Best Treatment Option for the long term

Dear Lou:

Welcome to HW. Sorry you have to be here but I'm sure you will find lots of caring folks here who are happy to provide support and advice.

The first thing I would suggest to you is to take your time in making your decision. Prostate cancer is typically a slow growing cancer and please don't get rushed into a treatment choice. You get one chance to do this right the first time, it's a potentially life changing decision and you want to have confidence in your choice. You should make sure you get educated on our disease. A great place to start is the "sticky" thread at the top of our forum that is designed for newly diagnosed patients: https://www.healingwell.com/community/default.aspx?f=35&m=2652250. There are also some great books that I would highly recommend. My three favorites are, "Guide to Surviving Prostate Cancer" by Dr. Walsh, "Invasion of the Prostate Snatchers" by Dr. Scholz and "A Primer on Prostate Cancer" by Dr. Strum. Another excellent resource is the NCCN guidelines for patients: http://www.nccn.org/patients/guidelines/prostate/#1.

Reading biopsy pathology is as much art as science. It's always a good idea to get a second opinion on your biopsy slides from one of the acknowledged experts in prostate cancer pathology, e.g. Dr. Epstein of JHU or Dr. Bostwick of Bostwick Labs. You can find instructions on their web sites. It is critical to make sure you know what you are dealing with and is worth the time and trouble to get this second opinion.

Before choosing a treatment you should make sure that your cancer is properly evaluated and staged. A fairly new tool, the multi-parametric MRI is extremely useful for this purpose as is color doppler imaging. If your urologist is not familiar with or comfortable with these tools then it's time to seek another doctor.

Since your cancer is early stage, Active Surveillance should be examined as one of your alternatives. There is a good chance that your cancer will not harm you and, even if it does progress, studies have shown that treatment is likely to be just as effective "then" as it is "now". However, you need to make sure that you are being seen by a doctor/program with experience in AS so that you are staged and monitored properly from day one. Today's AS is not your father's Watchful Waiting.

If your cancer is contained, then it is likely that any of the major treatments will cure you with equal rates of success. Surgery has the advantage of providing immediate knowledge of post procedure pathology and gives patients who need it the psychological satisfaction of "getting it out" of their bodies. However surgery also generally yields the most onerous side effects including immediate incontinence with a small chance of permanent incontinence as well as a 50% chance of permanent erectile dysfunction. It may also leave the patient with a smaller penis and the chance of ejaculating urine.

There are various forms of radiation that generally provide cure rates equal to surgery but with less onerous side effects. LDR Brachytherapy, HDR Brachytherapy, SBRT, IMRT and PBT have all shown excellent results. There is generally minor urgency and frequency or urination, a small chance of bowel effects and. on average, about a 35% chance of permanent erectile dysfunction.

The oft repeated mantra that "saving" radiation for a backup plan is somewhat suspect logic, IMHO. If the cancer is contained in the capsule then either surgery or radiation will provide a cure. Radiation will also treat the areas just outside of the capsule for any little buggers who have barely escaped. If salvage treatment is needed after failed surgery, then radiation is available. If salvage treatment is needed after radiation then I personally think that surgery, while possible, is problematical. However, what some surgeons fail to mention is that if savage treatment after failed radiation is needed then there are many salvage options available that are equally effective to the salvage options offered after a failed surgery.

In any case, there are multiple studies that show that the experience of the doctor performing the treatment is VERY IMPORTANT...both in cure rates and in reduction of side effects. Experience matters and I wouldn't choose any physician for any treatment whose experience wasn't at least several hundred procedures.

At the end of the day, the final treatment choice is a very personal decision. Some doctors will push; some friends and relatives will push. But, IMHO, the best approach is for a patient to become educated, get properly tested, evaluate the alternatives in a logical fashion and then make the best decision possible after becoming armed with the appropriate background.

Good luck and please keep us up to date on your progress.

Jim

Thanks Jim & Peter! Being new to this, I know there is allot of research that I need to do before making such an important decision. It's great being able to speak with folks that have already been down the road and can give me some insight. I really appreciate your feedbback.

Thanks John! Will definately do a search for the that info.

Hi Lou,

I'm one of the guys who just wanted it out and move on with my life.  I have Da Vinci surgery on 2/27/14, incontinence is improving dramatically each week.  I'm very happy with my decision.

Good luck with your decision!

Lou,

I hope you will follow Tudpock's excellent advice, especially with regard to taking your time and investigating options. I'm assuming you're in the NYC metro area? If so, FWIW, here's a list of doctors I would visit before deciding:

Active Surveillance: I would go with the program at Memorial Sloan Kettering. Peter Scardino is the head of the Prostate Cancer Program there and Chair of the PC Surgery Dept. They have world class radiologists who can expertly read mpMRIs. And, if you're on AS waiting for the next big treatment, MSK is sure to be where it's happening.

Surgery: NYC has many of the top urosurgeons in the world. At MSK, there's Eastham and Scardino; at Lenox Hill, there's David Samadi. But my top pick would be Ash Tewari at Mt. Sinai. He pioneered a technique that involves monitoring of penile oxygenation during surgery and tortionless nerve sparing. Results are never guaranteed, but if there is a technique to minimize the damage - AND lower the risk of penile shrinkage - that would be it.

SBRT: This was my choice, and if I still lived in NYC, Alan Katz would be my RO. He's been doing it for about 10 years, and he probably has done more than any RO. His main office is at Flushing Hospital, but he also treats in Manhattan and Brooklyn, I think. He does SBRT with CyberKnife, RapidArc, Tomotherapy, and Elekta Axesse that I know of. (See link in my signature for his 6 year results).

Brachytherapy: Michael Zelefsky at MSK is the Chief of Brachytherapy Services, and THE East Coast Master, in my book. What's more, he does both kinds - high dose rate (HDR- temporary implants) and low dose rate (LDR- permanent implants). Of the two, I would go with HDR, but for a low risk guy like you, you can expect excellent outcomes with either in his capable hands.

Protons: I know there's a new proton center in NJ. It is very new though, and my question would be about the experience of the RO in charge.

IMRT/IGRT: No advantage and lots of disadvantages vs SBRT.

focal/ablative therapies: You're not a good candidate for focal - too many positive cores. Whole gland ablation can have very serious side effects.

That should keep you busy for a few months at least.

Hi Lou,

My situation was similar to yours and I'm about the same age. As you're seeing, the good and bad news is that we have lots of options now. If I can offer any advice, it's to follow the advice given in several earlier posts: take your time. My wife and I were overwhelmed when we first found out. Thankfully we found HW, took the advice to take our time, and spent several months researching options and also, most importantly, clarifying our priorities. At some point the decision became "obvious" and we moved ahead. Some of our personal priorities ultimately made surgery the best choice for us, but those priorities were uniquely ours.

If I could offer one more bit of advice: all treatments are evolving incredibly quickly, and information about outcomes and risks, even as recently as 5 or so years ago, may not reflect today's outcomes and risks, so be aware of the age of information that you find.

Cheers and welcome,

Dave

Lou,

Your diagnosis gives you the time to properly research all of the possible methods before making the final decision. For me my decision was based on my urologist's recommendations, reading at least 6 books on the subject, watching a few youtube surgeries, listening to people here and finally taking to friends that have gone through the different options.

At first I was looking at low or high dose rate brachytherapy, but several friend that went through this still have doubts on long term prognosis since they don't know their final pathology. I decided daVinci based on the above and was weighted heavily on my urologist recommendations (trained at M.D. Anderson) and several friends that are doctors that have been through this.

As for all of the negative consequence of this surgery, I don't have any. I had nerve sparing and even before I had the catheter removed I was having night time erections. On removal of the catheter I was totally dry and only experience rarely stress incontinence which isn't a problem at all since it usually is a drop or two. Orgasms are as good as ever, but dry, and in my opinion is a nice improvement.

I can say that I am 100% happy that I went with robotic surgery.

Of course there are no guarantees on the outcome of any procedure which makes your decision harder.
An lastly your health can dictate which options are available to you.

I would like to hear it also, Medved. I'm talking about for primary treatment of favorable risk PC. Looking at six year outcomes, SBRT has higher oncological control and lower urinary, rectal and sexual SEs compared to IMRT/IGRT. It is also much more convenient and less debilitating that the 40 treatment ordeal, and it costs about half the price. Long-term studies have matured to the point that ASTRO has fully endorsed SBRT. I was quoting the opinion of Michael Steinberg, Chair of Radiation Oncology at UCLA, at the PCRI conference 2 years ago who said that there is no longer any role for IMRT in primary therapy in that setting.

Clinical trials are underway now to expand its use to high risk cases, which makes sense because of its radiological similarity to combo therapy with HDR brachy+ EBRT. I think that IMRT will eventually be relegated to use in salvage radiation after failed RP.

Having a post op pathology is over rated. 10% of all surgical reocurrances happen after 10 years and still happen at the 25 year mark. Few patients actually take action on unfavorable post op pathology and choose to wait for a rising psa. Favorable pathologies still have reocurrances and unfavorable paths never reocurr. Unless your post op is very bad it doesn't provide enough info for a good decision, and if was that bad it should have been identified by imaging before surgery.