New Diagnosis - 38, Gleason 3+4=7

I'm 38. Everyone says surgery because of my age. I already have RALP scheduled for 8/13/14, but people keep telling me to get other opinions. I'm trying to decide and need advice.

PSA in 2013 - 5.7
June 2014 - 6.4
Biopsy 7/3 - 3 of 12 - two with Gleason 6 and one with Gleason 7 - 70% of this core, only 10% of the other two.

Thanks for your help!

Doctor gave me every reason to believe we caught it in time. My prostate is the normal size and doctor felt nothing in the rectal exam. The PSA is the only reason doctor recommended a biopsy. My dad had his prostate removed three years ago (63) for prostate cancer. That is why I decided to check my PSA before 40. Glad I did! But now what?

Hi eric,

What a bummer to be among the rare unprivileged few to be diagnosed at under 40. I recommend you get a second opinion on your biopsy slides from Bostwick or Epstein. You should also read the sticky: Newly diagnosed with PC? – read this thread first

I opted for SBRT because of my (relatively) young age at diagnosis. I figured I would have more years to suffer with the potential symptoms. Because I am still very sexually active, I couldn't imagine having surgery - a therapy that has a high likelihood of cutting off that aspect of my life, especially when there were so many other curative alternatives. Even the 10% or so likelihood of permanent incontinence over so many years of life was anathema to me. Add to that the possibility of climacturia, stress incontinence, and penile shrinkage sent me looking for alternatives. On the other hand, I don't know what will happen in 20 years because there are less than 10 years of data for the therapy I chose. I was willing to take my chances, but others may not be.

The SEs of any therapy you choose will be lesser because of your younger age. And your favorable intermediate risk status (I'm assuming Gleason 3+4 and no sign of EPE) means that all options are likely to be curative for you, including surgery, SBRT, LDR brachy, HDR brachy, protons & IMRT. I think you owe it to yourself to get several opinions before making up your mind. Remember that each specialist knows and will likely recommend the therapy he gives, and will really not know all that much about the other therapies. It's incumbent upon you to make the effort and seek out their opinions.

Hopefully surgery will nip it in the bud, but should you need further treatment down the road you will still have the salvage treatment option of radiation. If you choose radiation as your first primary treatment you don't have the option of salvage surgery as a choice.

My biopsy pathology report had my PCa as a Gleason 7, my post op report downgraded it to a Gleason 6.

Being so young make sure if you choose surgery that you understand that if you want to father any children in the future you should look into opening up an account at a sperm bank.

When I was dx over three years ago (51) hearing the word Cancer gave me tunnel vision where all I wanted to was to be cured at no matter what cost and deal with the side effects afterwards.

So make sure you really understand the SE of surgery ...you still have a lot of living to do.

Cmetalman

you have been given great advice already.

I think most urologists will advise you to have surgery, due to a Gleason 7 and being only 48. That is what two urologists advised me to do. I am older, 58, had a PSA of 7 and a Gleason 7 ( 3 + 4 ) It's almost 2 months after surgery and no regrets. I recovered quickly from the RP, have no ED or continence issues and have an undetectable PSA.

Watching my PSA level for the rest of my life is about as much Active Surveillance as I am comfortable with.
I also wanted to minimize the chance of the PCa spreading and becoming uncurable.

Surgery can change your life, and there are other treatments available, so do your research by reading here ask your doctor as many questions as you need to help you to decide the best treatment for you. There are pros and cons to all treatments, so choose carefully after you know the facts.

I wish you and everyone reading this well.

eric,

I was diagnosed and treated last year at age 41. 38 is really young (youngest I've seen on this site). Sorry that you have to deal with this.

My stats were pretty similar to yours. Normal DRE, PSA 9, Gleason 7.

Everyone (including radiation/seeds specialists) told me to go with surgery. There is almost no data on the very long-term outcomes of radiation/seeds. You and I should hope to live another 40-50 years, or so. Because most guys treated with radiation/seeds are already in their 60s, their natural life expectancy doesn't extend another 40-50 years. Therefore, there is basically no data for guys like us to use in deciding whether radiation/seeds is a good option. Also, young guys usually recover well from surgery. For all of these reasons, I went with surgery and am glad that I did. More info in my "Introduction" and "Plan" links below.

I strongly recommend you visit the links in my signature below. You'll find very important information. I especially recommend that you read Dr. Mulhall's book before choosing a treatment option, so you understand clearly the implications of your treatment choice on your short-term and long-term sexual health.

Feel free to contact me via email (envelope link to the left) if you want to ask any questions privately.

-Gedman

Gotta sympathize with F8's comments on this. Hers is what Dr. Moran at the Chicago Prostate Center says about young men: "Published data has demonstrated brachytherapy to be an excellent and equal treatment option for younger patients. There is no scientific data to suggest younger patients have better cure rates with surgery. This has long been a misconception on the part of some physicians. In fact, there are numerous studies that show that there are no differences in cure rates with young patients (age 62 or less) versus older patients"

Yeah, he is a radiation guy but he cites the studies to back up his claims. All of the main treatments essentially destroy the prostate and the associated cancer cells. With surgery they are removed with seeds they are nuked. If the cancer is contained there is no logical reason for a recurrance unless the surgery or radiation was not properly performed OR unless the cancer had already escaped.

Jim

For what it's worth, Dr. Michael Zelefsky (link) is the head of brachytherapy at Memorial Sloan Kettering Cancer Center (MSKCC) in NYC. Many consider him to be one of the leaders in the field of brachytherapy and research. He personally told me to go with surgery instead of brachytherapy for the reasons I mention above.

Eric: What part of the world/country do you live in? Folks here can likely help recommend experts who are in your area.

-Gedman

for me pissing my pants was my second biggest fear. I've never had a single incidence of incontinence with my treatment and with daily Cialis I can have sex anytime, and while sex has changed It is getting better again.

ed

Eric, Your surgeon looks like a winner..
http://ohiohealthroboticurologicsurgeon.com/about-Dr-Abaza

With an experienced surgeon and youth on your side you should fair well on recovery. Do kegel exercises, if you need to lose a few pounds do so, and do stomach crunches.

I went into surgery right after training and running the Disney marathon and was in great shape going in. Made my recovery much easier. After surgery I got up and walked the hospital floor over and over to work out gas and move the bowels. I rested for the 4-5 weeks my doctor ordered me to do then got back into long walks.

Best to you on a speedy recovery

Eric, I had surgery when I was 54, so still on the younger side not nearly as young as you. I had surgery and now my erections are sufficient when using cialis or viagra; marginal without. But i am also five years older now, at the age when I would start losing it anyways.

Something to keep in mind is that E.D. after surgery is not binary; it is more like you will lose a percentage of your erectile function if you go the surgery route. I won't try to answer for the radiation since I have no personal experience.

I've been told, and it was my personal experience that the following are true:
1.) If the surgery is done by someone really good and experienced...
2.) If there is no visible extra-capsular extension and the surgeon does bilateral nerve sparing surgery
3.) If both you and your surgeon take seriously the need for a penile rehabilitation protocol after the surgery, and follow it...

...then there is a good chance you will keep some 70-80% of your erectile function, and lose 20-30%. That might mean you need to have more manual stimulation before you are ready to go, might not be quite as stiff, might climax a little sooner, might need to use the drugs (they come in a wide variety of doses depending on how much you need.) You will have some shrinkage, most likely. The more function you have going into the procedure, the more function you will have coming out. Obviously some people do better and some people do worse. But there is a good chance that if you have strong function now, you will have less strong but still adequate function afterwards.

If you go the surgery route, take the rehab seriously. It is important to keep the blood flowing while the nerves are recovering from being bruised. If you don't do that you run the risk that while the nerves may ultimately recover, by the time they do you have scar tissue built up that prevents the penis from inflating properly.

Good luck with whatever you decide.

The good thing is that you have a lot of options. The bad thing is that you have a lot of options.

Guys like me who have had successful surgery tend to recommend surgery. Guys who have been treated with radiation tend to recommend radiation. All procedures seem to be effective, all have side effects, and none provides a lot of data regarding outcomes 40 years down the line when performed on someone as young as you.

Yes, I have ED issues, but then I'll be celebrating my 69th birthday on the same day you're scheduled to have surgery, and a week after that I'll be noting the fourth anniversary of my surgery. I'm also dealing with hypertensive drugs and Type Two diabetes, so at my age ED would likely be a problem even without the prostate cancer treatment. I doubt that you'll have those factors to contend with.

I wish you well, and I know these are tough decisions. However, once you settle on a treatment, commit yourself to that course of action and resolve to never second guess yourself. If I were to make a prediction, it would be this: you'll do fine. Good luck.