Worried About RP Side Effects; looking again at Brachytherapy

Here is my two cents.

First off, I just turned 61 and I am in good physical and mental shape.

I too was very leery of surgery and was opting towards brachytherapy because of the downside side effects of surgery. But after doing a lot of research, and talking with people that went through both options I decided on surgery.

My urologist said that brachytherapy gives me the same probably of a cure, but then he said that he
is one of the few surgeons in the south that does salvage surgery after failed brachytherapy or external radiation, and said that this outcome is very poor towards quality of life afterwards (colostomy bag, removal of bladder, etc.)

It has been 3 months since my daVinci robotic surgery. I have no regrets. I was at least 98% continent (minimal stress incontinence) and no ED issues. I had both nerves spared. My urologist told me that since I was healthy, in good shape and didn't have any medical issues (diabetes, heart disease, high BMI (overweight)) and no incontinence or ED issues prior to surgery that I should be fine afterwards. Of course he did say that there are no guarantees.

I dunno, Hank. I can't tell you what to do. Nobody can.

You pick your poison and take your chances with this stuff. But if I had it to do over again, I'd look much harder at brachytherapy than I did. Thinking as you do, I think you owe yourself a visit to the best brachytherapist you can find before having surgery.

Best to you, whatever you decide.

Jonathan

I believe that if you are in decent shape and don't already have incontinence or ED issues and if you truly found a good surgeon that with your stats you will be fine. I was 58 at diagnosis and was lucky enough to have relatives in the medical field who could point me towards the surgeon that was best. The skill of the surgeon makes all the difference in minimizing side effects from surgery. Don't let fear dictate your decision because you can easily find horror stories regardless of the treatment you choose. Go with what you're most comfortable with don't second guess or look back. Odds are in your favor that you will be fine.

Good luck,
Tom

Why did Hopkins say you were not a good candidate for AS? You are a Gleason 6 and only have 2 positive cores.

David

Also....consider your personality. Will you feel less anxious, less stress, less constant worry one way or the other? Considering your low numbers, which were similar to mine, your cancer may be totally confined to the prostate and surgery may be the total and immediate cure. I wanted it out! My surgeon teaches others how to do divinci and has done thousands of them. I didn't want to hear, somewhere down the road, that brachytherapy didn't work. You are not a candidate for a follow up surgery...........

I am 48 years old. I found out I had PC last Feb. I had a normal DRE but my PSA was elevated to 3.7. My initial biopsy was positive 2 of 12 cores. One 20% and 50%. We went to Vanderbilt and then on to MD Anderson in Houston. Best decision I feel I have ever made. At the time - I had no idea what path I would choose. I was considering AS, and looked into Proton Beam Radiation as well as brachytherapy. I highly highly recommend Dr Thomas Pugh at MD Anderson for any radiation. I did my homework and studied all my options. With all of the doctor's opinions and my final choice led me to have DaVinci Surgery by Dr. Louis Pisters at MD Anderson. He was able to spare 100% of the nerves. I am now 3 weeks post op. Unbelievable recovery so far. If you would like to private message me - I would be more than happy to discuss my results so far.

At your young age and ability to remove the offending gland I'd look hard at removal. I looked at everything saw Docs at Sloan, Fox Chase, UPenn

There are very few cancers that can be effectively cured and this is one but only by radical means.

We are all never the same. This is a life changer and sadly we all need to accept a modified future.

The stress is terrible. The impact on your self esteem. Your manhood and more totally blows. But I am glad I am here today.

Lean heavily on your family and close friends. I myself have cried more in the past 4 month than most rest of my life sans when my Mom passed. This is when those people around you need to hold you up. Never get negative. Keep moving.

Many have gone down this path and many will follow. Your exact path will be different from all of ours. But we all have a common goal to enjoy life.

Buddy Blank said...
I also believe the "no surgery post brachy" is a scare tactic. If brachy fails my guess is it fails because the cancer is already out and surgery would not have gotten it & you will need radiation anyway. Why have the side effects of both treatments? The success of brachy is better than/equal to surgery w/out the side effects of surgery.

I hear this often, but have to wonder when people say the cancer was "probably" already out of the prostate & that surgery would have made no difference. To say "probably" is also saying, "I'm not sure."

Or to say "guess" is also saying, "I am not an expert and do not know for certain."

My point is that, if a doctor talks of possible radiation (brachy or EBR) FAILURE, this must mean that radiation CAN INDEED fail -- even if it is still confined to the prostate. It would be a mistake to consider every one of these doctors to be engaging in "scare tatics."

As with any case, nothing can be guaranteed and, as with any technique, the skill of the doctor is probably the most important factor involved.

Now, the fact is that there ARE side effects associated with ALL forms of treatment, including surgery. And, of course, with radiation.

I would HIGHLY recommend to anyone just starting down this road -- who read comments from myself, and others -- to do themselves a great favor by consulting with the REAL experts. Consult with radiation oncologists AND uro/surgeons and learn the true ins and outs of ALL forms of treatment.

Radiation CAN fail. Surgery CAN fail. Sometimes it's the doctor, sometimes it's the choice of treatment, sometimes there is more cancer than meets the eye. The patient must investigate all options and make the best choice for themselves.

While I AM a guy who leans toward surgery, I absolutely NEVER advise a new patient to go straight into an operating room. I freely tell them that, depending on the case, radiation can also be curative. If all options are on the table for them, they must be aware of this so they can make the right decision for themselves.

I wish the radiation fans would do the same thing -- advise that ALL forms of treatment might be effective (depending on the individual case) instead of constantly referring to "scare tatics."

That is not in the best interest of new patients just joining the forum.

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) : 2/11/2014 2:22:35 AM (GMT-7)

Tall Allen said...
You are definitely a good candidate for AS - especially if you are able to get a confirming biopsy done with mpMRI or CDUS imaging by an expert radiologist.

You are also a good candidate for focal therapy, either kind of brachy (LDR or HDR), SBRT or pencil beam proton. Your prostate isn't likely to get away from you anytime soon, so why not investigate all your options. You only get one shot at this.

Hi Allen,

If you are referring to Hank T, actually he probably is NOT a good candidate for AS. If I recall, one of his positive cores was 90% involvement. The general rule of thumb is that no positive core be above 50%.

Chuck

I understood the reason for this no core greater than 50% was because this indicated that there were relatively large chunks of cancer in that part of the prostate. Some recent papers that I read extend this to 60%. But 90% would typically fail most AS criteria that I have seen.

This may be the very reason the BT might be the best option - it will radiate beyond the borders of the prostate and kill any cells that may have ventured nearby. This is an unlikely scenario if you actually are a Gleason 6 but we know from surgery stats that 30% of those with Gleason 6 cancer at biopsy are actually Gleason 7 or higher.

Post Edited (An38) : 2/11/2014 5:08:25 AM (GMT-7)

As I came down to my final decision, I found myself saying the same thing over and over to my wife - "Every single option sucks".

I think that's the most frustrating thing about the whole process. You can't really say that one way is definitively better than another.

I finally opted to go with surgery. I'm a mathematician by education, and as I pored over one study after another and one nomogram after another, I couldn't find any reason to truly favor one option over another. So, my two reasons for choosing surgery ended up being completely subjective. One was the "just get it out of there" mentality. The other was to deal with the worst of stuff up front, and hope it all got better from there.

The docs were leaning towards surgery in their recommendations, but even the surgeons acknowledged that brachytherapy and standard radiation therapy were reasonable options.

HankT, if you'd like to send me an e-mail I'd be happy to provide you with my input regarding LDR BT. Simply click on the envelope in the upper left corner of this post and it will open up my e-mail.