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how the heck do you decide between surgery and radiation????

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Posted 4/16/2014 5:08 AM (GMT 0)
I have to admit i'm a mess....

background:  54 year old, married male, avon, indiana

PSA 6.02 dec 30, 13

biopsy done 03/14 with 5 cores positive  4 at 50% Gleason (3+4)  1 at 15% Gleason (3+3)

all positive cores on left side only.

PSA 7.38  april 14, 14

have met with both radiology oncologist and Urologist post DX.

Now it's time to decide whish option to go with and I havn't a freaking clue.  I've changed my mind about 6 times. I've talk to a few friends who have had the da vinci surgery but yet to talk to anyone who had radiology...  so confusing.  ugh!

Posted 4/16/2014 6:49 AM (GMT 0)
how many cores total? percent of cores positive is one relevant predictive factor.

Was perineural invasion (PNI) present?

how fast did your psa rise from 2012 to 2013?

did you have your biopsy slides read by a PC expert at a leading cancer center or a general pathologist at a small town community hospital?

can you get a doppler ultrasound to look for signs of extracapsular involvement?

basically if there are no waring signs for extracapsular involvement then both radiation and surgery are highly likely and equally likely to cure you and it's a matter of picking the side effects you can best live with.

If there are warning signs of Extracapsular involvement then radiation is probably a better bet. It can kill what is outside your prostate but near it, while surgery can't.
Posted 4/16/2014 7:43 AM (GMT 0)
sorry -- 12 cores total (6 per side)...

psa was done in 2010 (3.5) - 2013 (6.05)  none done in 2011,2012

no PNI that I'm aware of....

top indiana univeristy cancer center pathology department. (im more than comfortable with the results)

thanks so much for the input...

 

Posted 4/16/2014 10:59 AM (GMT 0)
You live in Indiana. Check out the Proton Therapy Center at Indiana University Health (Bloomington). With your stats you would be a good candidate for proton beam therapy. IU is one of the "old" veterans of the proton beam group. I went there for treatment 3 years ago and so far it has been a complete success. If radiation is a serious option for you, you definitely should check this out, especially since it is available in your home state.
Posted 4/16/2014 11:08 AM (GMT 0)
I'm an engineer so I used data and merit - demerit charts to help with my decision.

I found numerous charts and studies that showed the 5 yr, 10 year survival rates for both treatments were effectively the same. That meant I needed to factor that out of my decision.

Surgery Merits
1)The results give you the most accurate pathology report possible. They are holding the gland! I like having the data.
2) If surgery failed, radiation is available.
3) Small incisions and only the bad tissue is removed.
4) Recovery is within my control. Walk, drink, walk drink.

Surgery Demerit
1) 1/3 of men are still incontinent at 3 months. One in 10 is still incontinent at 1 year. But - Surgical incontinence can be fixed.
2) 50% chance of ED. But - pills pump injections can fix it in most cases.
I pooh poohed the above side effects because I was in great shape, never had ED, was not overweight and had frequent sexual activity. I figured I would be in the lucky groups and recover quickly.

Radiation Merits
1) The recovery is nil. Go there, get zapped, go home. Rinse and repeat.
2) Nil initial side effects

Radiation Demerits
1) Potential side effects, bowel or incontinence issues, 2 years down the road.
2) No 100% certain pathology report.

Other guys can add to the list and might argue my numbers a little but those were the numbers I had at the time.

Here's one more factor that I have found to be true in this, and other decisions. Any difficult decision that can be studied and argued ad infinitum from both sides means the differences are so small and the factors so out of your control, ultimately your decision really did not matter. The results are dominated by the other factors: the skill of the doc, infection, luck, your heart health, etc.
Will this coin land heads or tails? I can spend my life studying the coin, measuring its profile and determining the wind resistance of each face, measuring its weight, practicing my flipping technique all trying to answer the question. I can spin my wheels forever and be no closer to the truth. Sometimes you have to just flip it.

Find out if your insurance will even cover radiation. It is expensive. That might be a factor in your merit demerit chart.

Start exercising and getting in shape now. No matter which treatment you chose.

Good luck,
Jeff

PDA, Thanks for the edit.
Posted 4/16/2014 11:08 AM (GMT 0)
Been there, Brother, and I was a 'mess' too. At the time of my dx, I was working part time with lots of fellow retirees. I was 57...most were older. I talked to many guys who had survived pc. Most had had surgery. While all were obviously alive, none had the quality of life that I wanted. I was in a new relationship at the time, and I fully admit that I was more afraid of ED than I was of dying. I was in a bad state mentally until a very good friend referred me to a relative of his who had brachy therapy. I had no idea what that was, but I contacted him and finally had a ray of hope. I made an appointment with the oncologist who had done his treatment, and finally found my way out of what had been a very bad place for me.
My stats were similar to yours (PSA 6.1, 15 GL6 and 1 GL7 out of 60 samples). I'm not qualified to tell you what would work for you, but I can sure tell you that LDR brachy saved not only my life, but also the quality of my life.
God Bless
Posted 4/16/2014 11:28 AM (GMT 0)
It is definitely a tough decision. I opted for surgery and with a Gleason 8, I am happy I did. I am not saying radiation wasn't a good alternative but wanted the prostate out. It was more of a personal decision than looking at all of the data. I do know some have had the SBRT radiation and that seems like an option. I will tell you once I made my decision, I felt better. However, I do know it is a roller coaster of emotions. Good luck to you and keep us posted.
Posted 4/16/2014 1:01 PM (GMT 0)
It's a tough decision for sure. I, like others, just wanted it out and was more comfortable with that. 12 days post surgery I am 98% dry, one pad or less per day, and working on the ED. Same age as you and in good health, so I shared all your concerns as well. Was it the right decision? That can never really be answered with absolute certainty. Best of luck to you.
Posted 4/16/2014 1:05 PM (GMT 0)
Sorry you have to be here. These decisions are really tough. I have been trying since December to decide. Finally decided on HT/RT. My Gleason 8 and Possible extensions swayed me that way. The radiation oncologist said he would bet I would be back if I had surgery. (BTW he will suggest surgery if he feels it warranted). Visit with a medical oncologist. It sometimes helps to get a third view. Good luck with your decision and we all know what you are going through.
Posted 4/16/2014 1:18 PM (GMT 0)
There's an old philosophical argument that has been around for thousands of years in various forms.
A hungry donkey is walking down the road and finds itself between two similar piles of hay. The donkey can't decide which pile is closer and eventually dies of starvation. In other examples the donkey is both thirsty and hungry and finds itself between water and hay. It dies of thirst and starvation.
The point is: sometimes the best decision is to make the decision.

Right now you probably feel like you're being asked what condiment you want on your s**t sandwich. Neither choice is perfect. We've all been there, brother.

Just breathe. You'll get through it.
Jeff
Posted 4/16/2014 1:21 PM (GMT 0)
Heck - I ruled out radiation simply based on the large number of trips across town and how disrupted it'd be to my job.
Posted 4/16/2014 1:40 PM (GMT 0)
Well, one thing my doc said was that prostatectomy after rad is more risky or may not even be an option but, he said, radiation after surgery is an option. I opted for surgery because I felt that surgery gave me the best chance for getting rid of the cancer. I am 54 and have folks depending on me for a long time and I wanted, what I thought, was my best chance for long term PC free time. In my case, Gleason 6 with only transition zone PC identified, so far, I am at low risk even if I did nothing. I felt however, it was "selfish" of doing AS alone, so here I am going to have RALP on Monday. Having said all that, it is an individual decision as all are saying.

Best wishes whatever you decide, it is a tough decision.
Posted 4/16/2014 2:02 PM (GMT 0)
I chose surgery because of my personality. I didn't want to wonder about every ache and pain being cancer spreading. Even though I stress about every follow up PSA, it does tell me I'm fine when it comes back undetectable. I just wanted it out. If you are in decent shape and have no problems with ED now, you should be fine. The whole key with surgery is to find a doctor with plenty of experience. You would do equally well with radiation in all probability. Go with whatever your gut tells you and move on. The decision is the hardest part.

Best wishes,
Tom
Posted 4/16/2014 2:23 PM (GMT 0)
Hell of a choice isn't it?
The problem is that you'll likely do just fine with either treatment. I chose radiation because of heart/lung issues that the surgeon felt made surgery higher risk for me. I have a brother who did surgery. Two years later we're both doing fine. I haven't found the science or studies to clearly say one is better than the other.

This is a call that I'd say, just go with your gut instinct and what you'd feel more comfortable doing. Personally I hate be attacked by a knife and having my flesh cut open. Somethings just shouldn't be forced into a human body.

Remember that there are a couple of ways of doing the radiation - beam, or brachy seeds. The brachy treatments are an option too.

Have you considered flipping a coin?
Posted 4/16/2014 2:32 PM (GMT 0)
Worried Guy brings up a lot of good points in his posts.  I had Da Vinci surgery in 2010 and it seemed like the best way to go in my situation.   I weighed the effectiveness of surgery compared to radiation and it was a non-issue.  With surgery, if I needed treatment in the future for a recurrence, surgery or radiation were still options.  My prostate was badly enlarged so having it removed would clearly end future problems from the enlargement issue.  I also felt the possible after effects of surgery compared to radiation were more tolerable than possible after effects of radiation.  In my mind, surgery had more in the "yes" column than the "no" column than did radiation.  In either case, severity of possible after effect issues are unknown in advance.  I was a G6 with a psa of 5.2 so AS was also an option but I wasn't far from needing treatment for the enlargement issue and I figured surgery gave me the best shot at clearing up two major prostate issues with the most tolerable after effects.
Posted 4/16/2014 2:49 PM (GMT 0)
I have nothing to add than what has been said already.

I chose surgery.
Oncologist recommended surgery, and then if ever needed, I could fall back on radiation.
Posted 4/16/2014 3:16 PM (GMT 0)
turp you said above:

"so far, I am at low risk even if I did nothing. I felt however, it was "selfish" of doing AS alone"

Puzzling and troubling remark to me. Proper AS is not, "doing nothing". It takes teamwork between the doctor and the patient, frequent PSA tests, periodic biopsies, etc. Takes discipline to follow properly and safely.

For this with "entry" level PC, AS can be a godsend, as you can safely monitor what is probably a very small amount of indolent cancer, without any of the risks of either invasive surgery, or the risks of radiation, and if one's situation does change to the worse, in most all cases, one' still has the same primary treatment choices.

And I didn't get the "selfish" part, perhaps you have a misconception of what AS really is and isn't. Not trying to change your mind, whatever you do is yours to do alone, but just wanted to clear up what you were inferring with AS.

For those that qualify, AS is "treatment", and those fortunate enough to meet the safe criteria should strongly consider it. Having surgery, for a minimal amount of Gleason 6, sounds great on the front side. But if one encounters major incontinence and/or ED issues long term as the result, it may not look so good on the other side, when AS could have safely been utilized.

Just my personal opinion. I had both surgery and radiation, and both failed fast, and both left me with severe complications and side effects.

So I don't have a dog in the fight ,so to speak.

David in SC
Posted 4/16/2014 3:18 PM (GMT 0)
TC,

Much of the time you can tell what a man is going to recommend here on the forum by looking at his signature. By that standard I should recommend surgery. I guess I do. On the other hand I am a guy who is impotent and incontinent two years after surgery, so there's that for you to bear in mind. But on yet another hand, I went into surgery diagnosed as a very low volume Gleason 7(3+4) -- so little cancer diagnosed that my surgeon was reluctant to advise treatment -- and came out as a high-volume Gleason 9(4+5) -- a much more serious cancer requiring aggressive treatment. Because of my post-op pathology report I was immediately scheduled for adjuvant radiation and two years of hormone therapy to fully treat my suddenly more aggressive cancer.

I am coming up on the end of my treatment (the hormones end in July) and it currently looks like my cancer is thoroughly in remission (when you are a Gleason 9 guy they don't like to use the "cure" word.) If that holds up I will probably seek more surgery to fix the problems left by my treatments. Incontinence can be fixed nine times out of ten and penile implants have a higher success rate than that.

So what surgery breaks, more surgery can usually fix. If that makes sense to you then you are probably a surgery guy. If it sounds crazy to you then maybe not.

All your choices are good. Just choose the best doctor you can find -- a very high volume practitioner since all of the treatment options have ferocious learning curves -- and let that doctor take a whack at your cancer.
Posted 4/16/2014 3:30 PM (GMT 0)
I just went through 3 months of worry and research to determine what I wanted to do with my prostate cancer. After spending umpteen hours on the computer and talking to people I decided on SBRT radiation with cyberknife. Non invasive with only 5 treatments lasting about 45 minutes each. Super high success rate with low risk diagnosis with very few side effects. Success rate about 95 to 98% with about 6 years of data. I'm not far enough out to tell you how it worked for me but so far the side effects are minimal.

With your numbers I think you would be a candidate for SBRT and I am sure there are locations fairly close to you.
Posted 4/16/2014 3:31 PM (GMT 0)
TC, I'm a TC too,
Here's the good news (sic), You may qualify for both. I did.

But at least today I am doing well 7 years later. My surgical report is available here:

advancedpcatalk.freeforums.net/thread/86/sample-surgical-biopsy-reports
(I require a verified login to access my files at this site, but you can remain anonymous)

This will at least give you a glimpse of how the surgical side went. I immediately followed up with my advanced case with 28 months on hormonal therapy and radiation. All done in a complimentary setting (adjuvant).
Posted 4/16/2014 3:34 PM (GMT 0)
One of the keys to my success is that at all times I was in a high volume center with physicians with a lot of experience treating prostate cancer. That should very high on anyones list of priorities.
Posted 4/16/2014 3:48 PM (GMT 0)

TC,

Welcome, and the usual - sorry you have to be here. 

Lots of wonderful people on the forum and very good information.  At the end of the day, there won't be a right or wrong answer - just the answer that you find fits you best.  Each of us came to our own decisions in a variety of ways, I will share my journey to add what ever value I can to you process.

I was slightly younger than you when diagnosed, and originally told by my doctors that I had a G6 with just one core out of twelve showing cancer.  They said it was contained in my prostate and that Active Surveillance, or Radiation or Surgery were all options.

I didn't want to wait, no AS for me.  I have an older brother who had G6 and treated it with radiation, successfully.  My doctors told me that Radiation first, then surgery if needed was sometimes difficult.  The radiation turns everything into more goo (very official medical terminology).  So I opted for surgery, with radiation as a follow up if need. 

I think that decision saved my life.

Once in the operating room with the robot in place, the doctor discovered why my biopsy was only positive in 1 of 12 cores.  My cancer had moved into my bladder and possibly beyond.  He set about to remove the tumors, but ultimately was unable to get all of it - leaving me with some positive margins in what was left of my bladder.

Sometimes, I think, they just have to get in there to see what is really going on.

Side effects - yes and no.  I am still recovering my erectile function.  I take pills and they work more or less, but not sufficient to penetrate yet.  I am continent and wear a small shield to guard against leaks when I sneeze.

I'm glad I did what I did.  Surgery worked for me, and as I said, radiation worked for my brother.

So like I said, no right or wrong, just the answer that you will find that works for you.

Take care TC, we are all here for you.

Pat

Posted 4/16/2014 3:51 PM (GMT 0)
Tc 46123
Tough call. Your personality and ability to deal with uncertainty has a lot to do with the choice. I didn't want to go through months of RT and years of HT so I went with RP. Brachytherapy was not an option for me due to years of BPH. I was stage t1c going in and stage pT3b coming out. I am Gleason 9 with low volume so I thought RT could be curative. It wasn't. Now I'm dealing with what to do next if PSA climbs. sucks. I will say that as a Gl 7 you may have some Gl 8 Tumors. I would consider getting a 3t MRI to see if you have EPE or SVI.
Bob
Posted 4/16/2014 4:00 PM (GMT 0)
So far I have not done either surgery nor radiation.

However, from my research, since you are Gleason 7 (3+4) albeit better than Gleason 7 (4+3), the "4"'s make you less than an ideal candidate for pro Active surveillance, AS.

You can peruse the very first thread on the first page

www.healingwell.com/community/default.aspx?f=35&m=2652250

but it sounds like you have already done a lot of that plus have excellent advice from both sides of the surgery versus radiation discussion in htis thread.

Pick one and never look back.

LupronJim
Posted 4/16/2014 4:08 PM (GMT 0)
As you can see, there are as many opinions as there are people. For me, I have chosen Surgery. I am same age as you , turn 55 tomorrow. With my prostate at 76 g's, I wanted it out. Did not want it to get any bigger and wanted to get rid of BPH symptoms. I will deal with the outcome. I go in May 6th . Both Uro and Radiologist told me that I should be fine with either treatment. Read as much as you can and embrace the option you choose.
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