Advantages and disadvantages of a RP (if not organ confined)?

I know most Radical Prostatectomy's are performed on men where the cancer is completely within the prostate. Why then perform on men where it's spread slightly (eg.Seminal vesicles), particularly on 'younger' men?

If I could just add another question please. Why are some men offered nerve-sparing surgery and some aren't?

Post Edited (Ronnie44) : 5/12/2014 5:11:46 PM (GMT-6)

I asked if the cancer had spread to the nerves and was told 'no', apparently there is no evidence of that on the scans.

Can I ask how long it should take for treatment to start?

I had my blood test (PSA 33.9) over 3 months ago. Unfortunately the Doctors surgery didn't tell me. I put in a complaint about it, and have had a phone call apologisng. Apparently a doctor checked it and put it on the computer, they say that I should have been contacted for an emergency appointment but it didn't happen. They're looking into why.

The only reason I found out is because I made an appointment myself a month later and asked.

Anyway, it's been a month since my Biopsy and I'm considered high risk (due to SVI and PSA) but I have still not been given any treatment yet. I would have thought I'd have had something to lower the PSA by now (I'm in the UK so it's the NHS)?

I think the hospital have been good with me, the doctors surgery were a massive let down.

It sounds to me John like I should be demanding nerve sparing surgery.

Edit: Would this be an advantage to the surgery: that after an RP the cancer could not recur in the prostate (assuming, rightly or wrong, that cancer can recur in the prostate after radiation and you can only be treated with radiation there once)?

Post Edited (Ronnie44) : 5/12/2014 6:31:02 PM (GMT-6)

Ronnie,

It appears to me that you may be talking yourself into an unecessary surgery.   Several studies have repeatedly shown that radiation is more effective at cancer control than surgery in intermediate and high risk cases....which you clearly are.   Plus the side effects are reduced with radiation, both IMRT/IGRT and brachytherapy.    

JohnT has given you valid answers to your question.   He has studied this for more than 15 years and does not appear to me as biased.    Like you he had high PSA (40 as I remember).    I was 59 PSA and 12 of 12 cores positive.  For me, three different urologist/surgeons and a medical oncologist that does a lot of advanced PCa work, all said a big "no" to surgery.   They all said I would be guaranteed to need salvage radiation after a surgery that could not get all the cnacer.    None of them would sign on to essentially doubling the risk and side effects over using modern radiation techniques to begin with.   I am now nearly 3 & 1/2 years post treatment with an undetectable PSA and no adverse side effects from the radiation (I had HDR brachytherapy and IMRT).   Due to my high risk status I was also on hormone therapy for three years and had the normal and predictable side effects from that.

In my opinion your situation is better suited to combination radiation therapy (IMRT/IGRT and Brachytherapy) than surgery.   You are probably also a good candidate for some period of hormone therapy due to your higher risk status.   Take the information you already have seriously and understand that you are at a high probability of surgery failing.   Also take seriously that most doctors downplay the incidence of incontinence and ED from surgery.   Remember that the definition of incontinence is requiring more than two pads a day.   So you could be a pretty steady leaker and be deemed continent statistically.  

It is unfortunate that the docs knew you were high risk due to a very high PSA and did nothing.   If you are not getting what you need from your health care system you may need to go somewhere else for treatment.   In my case things happened much more quickly and I went from my blood test to starting my treatment in less than 90 days, including second and third opinions.  I hope you can get better response from your healthcare delivery system then you have so far.   While many prostate cancers are slow growing, they are usually the low grade G6 variety.   With your PSA and evidence of spread, you are more likely to have a more aggressive grade.   Alan is right that you shouldn't panic, but it is important to get on with treatment as soon as possible. 

Obviously I am biased toward radiation in intermediate and higher risk situations based on my research and advice I got from my different doctors.   If there is anything I can help with in your treatment decisions, please let me know.

Best wishes,

Jack

Ronnie
With gleason 9 and high tumor volume, it's likely that Pca has spread outside the capsule meaning the surgeon will have to cut wide and be unable to spare the nerves. But I see no reason why the surgeon should not try to spare them as mine did successfully, using open surgery rather than davinci. I had surgery because I had low volume and neg DRE and scans which meant it was possible that the pca was contained. But it wasn't. Now I'm off to the next stage of treatment 8 months post RP.
Bob
--------------------------------------------------------------
DOB January 1944
1981: prostatitis corrected with meds.
2000-2013 BPH treated with finasteride & tamsulosin; low T treated with androgel
PSA History:
Nominal / Corrected*
Pre 2009 0.4-.6 / .8-1.2
11/2011 2.2 / 4.4
8/2012 2.7 / 5.4
2/2103 5.5/ 11.0
4/2013 6.1/ 12.2
5/2013 6.6/ 13.2
11/2013 0.1
1/2014 0.2
4/2014 0.3

6/2013 Bx: PCa Gleason 4+4=8 (Bostwick), 4+5= 9(Johns Hopkins), 2/6 cores on right positive, 10% & 40%, DRE neg. (Stage PT1c)
7/2013 bone scan and pelvic MRI negative
9/7/13 open RRP, Johns Hopkins, Ted Schaeffer MD PhD.
9/9/13 Pathology: 33G, Gl 9, both nerves spared, SVI, EPE and 4mm pos. margin at base (Gl7), Stage PT3bN0M0)
9/20/13 Foley and staples removed
Continence: one pad per day for 13 weeks, now none. Some ED pre op, total ED post op.

*For finasteride effect

We have surgeons in the states, and we have surgeons. Some are noted for their expertise in getting all of the cancer out with surgery, or at least to the point where radiation and/or chemo can get at the remainder. Nerve sparing with high Gleason cancers is an invitation to leave some cancer cells behind attached to the nerves they are sparing. In my opinion, nerve sparing is a high risk gamble that percentage wise doesn't usually give the result we expect.

In the UK, it is my understanding that you don't necessarily have the ability to choose the surgeon of your choice in theNHS system. Perhaps if that is the case, nerve sparing may not be the best idea.

I'm not sure how some doctors can tell us so much pre-surgery about the cancer and others can't. Truly, if you have the surgery, you will know exactly if it has spread, what the real Gleason score is, and what the best follow up treatment is.

Good luck to you. I have been playing the time game. Got 3 years out of surgery, hoping for 3 or 4 out of Radiation, and then finishing up with hormones/chemo.

Let us know how it goes.

Allen I have a Gleason 7 which is maybe why they are not starting straight away.

I've rang them to remind them to get the Oncologist call me. I do wonder why they feel the surgery/adjutant radiation is so much a better option for me, is it maybe a better chance of a cure?

I'll take the advice you and Goodlife (among others) have given me on board when I get that call.

You asked, "is it maybe a better chance of a cure?"

An analysis of all the data on recurrence-free survival after adjuvant radiation showed an average of 64% after 5 years if performed before PSA rose over .2. By comparison, 93% of high risk men at Memorial Sloan Kettering treated with HDR brachy+IMRT combo therapy had no PSA-detected relapse after 5 years.

- Allen

Ronnie44 said...

Edit: Would this be an advantage to the surgery: that after an RP the cancer could not recur in the prostate (assuming, rightly or wrong, that cancer can recur in the prostate after radiation and you can only be treated with radiation there once)?

I didn't see anyone address this comment. The fact is that cancer can recur in the prostate bed after RP; if they didn't get all of the prostate tissue during surgery. That's why some RP patients have adjuvant radiation, when the PSA starts rising from the left-behind tissue. As my surgeon told me; it's not like it's one nice defined organ. They try to get everything; but that doesn't always happen. If they already know it has escaped; I have to agree with everyone else, that I don't see any advantage to surgery. If it's already escaped, that just says to me that there is a good chance that they might not get all of the cancerous tissue out of the prostate bed. Radiation will have a better chance of getting it all.

-Bob

If I was in your shoes I'd do some form of combination radiation therapy (IMRT/IGRT and/or brachytherapy) and hormone therapy (like others said above). Seems to me with a PSA of 33 surgery would likely be followed by salvage radiation therapy anyway so why have side effects from both treatments when radiation, combined with hormone therapy, can probably deal with it successfully?

Of course, I am not a doctor, and certainly not a lay expert (as we have here), just another guy with PCa.

"Men with locally advanced PCa can be CURED by RP. It is NOT just a de-bulking procedure."

This study from researchers at the USC and Stanford, suggests that for pT3b men it can be done fairly reliably in the recent era.

Long-term cancer control after radical prostatectomy and bilateral pelvic lymph node dissection for pT3bN0M0 prostate cancer in the prostate-specific antigen era

It may not be the best therapy but we shouldn't lose track of the fact that it is a pretty good therapy if there is some independent reason why other therapies are not appropriate.

Ronnie,
Don't panic, but your situation happens in the US also; ie., too many patients and turf protection. A few years ago some medical facilities only offered open surgery and if that was declined then hormone therapy; in my case I had to ask about radiation and was informed "we don't do that here, that's done by our RO's in Milwaukee" which was another 100 miles distant. Sort of like protecting the home plate.
You've received outstanding advice here so due to your circumstances and ad version to surgery investigate some form of radiation with hormones. I wish you well.
Bill

Thanks again Allen.

"Because Ronnie has been diagnosed with cT3b, his surgeon knows he cannot cure that by cutting alone and has already scheduled him for adjuvant radiation. This has a 64% chance of being effective if his diagnosis were pT3b. My guess is the odds are worse with cT3b. This is incomprehensible to me when the odds of combo HDR+IMRT are as high as 93% in high risk men. The only questions I would have would be about whether ADT is necessary with it, and whether to also irradiate the pelvic lymph nodes."

This is a big paragraph from your post for me to consider, and one I will certainly be asking about. The surgeon told me in his estimation there was a 31% chance it had spread to the lymph nodes.

I found this document which seems quite informative. I'm still working through it.

http://www.uroweb.org/gls/pdf/08_Prostate_Cancer.pdf

Why would someone be unsuitable for brachytherapy? (eg.big tumor, small prostate [44.2])

Post Edited (Ronnie44) : 5/14/2014 5:01:03 PM (GMT-6)

Hi Ronnie,

The European PC guidelines look pretty similar to the NCCN guidelines that you can access here:
http://www.nccn.org/patients/guidelines/prostate/

One factor that may be very different for you in the UK vs the US is that there has been widespread routine PSA screening in the US since the early 1990s. One of the consequences of this is that PC is often caught at an earlier stage in the US (There are positives and negatives to that, which I won't get into.) The widely accepted NCCN risk stratification system (very low risk, low risk, intermediate risk, high risk and very high risk) is based on the stages as diagnosed in the US. Your variety of cancer would be classified as "very high risk" by NCCN. Not only are men in the US diagnosed at an earlier stage, but the cancer is often less progressed within a given stage. In the US, NCCN does not recommend surgery at all if there is any evidence that the cancer is affixed to adjacent structures (i.e., the seminal vesicle fossa). That would have to be verified by an MRI - preferably 3 Tesla with endorectal coil (reference).

He is right about your odds of lymph node invasion, and the need for treatment of your lymph nodes, whether surgically by extended lymph node dissection (ePLND), or by radiation. There is evidence that two months of hormone therapy pre-treatment will improve the outcome of that radiation. Long-term ADT (for at least 1.5 years) may be necessary post-radiation, especially if LDR brachy boost (seeds) is used rather than HDR brachy boost (temporary implants). You said that your Gleason score was 7: 4+3 is more responsive to ADT than 3+4, and if there were any tertiary 5s in the tumor mix, that ADT is a necessity.

I hope you will be able to talk to a Radiation Oncologist soon. You might want to show both doctors the following two studies and ask for their reactions:

This one from Memorial Sloan Kettering showed 93% 5yr freedom from biochemical recurrence with HDR brachy combo:
Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT

This one, done across Europe, showed 61% 5yr freedom from biochemical recurrence with RP+adjuvant RT:
Postoperative radiotherapy after radical prostatectomy for high-risk prostate cancer: long-term results of a randomised controlled trial (EORTC trial 22911)

- Allen