Need help! prostrate cancer treatment susggestion

hi;

I am 56 years old now and my birthday present on Aug 18 2014 was being told I had PCA GL 9! I now have the choice of treatment to make and am just wanted the one that will give me the best chance of working without destroying all my quality of life. I have hypertension and felt my b/p med was not working so I went to an internist and had the usual blood panel done and asked for a PSA cause I knew it was due. The next day I returned to the office and he told me all was fine except the one that really mattered. PSA was 14.6! referred to a Urologist that did a DRE felt hard spot on left lobe the to to an Ultra sound and the biopsy which came back positive. This is how this bad dream all began.
Went to 3 different Urologist: one at an international well known hospital- will do open RRP to remove prostrate, sv, left side erectile nerve, 34 ea pelvic lymph nodes and cut a wide margin up into the abdomen. Frozen section biopsy to be done on r side erectile nerve and if neg will be spared. Urologists at two university medical centers will do surgery with da vinc robot method. Went to a radiological oncologist at one of these universities and he said start HT for 3 years & then Brachy HDR with 10-15ea ea Cathers inserted into prostrate and after loaded with radio active material for 15min a total of 2ea separate treatments one week apart to be followed by 25 ea sessions of 3d conformal, IMRT with GIRT to lymph nodes and pelvic area..

I DO NOT KNOW WHICH ROAD TO TAKE? FEEDBACK PLS from people who have been fighting this Pca nightmare. I am so glad I found this site!!!
Melvin5888

GL=9
T2B left side
PSA=14.6
4 of 10 cores pos with 60%, 20%, 5% and 5 % with 3 in PZ 60%,20% & 5% and 1 in TZ of 5%
MRI with contrast shows no EPE, no swollen lymph nodes, or pelvic bone lesions
Bone scan & CT Neg
tumor size= 2x2x1 cm

Post Edited (melvin5888) : 9/12/2014 6:45:25 AM (GMT-6)

Welcome to HW Melvin,
If you just go with statistics you will find the treatment success for daVinci surgery, open, RT, etc are all about the same. If one was much better thanthe other everyone would do it. Right?

So you need to look at other factors that might affect the treatments.

How old are you? The older you are the longer it will take you to recover from surgery. Are you in relatively good shape? If you are grossly overweight surgery will be more difficult.

Yu are a GL=9 . with a significant amount of involvement Surgery will try to get it all but itif it doesn not you will then be able to follow up with radiation. If you do radiation first you can't fall back on surgery.

Now for the side effects. Incontinence , ED.
Incontinence. At 3 months after surgery only one man in 1 is still incontinent. At one year only 1 in 9 is incontinent. about half of them will elect to have surgery to have it fixed. (That is what I did.)
ED. about half will have ED and diminished function. There are lots of tricks and aids to get around this: Pills, pump , prick (injections), and finally implant. I have seen vying numbers but the best average I can find is only 1 in 10 does not get a reaction to the injection.

You can read about RT radiation form other guys on the site. Their QOL is great soon after the procedure but quite a few have other issues a couple of years down the road, bowel problems, bladder issues, etc.
Someone from that camp will chime in soon with good info.

Meanwhile at 5 years my PSA is zero. I'm feeling good about my choice and would do it again if I was starting over.
I would change one thing. I would have delayed the surgery it for another month or two while I kegeled and exercised like I was getting ready to fight Apollo Creed. (Cue the Rocky theme)

-- And I would have enjoyed sex like there was no tomorrow. I'd by lying if I said I didn't miss it.

Good luck to you.
Jeff (Worried no more).

PeterDisAbelard. said...
FoxRun,

Didn't you misread that HT thing? As far as I can see it says three years which is plenty... Plenty.

Melvin,

Hello guy, welcome to the forum. Sorry you find yourself here but glad you found us. And, welcome to the Gleason 9 club. I've added you to our list of G9 members.

That thread is here: www.healingwell.com/community/default.aspx?f=35&m=3182035 (continuation of this thread).

While you are talking to urologists and radiation oncologists you might talk to a medical oncologist, too. They are often invited to the party too late for high-risk men and a Gleason 9 man should really have a MO on his medical team. If you do decide on surgery, talk to your surgeon (and your MO) about whether it would improve your odds to add a period of HT (maybe a year) to the surgery.

From the surgeons description of the surgery you are likely to have side effects. It sounds like effective nerve-sparing may be a long shot for you, buy ya never know. Since you are fairly young sexual function after treatment will probably be important to you. With your disease, any of the treatment options is going to take a bite out of you. The HDR brachytherapy might give you fewer side effects but even there you are likely to struggle.

And excellent resource for understanding what you are likely to face is a series of videos by Dr John Mulhall. Here are some links for those:

goo.gl/Mdw8Sr
goo.gl/Eqm1UF
goo.gl/dw6JOd

Dr Mulhall has also written a book entitled "Saving your Sex Life" which is a helpful read for men in your situation. Its a bit hard to find on paper in bookstores but Amazon has it (and the Kindle version is not that expensive).

Hope this helps.

My bad....but it does beg the other question ....how much is enough?

Melvin
There is no right answer. But the first thing to do is get a 2nd opinion on Gleason score and PCa volume (if you haven't) from Bostwick Labs or Epstein at Johns Hopkins. Some will say that if you're gl9, surgery makes no sense because PCa has probably already spread outside prostate. On the other hand only RP discloses your true condition and getting the prostate, seminal vesicles and any involved lymph nodes removed gives you a fighting chance for a cure or at least gets most of the bad stuff out of your body. Gl9s are usually started on ADT post RP, then either ART or SRT to mop up any remaining but undetectable PCa. The duration of ADT is controversial. From my experience as a gl9 with poor pathology (see signature below) the worst side effects come from ADT. Both RP and RT side effects are short lived.
I have no libido and total ED from ADT but I had mild ED pre op due to meds. ADT also causes night sweats, hot flashes and joint pain. But I endure it because it allegedly helped my SRT be more effective. I don't plan on more than six months however. It sucks !
I have no side effects from either RP or RT.
Bob

I just wanted to add the results of a new study that shows that 1 in 4 men are still suffering from Urinary Incontinence 3 years after salvage RT. Incontinence is a rare side effect of initial radiation treatment.

Long-term complications in men who have early or late radiotherapy after radical prostatectomy.

With combo radiation, urinary and rectal function typically, but not always, return to baseline with 24 months. about two-thirds retain sexual potency among previously potent men.

The Tall one's links are always very interesting.

I had IGRT by IMRT, an external beam only treatment, with neoadjuvant and ongoing ADT (3 year sentence). My Vanderbilt University RO (Nashville, TN) was not a big proponent of the triple-play combo RT HDR/EBRT/HT, preferring the capability of their Varian Trilogy with RapidArc IMRT machine's accuracy in attaining similar results without the added complications of HDR brachytherapy. At 16 months post-diagnosis, one year post-RT, and ongoing ADT, my PSA is still undetectable so I'm guardedly optimistic.

Interesting in the article itself, the Japanese researchers did not find their combo therapy method any more successful than the EBRT and ADT combo. They're not sure, but they think in part their great outcome with both methods may be due to some genetic factors.

Hiromichi ISHIYAMA1 et al said...
However, our outcomes may be attributable to
Japanese-specific high-sensitivity to hormonal therapy.
***agai et al. [26] reported that Japanese–American men
showed significantly better outcomes than Caucasian men
for overall and cause-specific survival rates after hormonal
therapy. Table 3 shows selected Japanese series of high-risk
prostate cancer patients treated with conventional EBRT and
hormonal therapy [27–31]. These favorable outcomes of conventional
EBRT seem to be equal to our HDR approach.
From the data of the 5-year follow up, our tri-modality
therapy did not show any advantages over conventional
EBRT with hormonal therapy.

The vociferous support on this forum for the "combo" RT modality has caused some consternation for me, and I've had some fairly lengthy discussions with my RO at Vandy about this in particular. People here really pushed it, and thus I was relatively demanding about it with my RO before my treatment series.

If it's so obviously superior, why wasn't Vandy offering it? He said they certainly have the capability and the equipment, but have not seen it to be demonstrably worth the potential additional side effects and complications. They're a referral center for those dealing with complications from RT elsewhere, usually urinary strictures, and thus may be a little gun-shy about adopting the procedure.

Hypofractionation seems even more interesting, since to this day there isn't agreement about the alpha/beta ratio of prostate tissue. My RO says this is still a debated topic without consensus. The SBRT modality, if it can be shown to work for very high risk cases, seems really attractive. It doesn't seem the studies are there yet to support it in those cases.

Jerry

F8, were you addressing my post? If so, that's exactly what I'm talking about. Vociferous support.

If you look at my post, obviously I did look at what Tall Allen suggests. It's what he always suggests. I posted a reasoned counterpoint, including a direct quote from the article to which he linked.

May I also point out G7 is not G9? Depending on various factors, they often have rather different treatment considerations. Further, it should be quite obvious from my post that I already had treatment.

These bun fights are no fun. On the other hand, I'm really happy for you that you are having a good response.

Good luck to you too.

Jerry,

If there's any question that the Japanese experience may be different from the American experience, surely the other study from MSK that compared combined high dose rate brachy to super-high EBRT and found the combo superior should be convincing. There are other studies:

Here's one where the 4yr bDFS for high risk was 94%:
Four-year outcomes of hypofractionated high-dose-rate prostate brachytherapy and external beam radiotherapy.

Here's one where the 5-yr bRFS was 91% on a group that was 92% high risk/8% intermediate risk:
External beam radiotherapy plus single-fraction high dose rate brachytherapy in the treatment of locally advanced prostate cancer.

Combo HDR brachy has been around since the 1990s, and is an established standard of care recognized by NCCN and ASTRO. As far as I know, there is no controversy about it. What we lack is a randomized study comparing it to EBRT - like the MSK study, except randomized.

I'm not saying that all results are this good, or even that an individual can expect that his individual results will be like the statistical average, but it certainly seems to be his best bet.

As for side effects, the results are better with the HDR combo than with EBRT mono, as I've demonstrated. If the doctors at Vanderbilt are seeing something different, they ought to publish - anecdotes just aren't good enough. You deserve better than that -- they owe you some evidence-based medicine.

As for the alpha-beta ratio, look at the following analysis of over 25,000 patients. It definitively establishes the alpha-beta ratio in the range of 1.4-1.6. Where is the controversy? For those not into radiobiology, the reasons this is important are because:
(1) The cancer is killed better by fewer more intense doses - hypofractionation - as from HDR brachy or SBRT
(2) Healthy tissues are preserved better by hypofractionation because of the reduced nominal dose that healthy tissues get

Is the α/β Ratio for Prostate Tumours Really Low and Does It Vary with the Level of Risk at Diagnosis?

- Allen

Thanks for the response, TA.

I'll look through those studies again. It doesn't matter for me anymore, but I'd like to have the confidence in the recommendation that you seem to have. We have folks come here constantly, seeking advice.

We have a major lack of randomized studies comparing treatment plans and effectiveness. That's probably why these discussions sometimes degenerate the way they do. There just aren't data yet to definitively state what an individual should or should not do.

I agree with that lack of comparative data. ASTRO is twisting proton's arm to do a randomized comparative study. See: Proton Therapy – Did ASTRO & Lancet go too far?.

There have never been any randomized comparison studies between robotic vs open surgery, surgery vs IMRT, IMRT vs SBRT, surgery vs BT, BT vs IMRT, etc. There has only been the PIVOT study on surgery vs waiting. All therapies ought to be compared within risk categories as well. One of the few RCTs I'm aware of is HDR vs LDR brachy. There's one expected to publish next year on IMRT vs SBRT, but a big one called PACE in the UK was cancelled.

All these studies are very expensive and hard to recruit for. Imagine agreeing to either, say, surgery or IMRT and not being given a choice -- most guys have definite opinions about what they want.

The alternative is a registry where very detailed, standardized, and comprehensive data is kept on every patient. These are also expensive to set up and maintain, but they do allow for well-matched patient comparisons.

Then there's the issue of that by the time we have long-term data, the therapies have changed considerably, and the issue of surrogate endpoints. Is a biochemical failure for surgery (PSA>.2) the same as for radiation (nadir+2), and are they good indicators of PC survival? At least there is now agreement on the classification of urinary and rectal toxicity, although there is no consensus yet for evaluation of sexual dysfunction. (See:Consensus on sexual potency measurement)

Sorry to kidnap this thread for my rant.

- Allen