Worried About RP Side Effects; looking again at Brachytherapy

"Not having surgery because of the side effects is not a valid reason." Really?? I've heard a lot of reasons for having or not having a treatment option over the years, but this one takes the cake.

The seriousness of the side effects are the MAIN reason not to have surgery when other less onerous and more effective treatments are available to the patient. The reduction of side effects is the main reason that other options such as focal treatments, radiation and ablative treatments even exist and continue to evolve.
For less aggressive cancers the reduction of side effects should be the MAIN reason in choosing a treatment option because all conventional options have similar cure rates and the probability of dying is extremely low. In cases where the cancer is aggressive the most aggressive options including combination treatments should be used with side effects being a secondary consideration.

If side effects are not an issue then why do over 50% of posts in this forum relate to either side effects or reoccurrence from surgery. None of the radiation forums have even close to this number of posts dealing with side affects or failed treatments.

John T said...
"Not having surgery because of the side effects is not a valid reason." Really?? I've heard a lot of reasons for having or not having a treatment option over the years, but this one takes the cake.

The seriousness of the side effects are the MAIN reason not to have surgery when other less onerous and more effective treatments are available to the patient. The reduction of side effects is the main reason that other options such as focal treatments, radiation and ablative treatments even exist and continue to evolve.
For less aggressive cancers the reduction of side effects should be the MAIN reason in choosing a treatment option because all conventional options have similar cure rates and the probability of dying is extremely low. In cases where the cancer is aggressive the most aggressive options including combination treatments should be used with side effects being a secondary consideration.

If side effects are not an issue then why do over 50% of posts in this forum relate to either side effects or reoccurrence from surgery. None of the radiation forums have even close to this number of posts dealing with side affects or failed treatments.

I think it's an individual thing, John.

At my age and in my situation I thought surgery was the best option for me vis-a-vis a cure and I went into it knowing I could have side effects. I was positive I'd overcome them, but always knew the potential was there.

I also considered the potential side effects I could have short term and longer term from other forms of treatment.

Highlander said...
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%.

Actually he is a good candidate for AS. You will have to get a new thumb.

According to current NCCN protocols, all low risk men with life expectancy ≥ 10 years are good candidates for AS. They define low risk as GS6 and PSA<10 and stage T1-T2a.

Number of cores and % positive cores (and PSA density) are used only to define a "very low risk" category for whom AS is also an option.

- Allen

Tall Allen said...

Highlander said...
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%.

Actually he is a good candidate for AS. You will have to get a new thumb.

According to current NCCN protocols, all low risk men with life expectancy ≥ 10 years are good candidates for AS. They define low risk as GS6 and PSA<10 and stage T1-T2a.

Number of cores and % positive cores (and PSA density) are used only to define a "very low risk" category for whom AS is also an option.

- Allen

The new thumb says the same as the old one. Here is an excerpt from a Johns Hopkins article that you might want to read:

**************************
Eligible men should meet the following criteria for Very Low or Low Risk Disease:

Very Low Risk Prostate Cancer

Life expectancy less than 20 years
Cancer not felt on digital rectal examination (stage T1c)
PSA density (PSA divided by prostate volume) is less than 0.15
Gleason score is 6 or less with no Gleason pattern 4 or 5
No more than 2 cores with cancer, or cancer involving no more than 50% of any core on at least a 12 core biopsy

Low Risk Prostate Cancer

Life expectancy less than 10-15 years
Cancer not felt on digital rectal examination and/or small nodule (stage T1c or T2a)
PSA below 10ng/ml
Gleason score is 6 or less with no Gleason pattern 4 or 5 on at least a 12 core biopsy
**************************

The full article is here: http://urology.jhu.edu/prostate/advice1.php

I find it difficult to trust the differences between "very" low risk and low risk PC. With 20-30% of all biopsies UNDERestimating the true aggressivness of the tumor(s), I think the very low risk stipulation of no more than 50% involvement is the best way to go. Anything less is playing games with one's life.

Chuck

Buddy Blank said...
Chuck none of us are doctors. Some are experts. I don't count myself as being one.

My opinion is that telling a patient they can't have surgery post-radiation is a myth, or scare tactic, without a lot of practical meaning. Why would someone need surgery if radiation fails? Maybe you can explain that to me. I am at a loss.

Age is a another radiation myth for me. I've heard "old men get it radiated, young men get it cut out" more than a few times on forums and that simply is not true.

All treatments can fail. We all give it our best shot and pray.

Hi Buddy,

The difficulty of removing a prostate, after failed EBR, is a fact. It is not a myth or a scare tactic. There is a lot of scar tissue that builds up around the prostate area from EBR -- this makes it a very difficult task, at best, to access the prostate in order to remove it. There are only a few doctors who will attempt it.

Why would someone need surgery if radiation fails? Radiation generally should do the trick. But NOTHING is foolproof or 100%. Some rad fans seem reluctant to accept that even radiation can fail. And, if it fails (probably not very likely, but not impossible), the "gold standard cure" of prostatectomy is seldom an option.

In short, if radiation SHOULD fail to cure a cancer that was confined to the prostate, the patient has forfeited the option to simply remove the prostate and eliminate the cancer through that method.

Hence, salvage radiation is an option if surgery fails -- but salvage surgery is the real myth here.

That is why many would prefer to simply remove the gland -- and, in theory, the cancer along with it -- and be done with it all at one time. And, it makes perfect sense that -- IF the cancer is still confined to the prostate -- removing the "baby with the bathwater" brings on an instant cure.

Removing the prostate is also the only way to truly examine the intrinsic nature of the PC -- through the post-op pathology. That is the only current way to know if the cancer was as predicted by the biopsy or if it was more involved and aggressive than the prediction shows.

As you say, none of us are doctors. And the best we can all do is keep posting, for new arrivals, ALL of the customary options that are available. Thus, as a surgery guy, I STILL INSIST on telling new patients that radiation MAY be the best for them. They need to make such a personal decision and they DESERVE the right to know about ALL forms of treatment -- the good & bad.

Make no mistake, there ARE side effects even with radiation. Some people post as if the SE's with surgery are horrible and wonder why people do not opt for radiation instead -- as if there were no SE's to deal with from radiation. This is doing a terrible disservice to new patients who are here to read about their new situation.

These patients need to be aware that they should consult with specialists of ALL forms of treatment so they can learn the chances of cure with each option AND with the SE's they they will probably have to accept no matter what they choose to do.

But the bottom line is that everyone deserves to know that there are options out there beyond whatever any individual here urges them to take.

Thanks,
Chuck :)

Post Edited (HighlanderCFH) : 2/11/2014 5:27:43 PM (GMT-7)

Well said Chuck!

I asked my surgeon WHY you could not have surgery after radiation. He said that the prostate is like cement and it is very hard to remove, and my surgeon has done over 6,000 Da Vinci's.

ALL treatments have side effects. My decision for surgery was because I wanted the cancer out and I did not need a cancerous prostate hanging around inside my body until my dying day.

Everyone needs to gather all the information they can, list their priorities and choose the best treatment for them. For me, side effects came way after fighting the cancer.

Bill from Florida

Buddy Blank said...
Chuck surgery is not a Gold Standard. I really wish you would quit referring to it as such. There is no Gold Standard. There has never been any head to head trials between the treatments. Dr. Walsh can call it a Gold Standard but he is incorrect. If you, or Dr. Walsh, have the head to head trials proving it the Gold Standard I would love to read them.

I am aware of the prostate condition post-radiation. I believe those of us who have been around these forums have heard it at least 1000 times now. I never said one word about removing the prostate post-radiation. There would be no need to remove it post-radiation. Tx would fail if the cancer had escaped so removal would never have cured it. And if the cancer is out, or close, surgery would never cure it either. There are other treatments than surgery or radiation and I do believe a different type of isotope could be used to seed twice (but don't quote me on that).

You like to talk about Gleason's being off (you use the 30% figure) so quite a few surgeries, per your own words, are a guess. I wanted to take the guesswork out as much as I could so picked brachy. If I had picked surgery and my Gleason fell into your oft-quoted 30% I'd have to have salvage radiation. What would my insides look like after surgery and radiation Chuck? How about the sx of both treatments?

Are you suggesting people risk removing a prostate, knowing they might have a 30% chance that radiation will be needed post surgery? Hardly.

Once again, you seem to be arguing for removal of a prostate just so the pathologist can tell you what the true Gleason score is. Is that right? I don't believe that is one of your arguments for surgery but I have heard it like 20 times now.

With brachy sx compared to surgery are much less. I have no erection problems and no urinary issues to speak of. I never said radiation is not without risks, or doesn't fail. I said it has less side effects and an equal to, or better than, cure rate. My procedure took about 45 minutes, maybe less.

Cure. Out. Cancer gone. Healed. Etc. are all words. I don't know if cancer goes into remission or we are cured. God I hope all of us are cured from whatever we decide and it is a tough decision to pick.

Sorry Buddy,

But I will continue to reference Dr Walsh's -- and others' -- references to surgery as the GOLD STANDARD. You may not like that, but I cannot help how you might feel. Remember that those are NOT my words. They are the words of specialists whom I "suspect" have credentials far greater than you or I.

If you feel comfortable and qualifed to proclaim Dr Walsh to be incorrect, you are perfectly within your rights to say that. That's the beauty of free speech -- I suppose. LOL

I like to talk about Gleason's being off? No, Buddy. The STATISTICS like to talk about this -- I merely reflect what those stats are saying. I am not any expert who can make stats up like that -- those simply ARE the stats given by medical records. Once again, you seem to be attacking what you interpret as MY comments.

Once more, I am only reflecting what I have read. I do not try to fight reality and neither should you.

You really seem to be arguing inside a vacuum with those comments regarding "surgery would never cure it either," or "people risk removing a prostate, knowing they might have a 30% chance that radiation will be needed post surgery? Hardly."

You seem to have a penchant for placing every case into the same category as if one size fits all. This is not the case. Sometimes radiation is the better choice, sometimes surgery is the better choice. It's a matter of each case having it's own individual size -- and NOT one size fits all cases.

You are also falling into a very subjective loop in saying that I argue for removal of the prostate. Many of you on the radiation side seem to push ONLY radiation and exhibit a hostility toward surgery. I am a reporter for a large daily newspaper -- a job that requires me to look at both sides of every issue. I am a hard news reporter, which is different than being an editorial writer.

As such, my training requires me to NOT push only surgery as what a person should do. Even though surgery IS the gold standard cure (that is, for PC that is still confined to the prostate), I also give fair balance to the OTHER side of the option coin -- that radiation can also cure. It is up to the individual patient to make the determination of which side of that coin is best for them personally. It is NOT up to me to push surgery on them -- and it is certainly not up to YOU to push radiation on them.

I'm pleased that you have no erection problems with radiation. Lots of people have no erection problems after surgery -- and there ARE lots of people who HAVE written about their erection problems after .... sorry .... radiation.

Once again, it is NOT a one size fits all.

And I wish that more people would come to realize and respect this.

Take care,
Chuck

Thank you. NOW you are being fair and balanced. LOL

Take care,
Chuck

Myth: Surgery can not be performed after brachytherapy

Fact: This is not true. However most surgeons are not trained to do this procedure and it must be done by an experienced surgeon who has performed it many times before. The likelihood that a brachytherapy patient will face a local recurrence is quite low, approximately 3% 6. In the rare cases when there is a local recurrence only surgery can be done successfully. However, a local recurrence can be associated with distant recurrence which would make the value of removing the prostate in this situation questionable. Of note is that Prostate Cancer Center of Seattle physicians have developed and are treatign patients with local recurrence after external beam radiaiton or brachytherapy with focal , noninvasive treatments. See description on home page.

http://www.prostatecancertreatmentcenter.com/faq/myths/

We can also cite Grimm on various treatments. I believe it gave brachy a slight edge but forget at the moment. There are a lot of guys who know a lot more than I do. I am just tossing out ideas to chew on.

Chuck you yourself told me "radiation is best for older men" - unsure why you're denying it now.

I again am asking you to prove, via trials held, that surgery is "the" Gold Standard for PCa treatment.

I would appreciate it if you stuck to facts instead of myths.

Can you cite ONE study proving surgery is better in terms of cure and side effects?

I would say surgeons have a bias for surgery and radiation doctors for radiation but what I want is a head to head trial for men except I sort of doubt there ever will be one. Who would volunteer to have someone else pick their treatment etc.

You said it at your forum. I probably have it saved. I might have saved it because I was so TAKEN ABACK by the statement. We discussed it then. I will try to find it tomorrow on my office computer.

I believe you remember our discussion on the subject months ago.

Now can you please give us the study proving surgery is THE Gold Standard? If not can you stop referring to it as the Gold Standard as that is not a correct statement.