w-w/o contrast, CT scan of pelvis w-w/o contrast, chest x-ray (all negative)
10/1/2012 - started bicalutamide (generic Casodex)
12/1/2012 - started Avodart
1/21-23/2013 - MRI of pelvis/chest/abdomen w/Ferreheme contrast, CT scan of pelvis/chest/abdomen, F-18 PET bone scan (all negative)
1/23/2013 - Trelstar injection (3-mo.)
2/19-4/16/2013 - 37 4/24/2013 - 45 palladium-103 seeds implanted
4/25/2013 - Trelstar injection (3-mo.)
To be done 7/22-8/9/2013 - 10 external beam radiation treatments (DART)

Just had my first meeting with radiology oncologist to discuss my options from his perspective. Very good doctor and very approachable..he spent over 2 hours talking to me and answering my questions. The upshot of the meeting was his strong suggestion that my best option is hormone therapy + radiation therapy. Have you had experience with this and if so what are your general feelings. I feel i should be asking a more specific question but still a newby to the wonderful world of PC and still pretty overwhelmed. He has ordered a bone scan for next week, and i will be calling my surgeon tomorrow to have further discussions with him regarding surgical options. My psa is 10.5, my gleason 4+4=8 and my prostate is unremarkable upon palpation. The radiologist says I am an ideal candidate for this.

Based strictly on my biopsy my surgeon says he does not believe the cancer has spread, the radiologist is unconvinced of that. I guess thts why the bone scan is being done. Any comments you have are welcome. Best wishes to all of you...Dennis

nothing worse in this process than being torn between different treatments and different doctors.

I'd say the best way to decide is to talk to various experienced practitioners in both fields and then go with your gut.

I was told that both would be successful in my case so it wasn't so much about being worried about picking something that would fail me.

One of my motivating factors, knowing that all things considered the outcome would be about equal was a practical one, I didn't want to bother with dozens of sessions and an extended process, I wanted to get it over with, get it out, get a pathology, hope for the best in terms of pathology and SEs and move forward from there. I was also concerned about potential long term SEs related to radiation given my very young age.

Drowl,

The bone scan will show if you have obvious metastasis to the bones.

An Endorectal coil MRI is often useful for determining the extent of spread (if any) and whether the tumor has invaded the prostate wall and other soft tissues, such as the bladder, or rectum, etc.

That is why in my first post, I said that I personally wouldn't make any decision unless there was some other imaging done.

In the rare event that the tumor escaped the prostate and invaded the bladder (my husband's scenerio) surgery would have required the removal of his bladder. Removing his bladder then took away his option for radiation, as the bowels would fall into the void where the bladder was and make RT extremely dangerous.

If he had not had this imaging to determine the spread, imagine his surprise when he awoke from surgery to discover his bladder had been removed also.

Hormone Therapy reduced his tumor load to the point where he finally had an option (initially, he had none other than HT.) He went with ADT and RT even though radiation was initially his last choice. We simply couldn't argue the science and make it fit our preference.

Thus far, we can't complain with the plan. He's still pulling as close to zero's as possible and certainly surpassed M.D. Anderson's expectations.

Personally, I don't understand why this imaging is not used more often in helping a patient understand that which they can already see, or not. It sure did take any confusion out of our decision.

Best of wishes in whichever treatment you choose.

Newspaper, my boss had a Gleason 8 and did a combination of HT, radiation and BT and after some minor/annoying SEs the first few months (didn't prevent him from coming to the office) finished up scoring zeros and is very happy with his results. He didn't like the idea of surgery and ironically is now considering surgery for lower back problems which is possibly not a wise choice given what studies show in that area.