Visit with RO - now officially confused

Pratoman
I do understand the dilemma that you face. As my signature shows I had a very small amount of G6 found in 1 of 12 biopsy cores. I visited with 3 surgeons and 4 RO's. In the end, being a "risk averse" engineer, I chose surgery by a top urological surgeon. My thinking was surgery would cure me BUT if I needed a second round of something, I would have radiation to fall back on.
It made sense to me and once I made the decision I did not look back. I took 3 months to decide and consider all options. It will be 5 years in April 2015. I had a blood draw today for my annual PSA test. I expect (and hope) for continuing "undetectable". After my surgery I was continent in 5 weeks and within 6 months any ED symptoms were overcome with Cialis. Today, no Cialis needed. I am very lucky. Good Luck to you.
RickyD

Positive margins is never a go-ahead for automatic secondary treatment, i.e., salvage radiation. Some men have positive margins that never ever lead to recurrence, while others do. In many cases, it makes sense to see where your PSA begins post-surgery. In my case, my first PSA post, was .05, and I had one tiny positive margin, so within 6 months of surgery, it recurred, and my surgery was considered a failure. But that was not typical for most.

There are many here with positive margin(s) that have never had recurrence, and keep pulling zeros.

Don't assume the worse, with the exact location of your particular cancer. PC is a funny thing, and typical doesn't follow any set logic or rules.

Due to the low success rate of SRT (30-50% depending on what you read), I would never push it on a man unless they were clearly in a true window of recurrence. Experts differ on what even that means, but at the least, 3 PSA increases above .10, spread 3 months apart. Others say 3 rises above .20. There are a lot of risks associated with SRT, and they shouldn't be taken lightly, or if not truly needed.

LoL@ Tall Allen. I don't think he is going to let the brain explosion thing drop

Thanks all, for the explanations. That is why I ask what I guess are sometimes seemingly dumb questions, it's how I learn. I appreciate it, apparently I misunderstood.

Yes, I was told by the RO that SRT after surgery has about a 59% success rate.

Caspar, you are a funny man

Allen, I ordered a book on mindfulness. The groups around my area all seem to be Buddhist based. Besides, Its not as easy to be a "in touch with your feelings" type, for me, in a live group, as on an Internet forum.

Pratoman
There is also considerable debate on whether a G3 cancel cell can exist outside of the prostate. If accurate, it may be that G3 cannot spread once prostate is removed. Tall Allen had some very good posts on this theory. I will try to find them for you.
RickyD

Edited to add this post from the past on G3 debate:
www.healingwell.com/community/default.aspx?f=35&m=2690326

Samster,
Your numbers are very similar to mine and I also watched PC take my Dad 9 years after he was diagnosed with T4 PC with mets. He passed in 1999 at age 64. he died with his boots on without getting to retire, along with his Dad and all his uncles. Also, younger brother diagnosed at age 45 with T2 PC.

I have looked at Brachy and have religiously read everything on the web and 6 books including Walsh. Walsh makes a very strong statement (that I cannot find right now) that a high percentage of cancer is near the urethra. In RT including BT, you want to kill all the cancer cells and ideally all of the prostate cells, but you don't want to damage the urethra. This is a tall order.

So I have chosen RALP because:
* High chance of negative margins and removing all of the cancer cells and all of the prostate cells
* Don't have to wait 1-2 years to see PSA drop to <0.1
* No rectal side effects
* I will know a lot more about my total pathology (are all of my cancers 6 and not something higher?)
* I understand the side effects risks with surgery
* RT and particularly low and high dose BT are not without side effects
* I want a fast, definitive result and want to avoid the anxiety of waiting for PSA to drop

I am very confident that this is the right choice for me, particularly in light of my family history.

__________________________________________________________________________________
Strong Family History of PC
Younger brother: PC at age 45 T2, PSA=2.95, + DRE > open Prost, doing fine now
Father: PC T4, age 55, PSA=20, Met to Lymph Nodes and Bones, Hormone, Rad, passed at age 64
GrandFather, Great Uncles all died of PC at age 62-64
Me: Year of Birth 1959
Diagnosed Oct 2014, Negative DRE, PSA=1, no symptoms, T1c
Biopsy shows 4 of 14 cores(with fragmentation) Adenacarcinoma 5mm, 2mm, 1mm max all G6(3+3)
Preemptive Biopsy due to Family History and age=55

Scheduled RALP 18 Dec with Dr. A. Martinez

compiler said...
Prat:

Purg's last post in this thread is a good one.

I had a focally (ie: VERY small) positive margin and was advised not to have adjuvent radiation. The hope was that I would not recur.

I did and had SRT.

I won't go into my history, but even a positive margin does not automatically lead to radiation.

Mel

Mel, your post leads me to a question I have often pondered...one of the advertised advantages of surgery is that you receive a definitive pathology report right away. But, to me that has always been a bit of "so what?". It seems to me that only if the pathology changes drastically (e.g. PeterDA who did not have pre-surgery MP-MRI imaging) will the patient really do anything, i.e. take some action.

I hope you don't mind if I use your case as an example since your brought it up. You had a positive margin. Some would say that indicates ART is advisable -- you and your doctors opted to "watch and wait" (which is also what I would have done in the same situation). As it turned out, the waiting ended up showing SRT was advisable and that's what you did. Do you ever second guess about what might have happened if you had ART right off the bat?

Or, take a patient whose Gleason is upgraded from G6 to G7 which surely does happen. What does that patient do with that new found info? Jump into ART? I think most will "watch and wait", hoping that the PSA drops and stays low.

I guess my point is that, even with the perfect knowledge of definitive pathology many (most?) surgery patients don't do anything with that info but "watch and wait"....which is pretty much what radiation patients do as they wait for PSA drops.

Seriously, what am I missing here?

Thanks,

Jim

This is an interesting discussion touching on a number of different topics, while making my head spin. (Faster than it was spinning before) I think I am learning the downside of too much information, or information overload.

Logos - I seriously believe the RO at MSKCC was not using the SRT failure rate as a marketing tool. BTW, the 59% was a typo on my part, he said 50%. He clearly stated to me that Surgery and Brachy will both give me an equal 95+ % chance at cure. He would be referring me to another MSKCC Dr at their main campus for Brachy as he does not do it.

Ricky, thanks for the response, I did read that study a while ago I think it was pubmed.gov, where I ran across it. As evidenced by this thread, even the most widespread studies, done at the foremost institutions , are subject to interpretation as to their meaning.

Samster, yes our numbers are similar except for the 80% of tumor volume in one of my three cores. Were any of your cores in the apex, as mine were? I know that makes a difference, not sure how big a difference. Love your results, hope I follow in your footsteps

ScientificLifestyle - your bullet points - every one of them, are exactly what is on my mind and why I am still leaning towards surgery (but not as heavily as before) I think one thing that can easily be minimized, and shouldn't be, is the benefit to one's mindset, of knowing - really knowing - with as much certainty as possible, exactly what the pathology is, seeing the final PSA in 3 months, etc. Not saying it eliminates stress, but if things go well, it would greatly reduce it, at least for an animal like me.

Jim and Mel - interesting question that you guys are discussing in the two posts above. I can't even begin to get involved in that debate, I am not knowledgeable enough (yet). But what I would say is see my comment above. For some people , me being one of them, there is simply value in knowing.

Thanks again for all the input.

Post Edited (Pratoman) : 12/10/2014 4:39:22 PM (GMT-7)

Pratomaniacal one,

Sometimes I think we get a bit too much into the idea that surgeons are pushy guys trying to rush their patients into treatment without giving them time to think. Your surgeon doesn't read this forum. He has no idea how conflicted you are. You are scheduled on January 6th. Your surgeon probably has more than one patient scheduled for that day. Chances are the other guys were scheduled for January 6th because there were no openings in December. I imagine one of them jumped at the chance to pull their date in. You can choose whatever treatment you want for whatever reason seems good to you but it's not that rational to decide on brachytherapy because your surgeon had a cancellation.

Jim,

The value of the information from a post-op pathology comes from those cases where the results are really good (as expected for low-risk diagnoses, or better than expected for higher-risk) or are much worse than expected (motivating, as mine did, a chance of treatment plan). Pratoman has a fairly low-risk diagnosis and if he were to select surgery and get a post-op result that showed well-contained Gleason 6 disease then, maybe, even he could stop worrying and concentrate on being grouchy about the side effects.

PeterDA, I have to disagree (mostly) with your first paragraph, and (mostly) agree with your second paragraph.

"He (Prato's surgeon) has no idea how conflicted you are." Really, wanna bet? After a few conversations with Prato my money is the surgeon knows a bit about his makeup. Also wondering how you figured out that his surgeon probably has more than one patient scheduled for that day, that the other guys were scheduled for January 6th because there were no openings in December, and that one of them actually jumped at the chance to pull their date in? Having said that I DO agree with your last point about switching back to BT just because of that phone call!!!! NO logic to that!

Second paragraph - I agree that if the post-op results showed well-contained Gleason 6 he might worry less than he is prone to - but of course that's if it stays a G6. Holy Crap tho Batman, what if it comes back as a G7? Back to Tud's comments - logically there would be no need to rush into anything - but I'm afraid if that were the scenario our Pratomaniac would melt down further. . . .

PeterDisAbelard. said...
br /> Pratoman has a fairly low-risk diagnosis and if he were to select surgery and get a post-op result that showed well-contained Gleason 6 disease then, maybe, even he could stop worrying and concentrate on being grouchy about the side effects.

Peter, yeah...maybe. But it just seems to me that selecting the most highly invasive treatment and the likely SE's from that are a high price to pay for that knowledge. I certainly would not (and did not) make that trade off -- but I guess that's part of everyone being a bit different in our choices and priorities.

Jim

Logo-- do you mean that somebody DOES understand your posts?

Mel