Recently Diagnosed - Surgery or Radiation

Hey Civitas... I understand the daunting task before you. I faced it just a few months ago as a 45 year old, now 46.

Here's how I thought about it... Radiation is a better follow up strategy than initial treatment because, as you noted, once you radiate, the surgical option disappears. Radiation also poses a risk of creating cancer in another part of your body somewhere down the line. Radiation, in general, is not a very appealing strategy as it ravages the body. It kills cancer but it kills you a little, also.

Surgery is the "scorched earth" let's hit a grand slam strategy. It allows for salvage radiation therapy, which I wouldn't choose if it becomes suggested for me. Who really wants things given at birth cut out of them? The side effects are very troubling but do you want to live with them, or potentially not live at all?

Initially, it was a huge struggle for me. I really wanted to choose some newer cutting edge treatment option but I never felt comfortable with the data available regarding it's ability to be curative in any sense.

Surgery seemed to be the one option that granted what I wanted most...to continue living to see my children grow up. (I have 3 under age 13) Surgery is more immediate. You go in...it's over, your pathology soon follows and you can go about your business. There is nothing foreign in your body that your body doesn't want there as there is in radiation.

While neither is "natural" I felt surgery was closer to natural than radiation. We can live just fine without our tonsils, appendix, gall bladder, wisdom teeth, etc...so how necessary is our prostate and seminal vesicles once we're done procreating?

The side effects of this surgery aren't pleasant. It is very much up in the air which way it'll go for you. I'm continent so I consider that along with a clean pathology a HUGE win. ED is a concern... I was like an 18 year old prior to the surgery. It turned me 70 overnight, but I'm going to find that Benjamin Button and push and get back as close as I can. There has been progress in that regard and I'm incredibly optimistic about my long term life prognosis as well as my ED one.

My thoughts and prayers for you as you wade through this difficult process. I'm hoping your decision becomes as clear for you as mine did for me.

Welcome to HW, sorry you need to be here.

I went with IMRT because I didn't want surgery due to possible heart complications. With your numbers you'd do fine with either but in the end I'd go with what you're more comfortable with. The long term side effects are about equal or trade off enough to be about the same. I have two brothers and we all have PC (all G7), one did surgery, I did IMRT and another brother did Brachy - we're all doing well and have about the side side effects at about 2 years out.

Proton is difficult because most insurance still considers that experimental and some studies suggest it's no better than IMRT (plus it's more expensive) so it's largely not covered.

It's hard to decide because at your numbers, either treatment will likely be curative and the odds you'll need a second treatment are likely very low. There is very little science that can defiantly point you to one treatment path or the other.

Hang in there and keep us updated on your progress.
Andrew

Check with UFPTI, MD Anderson, or Loma Linda. They will help you with insurance issues. It may be difficult to get coverage for Proton, but I think it is worth it. I really don't understand the argument that once you radiate you cannot have surgery. If you radiate, the cancer cells in the prostate are dead and I see no reason to physically remove them. Recurring cancer after radiation is generally because it has escaped the prostate gland. I am a year post treatment and have no side-effects that I can attribute to the treatment. Don't give up on proton too easily. Good Luck with your battle.
Regards,
Kris

I chose surgery because I wanted the cancer out. I didn't want to wonder if every little ache and pain was cancer. Even though I hate them, your post surgery PSA will pretty give you the answer if your cancer is truly gone. I'm much older than you and I came through the surgery just fine--no incontinence and it took a few months, but no ED and no need for meds. Find yourself a top notch surgeon and you'll probably be fine.

Tom

Radiation, especially brachytherapy, has a higher cure rate across all risk classifications than surgery. On all quality of life studies it also has the least side effects. The only reason that salvage radiation is used after a failed surgery and is successful is because the surgery did not remove cancer cells that would have been killed the first time with radiation.
Countless studies have shown the risk of secondary cancers from Brachy is zero in 20 years. These are some of the many myths about radiation that continue to be espoused by both doctors and Uninformed patients. Proton is not any more effective than other forms of radiation, and is less effective on the higher grades.
Any of the treatment options would work well in you case. If your main concern is QOL then Brachy or Cyberknife should be high on your list.

I agree with you Inchoation. Despite what many claim, Dr Walsh still says that surgery remains the gold standard of cure that ALL other forms of treatment strive to match.

It is simple -- if the surgery is successful the patient has NO more PC in his body in just a few surgical hours.

Some say that a failed surgery with salvage radiation is using radiation that would have cured the entire cancer in the first place. That is the same as saying that radiation NEVER fails -- and I doubt that this is true. There are times when radiation does fail.

In such a case, it is usually too late to opt for surgery because of the scar tissue built up by the radiation treatments. This is what happened to my uncle. He opted for radiation over surgery -- and the radiation failed. He lived for 18 months basically bedridden until he passed away -- although not in any real pain and still having some quality of life. But I'm sure, if he could do it all over again, he would go with surgery & get it over & done with.

Some radiation fans often refer to the horrible side effects of surgery -- as if there are no SE's involved with radiation. But I've heard far too many stories from people who are suffering bad SE's from radiation treatments.

While there is a risk of SE's with surgery, much of it involves the skill of the surgeon. In my case, I was fully continent just a few weeks after surgery. I am just starting to recover in the erection department, but those ED problems were present prior to the surgery because of severe BPH. No other SE's and it hardly seems like I ever even had any surgery.

Now, to be fair, I was told at Mayo that radiation could cure my particular case as easy as surgery. And I might have opted for radiation except for the severe urination problems I was having from the BPH. The RO said that he could cure my cancer but radiation could do nothing to ease the urination problems -- and he then recommended that I see a surgeon and have the prostate removed. Since the surgery, I've been urinating like a firehose.

Now, neither treatment is a day at the beach -- a choice of whether to nuke your body or cut it open is not something that any of us wants to make.

But, for everyone reading this who is just starting down this road, do NOT just take my word or anyone else's here.

Instead, seek out a VERY EXPERIENCED radiation oncologist AND a VERY EXPERIENCED uro/surgeon and ask many questions. Learn the pros and cons involved with both types of treatment. Then you can make a decision based on YOUR knowledge -- a decision that makes you feel most confident in and comfortable with.

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Pathology showed Gleason 3 + 3, pT2c, N0, MX, R1
adenocarcinoma of the prostate.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1. PSA tests now annual.
Firm erections now briefly happening in early mornings, 2 years post-op.

Post Edited (HighlanderCFH) : 1/19/2014 1:06:57 AM (GMT-7)

Chuck,
You can go on The New Prostate Cancer Infolink and do a search for "Quality of life" or QOL.
There you will find a good number of published studies on the QOL statistics on all the treatment options. In just about every published study the rankings for the highest QOl are Brachy, external radiation, then surgery. You can also do a search on secondary cancers and will find zero for brachy and about 1-2% for external radiation, excluding the older ERBT2 radiation. This compares very favorable to the 1% medicare death rate in 30 days following surgery.
It is unquestioned that radiation, especially forms like Brachy and cyberkife have much higher QOL as judged by both patient questioners and followup studies when the universe of patients are considered. It is no coincidence that 50% of the posts on this site deal with the side effects of surgery or reoccurrance after surgery.
This does not mean that surgery doesn't work, but to label it the "gold standard" is ridiculous in this day and age. It was the "gold standard" in the early 90s, but the newer forms of radiation are much better now than 10 years ago. I would not call any treatment that leaves 50% of its patients with ED and 11% with permanent incontinence and 30% of patients with positive margins a "gold standard" for excellence.
Surgery works best for younger men who have the capacity to heal faster and have their cancers fully contained. The ability of radiation to treat 5 to 15mm outside the prostate and to hit areas such as the nerve bundles and margins gives it an edge for all cancers that may not be contained solely within the PZ or close to the nerve bundles.

Here's a little blurb from WedMd regarding a topic that may be of interest... (however, someone could post something very contradictory to what you find below, and that is an issue when trying to research your options)

Under the heading of: How Effective Are Oral Erectile Dysfunction Drugs?

Following surgery, as many as 60% to 70% of men who have had nerves spared on both sides of the prostate will regain erections. Results are less favorable for men who have had a single nerve spared or no nerves spared.

Following radiation therapy, overall, 50% to 60% of men regain erections with medication. However, current data are rather limited, especially for patients treated with radioactive seed implants.

Hormone therapy. Men treated with hormone therapy do not respond well to any erectile dysfunction treatments, but data are limited.

Hi Di,

I'm so very sorry to read about what your husband has been, and is still, going through.

I will keep him in my prayers!
Chuck

Hi Gunner,

Do you live in the Rochester area or are you staying at a motel near Mayo? Here's wishing you the best on Tuesday.

Who is your surgeon?

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Pathology showed Gleason 3 + 3, pT2c, N0, MX, R1
adenocarcinoma of the prostate.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1. PSA tests now annual.
Firm erections now briefly happening in early mornings, 2 years post-op.

Hi there,

You're lucky to live somewhat near Mayo. For us, it's a 6+ hour drive from Northwest Indiana. But well worth the trip. We usually stay at the Brentwood Motor Inn, which is just a block from the clinic. We usually just walk to the clinic through the underground pedestrian subway.

Good luck!
Chuck

Civitas good luck with whatever you decide. Picking one over the other is grueling emotionally but once you decide I think you'll feel better.

I've never agreed with Walsh saying surgery is the Gold Standard and don't feel the statistics back him up but who I am to challenge such a pioneer.

I had treated with radiation (brachy) after being bx'd at G7.