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Posted 12/30/2014 1:32 AM (GMT 0)
Mike:

You DO get two bites of the apple (second bite is low probability) doing surgery first.

According to Tud and others, you also have a salvage possibility of radiation as primary fails. I wish they would emphasize that more and indicate what the salvage possibilities are.

Mel
Posted 12/30/2014 1:34 AM (GMT 0)
Sorry...poor phrasing on my part. I meant to say the statement implies two bites of the apple with surgery first, but only one bite with radiation first. And it's the second part that's not true.
Posted 12/30/2014 1:35 AM (GMT 0)
Michael, that is exactly what is being implied. I'm not sure how accurate it is, and I see that there are devoted, convinced folks on both sides of the debate. In the end, I think a lot of it boils down to the individual rapport the patient develops with the lead physician. One thing I have already picked up about all this: An individual outcome depends significantly on the experience and skill level of the lead physician combined with the attitude and trust the patient has about the chosen treatment.
Posted 12/30/2014 1:42 AM (GMT 0)
Halbert:

Rapport is important, but knowledge is essential

Mel
Posted 12/30/2014 2:04 AM (GMT 0)
Isn't the same option available with both treatments?

I had HDR Brachytherapy. If it fails, I certainly can have more radiation, whatever the method, right?

IF I had chosen surgery. If it fails, (can't I just copy the second sentence above?)
Posted 12/30/2014 2:12 AM (GMT 0)

Dewayne said...
Isn't the same option available with both treatments?

I had HDR Brachytherapy. If it fails, I certainly can have more radiation, whatever the method, right?

IF I had chosen surgery. If it fails, (can't I just copy the second sentence above?)

I think when they're saying that about radiation, it's more like what I had. With 79.2 Gy to the prostate, in the unlikely event of recurrence within that cooked prostate, you can't do more radiation to those tissues. They've had the max lifetime tolerable dose, so not possible. More would be unacceptably toxic.

I think HDR brachytherapy gives a lower dose, but at a far higher rate with (hopefully) the same or better effectiveness (based on the whole alpha/beta ratio discussion). So, there's a chance of further radiation to such a prostate because it hasn't reached its exposure limit yet.

No answer seems simple with this stuff.

Jerry
Posted 12/30/2014 2:19 AM (GMT 0)
Mel, the point is that there are salvage backups to BOTH surgery and radiation. So, choosing surgery "because there is a backup" is faulty logic. The reason it is faulty logic is that there are salvage backups for BOTH...so the backup "advantage" to choose surgery just does not exist.

You asked me to elaborate on the backups for failed radiation. I and several others have done that many times yet you keep asking the same question. On a thread on December 6 of this year I referred you to a thread from JohnT from 2009...here it is again: www.healingwell.com/community/default.aspx?f=35&m=1625554 I urge you to read it.

JT has made this point on numerous occasions as I have and as Yooper has. How much more specific do we need to be?

Additionally, Yooper has told you the following:

"Can't believe there's still a discussion about the OLD argument of posturing surgery as a primary treatment because then if you have a recurrence then you can go the radiation route but not vice-versa. That's pretty much old/outdated thinking (unfortunately still being promulgated by many) right along with (cue music, "da da da daaaa!) "The Gold Standard."

There is plenty of information out there about the options if radiation fails - and as one would expect they come from the radiation guys. For example - from Dattoli: "Patients experiencing recurrence following single modality radiation are often eligible for additional treatment using a different form of radiation. For instance, the man who had EBRT alone may find benefit from a small dose of DART followed immediately by seed implant (depending on the location of the active cancer cells).

Men who had seeding (brachytherapy) alone might benefit from additional seeds of a different isotope. If he had Iodine-125 seeds, he might now have Palladium-103 seeds (referred to as a "crossover isotope"), or vice versa, and DART to the surrounding periprostatic tissue and relevant lymph nodes. Often these post-radiation recurrent patients will be prescribed hormonal therapy in addition to the new radiation."

There's plenty more out there as well, it's just newer information versus the old. I for one have done much research on this as I always have a "Plan B" in my life, and in the case of my own PCa for me should I have to deal with recurrence I would go to Dattoli. I made THAT decision as part of my own intensive due diligence leading up to my decision on primary treatment."

Geez...the FACT is that there are numerous salvage opportunities if original radiation fails so when urologists promote a "backup plan in case of failure" they are telling the truth but just omitting some additional truth that every new patient should have.

Jim
Posted 12/30/2014 3:12 AM (GMT 0)
Mel - "C'mon Man!" How many times does this have to be stated already? Tud posted what I would have - RE-STATED. What is it that you're missing here? No way I can make it any clearer than the way I did and Tud just re-posted. This is getting redundant and embarrassing already.

halbert, pretty clear to me that you get it: "In the end, I think a lot of it boils down to the individual rapport the patient develops with the lead physician. One thing I have already picked up about all this: An individual outcome depends significantly on the experience and skill level of the lead physician combined with the attitude and trust the patient has about the chosen treatment." Well stated!!!!!!!!!
Posted 12/30/2014 3:42 AM (GMT 0)
Tud and Yoop:

Listen you two: Instead of acting like defensive wusses, yes you better repeat it, and often.

The fact remains that if I asked folks with PC looking at tx. choices and having seen a surgeon and an RO and IF I asked what if surgery fails, MANY will KNOW they can do B/U radiation.

If primary tx. of radiation fails??? Even YOU GUYS KNOW that for some reason the message is not out there or is not clear.

So, instead of yelling at me for asking again, make the message clear.

Or does everybody know this and my HT-addled brain is getting mushy?

Mel
Posted 12/30/2014 3:46 AM (GMT 0)
Thanks, Yooper. I have a lot of friends and colleagues who have dealt with one cancer or another. I see that attitude and trust have a LOT to do with the kind of progress that is made. I'm an information junkie, always have been. A forum like this is a great tool to sift out the general insanity of millions of google hits. I solve problems for a living, and this is just another one to solve.
Posted 12/30/2014 4:03 AM (GMT 0)
Hell, Mel, maybe it's just me. I'm tired and hate typing on my phone. I'll try again tomorrow - copy and paste is easier on my PC.....
Posted 12/30/2014 4:22 AM (GMT 0)
Some of us guys, myself included, do research on our own and come to our own conclusions as to treatment that best suits our personality and personal experience. And we are ok with that.

Others want us to do what they want but it may not be what we want..

Just a thought, not a sermon..
Posted 12/30/2014 4:35 AM (GMT 0)
halbert, regarding your quote "An individual outcome depends significantly on the experience and skill level of the lead physician combined with the attitude and trust the patient has about the chosen treatment"

I completely agree with the first part of your sentence. As for the second part of your sentence, when it comes to regarding treatment choices, there are certainly options that resonate with individual people and that is something that everyone respects. No one walks in your moccasins, but you.

But most of us here do have a bias for getting as much info as possible before making your decision. I'm not saying that you're not--the very fact that you're here shows that you are. But if you look past our quibbling on your thread (with myself as one of the quibblers), I think that's the spirit that's coming out--trust is something that's earned through your learning experience.

Sometimes you learn something that makes you think of your options differently. And sometimes you get additional confirmation that your initial way of thinking is the right approach. There's goodness either way.

I do hope that's your main takeaway. And we're all PC brothers here and we want everyone that passes here to kick that PC beast to the ground. No matter which kick you use.
Posted 12/30/2014 4:40 AM (GMT 0)
At this point I hesitate to even get involved in this discussion, after all I'm still a newbie, having been diagnosed recently and not yet treated, so I haven't earned my stripes yet.
But I will anyway.

I think there are a fair number of patients who make their decision on surgery vs rad (vs As) based on facts. Grimm studies, Walsh / Tewari /Samadi papers, etc.
But I think far more patients , many of them well educated about the options, make their decisions based on gut, and emotion. It's a very personal decision, and often, as in my case, there is no wrong decision. You just have to have a comfort level with the direction you choose.

I think there is a natural tendency to think, well, if radiation as primary tx didn't work , and I can either have salvage surgery which is real hard, or more radiation even though radiation didn't work the first time, or HT which isn't really a chance at cure, what the hell kind of choice is that? I'm not saying it's right, I'm just saying I think that's how a lot of us think.

And there is No question that there are a ton of people who have surgery because they "just want to get it out" which may be the wrong approach based on facts, but it's not the wrong approach for those people. Right or wrong there is a lot of emotion and gut involved.
I've chosen surgery, and I admit that I STILL am not sure I made the right decision. But my decision was well informed, it feels right (most of the time) and that has value to me.
That's why sometimes I think these discussions are not worthwhile.

Also, just a comment, sometimes I feel like the pro rad guys here are way more vocal and viceiferous in defending their position than the guys who've chosen surgery. Without question, it's because of a strong desire to help people. And I don't feel the pro rad guys push anyone to do ANYTHING, except educate themselves before doing something, which is good. I know that first hand and very much appreciate it.
Still, I think there is sometimes a pro rad undercurrent here.

Let's just hope the DRs are right when they say that both work equally well . In the end that's all that matters.
Posted 12/30/2014 5:23 AM (GMT 0)
Prat:

Emotion and fact are not mutually exclusive. For example, in your case, it is a fact that your emotions can't handle AS (me too). Knowing that fact and acting on it, are you using emotions or facts. I claim you are using facts.

Mel
Posted 12/30/2014 12:09 PM (GMT 0)

compiler said...


If primary tx. of radiation fails??? Even YOU GUYS KNOW that for some reason the message is not out there or is not clear.


Mel

Mel, I can certainly agree that the message is not out there, especially for new patients. Most likely this is because most of the new patients get their info from their urologists who may not know about back-ups for radiation -- or may not care to share that info in their enthusiasm to sell surgery. However, for those of us who have been posting/reading on HW for years the message has been relayed many times. I can't speak for Yoop but my frustration is that YOU don't seem to understand this...despite the fact that we have both personally replied to your many questions on the subject. Hopefully, I have communicated well enough on this thread so that the message is clear. I will continue to post that info for new patients but, hopefully, the veterans who have seen this time and time again will already have the understanding.

Prato, I think you are correct that many make their decision on gut/emotion aka their individual personality traits. I have no issue with that but hope that men would get educated on the facts first -- as you did -- before making the decision.

Jim
Posted 12/30/2014 12:35 PM (GMT 0)
I think Mel is right that the message is not out there, in the general population. Here on Healingwell it's been made clear, the question is yes, there are options after surgery, but are they as good as having salvage radiation for the first time. The very unfortunate fact is that the vast majority of newly diagnosed patients make decisions without the benefit of the message and knowledge on places as robust as HW

MEL, yes for me I guess fact and emotion were involved, and one fact was AS was not for me, based on emotional makeup. Another fact was that I have same chance of cure with Brachy as with surgery. I chose surgery based on the emotional need for certainty of Prostate path.

Probably just semantics we are saying the same thing
Posted 12/30/2014 12:41 PM (GMT 0)
Halbert, sorry your thread got a little,off track but hope the discussion becomes food for thought in your process. Please keep us posted
Posted 12/30/2014 1:07 PM (GMT 0)
halbert (My wife's maiden name is Halbert) You have come to the right place for advice comfort and knowledge and a great group of caring people. I was like you eight years ago at age 57 good numbers, healthy for the most part. I had the daVinci. You Uro saying he didn't want to take the time to learn how to do the robotic would bother me. He may be very competent but he is not at the top of the game and maybe doesn't want to be. The first Uro I had was over 70 one of the founding members of the group. He said, "what we do is cut you from the bottom of your navel to the top of your pubic bone and take it out. 50% will have incontinence and 50% will have erectile dysfunction." I thought HOLY CRAP!!!!!! I joined this forum, got lots of good solid advice from the been there done that folks. I got me a young Uro in the same practice no less and he did the daVinci. I had no incontinence and regained sexual function within 10 months. Everything has been really great until now eight years down the road the PSA is creeping and I am at 0.20 and watching to see if it moves more and will have to consider my options. So, I am not a newbie but have only been posting once a year or so as to how it was going and feeling a little guilty because it was going so well compared to many of the fine people here. So welcome to a great place to be. Life is journey and every day is a blessing. God bless you in your journey.
Posted 12/30/2014 2:01 PM (GMT 0)
First I too apologize to halbert if your thread has not provided you with what you had intended it to - but as Prato mentioned hopefully there are some take aways here.

(And BTW Prato - "Also, just a comment, sometimes I feel like the pro rad guys here are way more vocal and vociferous in defending their position than the guys who've chosen surgery." YES, as I have stated on a number of occasions, when something needs to be corrected, I will get vocal.....)

So then Mel I thought I would take a different angle, and take you up on your request to have the options if radiation fails better explained as opposed to just pushing back. So here goes:

First of all and I think this is of merit, due to the "infrequent occurrence of unfavorable outcome... there are limited data to guide us directly when a brachytherapy failure does occur." (Quoted from "The Oncologist, the "Official Journal of the Society for Translational Oncology." So then I believe that may be a part of the problem with respect to not much being out there on this topic.

In Summary:

LDR BT: In carefully selected patients with local persistence of disease, partial LDR (125)I permanent prostate seed implant appears to be a feasible option for salvage local therapy with an acceptable toxicity profile. NCBI

Men who had seeding (brachytherapy) alone might benefit from additional seeds of a different isotope. If he had Iodine-125 seeds, he might now have Palladium-103 seeds (referred to as a "crossover isotope"), or vice versa. Dattoli

Prostate BT is an effective salvage modality in selected prostate local recurrence patients after radiation therapy. Additionally some potential predictors of biochemical control and toxicity for prostate salvage BT can be provided. Radiation Oncology.

HDR BT: Salvage HDR prostate brachytherapy for biochemical failure after radiation therapy appears to be safe and well tolerated with promising results. PCRI

Prostate HDRBT is an effective salvage modality with relatively few long-term toxicities. We provide potential predictors of biochemical control for prostate salvage HDRBT. International Journal of Radiation Oncology

Cryoablation: Can be used with recurrent cancer following radiation treatment (external beam or brachytherapy). One benefit of cryotherapy is that it is equally effective when ablating (removing) cancers of any Gleason grade. Due to the ability to use smaller needles, it may be possible to eradicate an area of the prostate that contains the cancer rather than treating the entire prostate gland. American Urological Association.

So I could go on but I think this at least starts to clarify this topic.
Posted 12/30/2014 4:12 PM (GMT 0)
[quote](And BTW Prato - "Also, just a comment, sometimes I feel like the pro rad guys here are way more vocal and vociferous in defending their position than the guys who've chosen surgery." YES, as I have stated on a number of occasions, when something needs to be corrected, I will get vocal.....)

Yoop, hope I was clear, I DIDNT mean that as criticism towards you, or anyone in particular, or the forum in general. Just stating that there is less defending of surgery than there is of rad.
Hope I didn't offend anyone because the rad guys did help me tremendously in learning about Brachy, which I think was very important in order for me to go into surgery feeling I've done as much as possible to make a good decision
Posted 12/30/2014 4:59 PM (GMT 0)
Yoop:

Thanks for posting the list.

I always found the what to do if radiation fails a bit hazy.

This is clearer. I guess it's other forms of radiation, but quite a few choices.

Mel
Posted 12/30/2014 7:11 PM (GMT 0)
Thanks for that Mel - and please accept my apology here for coming across as too much of a smartaxe in my earlier post! I should have stepped back from square one and addressed your question in a more positive manner.
Posted 12/30/2014 8:43 PM (GMT 0)
LOL!! I plan to be extremely nasty here on HW and blame HT for it!

(Sorry!)

Mel
Posted 12/30/2014 9:13 PM (GMT 0)

Jerry said...
I think when they're saying that about radiation, it's more like what I had. With 79.2 Gy to the prostate, in the unlikely event of recurrence within that cooked prostate, you can't do more radiation to those tissues. They've had the max lifetime tolerable dose, so not possible. More would be unacceptably toxic.

Yes and no. We have to make a distinction between whole gland salvage radiation and focal salvage radiation. So if you have had the full dose (80 Gy) of IMRT or LDR brachy and a local recurrence is suspected, they would do a biopsy to confirm it's a local recurrence, and to determine just where it is. A newer tool is to use mpMRI to locate the specific site of recurrence. Then, if it's not in too dangerous a place, that site, with a margin around it, can be re-treated with SBRT, HDR brachy or LDR brachy (conceivably proton or carbon ion too, although I haven't heard about it being done).

After HDR brachy or SBRT, it is conceivable that the whole gland can be re-treated, although I haven't heard of that happening. Ablation with cryo, laser or HIFU are all possible for focal salvage as well.

- Allen
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