Need opinions on the issue of surgery vs. RT, vs. Brachytherapy

Here's thing that will drive you nuts - they will all work for you.

Which one would are you most inclined to do?

I chose beam RT because I didn't want to do surgery because of heart/lung issues that make surgery difficult on me. I thought about brachy but with my health provide I would have had to have gone to a different city for treatment so I picked the cancer clinic near home. They were a team that I earned my trust very quickly and I had great set of doctors and techs working on me.

My two brothers have PC too. One did surgery and one did brachy. We're all doing fine, have about your numbers. We each have about the same side effects. The SEs from surgery hit all at once while the radiation effects show up slowly over a couple of years.

Knowing what I know now, I think I would have taken more time to investigate Brachy as my brother's experience with that was great and like it was the least invasive procedure.

You'll be fine whatever you pick.
Sorry that's not more helpful,
Andrew

Yup, that's the problem. Best you can do is get all the info you can and decide which option makes most sense to you. Some guys hate the idea of radiation while others don't want to be attacked with a knife.

Sometimes it's like my dear old daddy use to say, "you pays your nickle and takes your shot."

Let us know how the next visit goes,
Andrew

I'm scheduled for surgery 2 weeks from today. I chose surgery because of extensive family history of PC, my father died in 2004 at 78 of metastatic PC (spine). He chose initial treatment by cryo in the early 90's, and later had HT for several years, then they found cancer on his ureters and bladder (radiation). I want the assurance that "they got it all" and am willing to deal with the SE's as they happen. Scroll back a page or two and find my story....a thread called "my story". I'd link it here if I could figure out how. ;)

I agree with Andrew - they all have excellent chances of curing your type of PC.

When you say "brachytherapy" I assume you mean LDR brachytherapy or seeds. My one caution with that, and I would say the same for surgery, is if that's your decision, have it done by one of the renowned rockstars. It makes a big difference.

My top two were HDR brachy and SBRT because, aside from excellent long-term control, they have the lowest reports of side effects, especially sexual SEs, which were especially important to me. Also the top practitioners of each were 10 minutes from home. I chose SBRT just because it was so hassle-free - just 5 short sessions.

I ruled out IMRT because it had worse reported SEs, cost more, and was a long-term hassle (40 treatments). I ruled out proton because it's no better than IMRT, and a lot more expensive.

Make sure you talk to experts in each treatment and that you don't rely on what an expert in one treatment has to say about another treatment. It would be unreasonable to expect that he would really know.

- Allen

Gotta go with Peter and Allen on this.

Cheers, Doug

Logic1, very well expressed! Though our stats are quite different, that was very close to my thought process. Best of luck in the future!

Cheers, Doug

logic1-

I don't like to comment after someone says his mind is made up, so I am addressing these remarks to the OP because many of the issues you bring up are quite common. I don't disagree with most, but just wanted to add my POV on some.

1. Timing/travel to best practitioners
I think this is terrific, no matter which treatment is chosen. Seek out and go with the best practitioner one can find that insurance will cover. External beam radiation no longer has to take 8 weeks -- it can be done in 5 treatments. LDR brachy is done in one office visit, and usually a follow-up a month later. HDR brachy can be done across a single overnight hospital stay.

2. Path report
I think that this is the best reason to go with surgery. If it's indeed contained, a clear path report an undetectable PSAs are very reassurance. It's very personality-dependent, and no one can judge the importance of this but the patient.

3.Rectal/Urinary complications with radiation
Quite true, although for most of us they're fairly mild and transient. But if someone has inflammatory bowel issues or urinary retention before radiation, they are much bigger concerns.

4. Undetectable PSAs
For a well-contained low or intermediate risk PC, that is most often the case and is very reassuring. The converse is also true though - if PSA becomes at all detectable, it can be nerve-wracking, and doesn't always mean that salvage radiation is required.

5. Salvage radiation after surgery
As I said in a recent post, this is not at all a good reason to choose surgery. Salvage anything is bad, and salvage radiation can have some horrendous SEs that might never have occurred if radiation had been done initially. There are salvages for initial local radiation failure -especially salvage focal radiation - but local failure is rare for primary radiation (most failures are distant) because radiation already treats the area outside of the prostate capsule. This used to be a bigger issue in the olden days before dose escalation or hypofractionation.

Firstly, I decided on surgery because of my Gleason 9. Being able to get an accurate Gleason, and knowing if it was contained seemed to be important to me. Surgery is the only way to get a conclusive pathology. Surgeons are fairly easy to evaluate. Number of robotic surgeries, any malpractice claims, PSA levels of patients at 3 months, etc. Like you going to Duke, I chose Cleveland Clinic, so the head of the department, or some other auspicious title makes a guy feel good.

RO's are a little harder to evaluate, and again with Gleason 9, it is even harder. Being nice guys with plesant personalities are nice, but may not matter. Also, the RO usually doesn't actually do the work for IMRT or IGRT. The radiation tech is a key figure.

Surgery gave me 3 years of good results. Low PSA, few SE's, but not negligible. After watching a slow trend of increasing PSA from <.01, to .06, I decided to do IGRT. It too has given me 3 good years. Hoping for a couple more years at least.

I have concluded that a Gleason 9 is probably not curable. Seems that it will resurface again in many cases. So, if I can get 6 or 7 years with surgery, and IGRT, I wilk feel successful. Who knows, may get 10 years.

Then I will move on to chemo, or Ht, or chemo and Ht. Have seen some great advances since my surgery. Provenge, Xtandi, etc, all seem to be doing some great things. Combo therapies are also making great strides.

Just wanted to give my rationale, but as has been said, all treatments are real close in successful treatments. I just think it is important to pick one, go for it, and NEVER LOOK BACK. Dont let anyone try to convince you should have done something else. Find a doctor or team you can trust, and let them help you.

Good luck to you. Odds are in your favor.

Newlife,
One poster stated that all of the options that you've mentioned will likely work for you. I was in the same situation. Since I was fortunate enough to have multiple was of 'curing' my cancer, I wanted the one that gave me the best chance of preserving my quality of life. For me, LDR brachy was a clear and easy choice, one that I am eternally grateful that I made. Since my treatment nearly 5 years ago, I have come to the realization that HDR brachy may be at least as good a choice.
Like Dewayne, I knew lots of guys who had gone the surgery route: not one of them had the results that I wanted especially in the area of sexual function. I'm not saying that no one has good surgery results; I am saying that I never met one.
Best to you.

Hi newlife, and welcome to our little corner of the world. You have come to a good place with immeasurable help and knowledge from those that have "been there, done that" with respect to being told we have PCa, learning about the beast, deciding on a treatment path and moving on.

I didn't pick up if you have had a 2nd read on your biopsy slides yet? Typically that should be one of your next steps, and more specifically doing so with a lab such as Bostwick and Epstein who are among the very best at that.

As you continue to move down the path to a treatment decision, I would suggest that you talk to and if possible meet with as many of the medical experts in the different treatment approaches as you can. When you do, be sure to ask for their specific outcomes post treatment - % regression free, continency (and have them define what "continent" means - to you and I it means NO issues, while others may qualify that with "only one pad per day" or "only when straining") - same goes with ED. They all have these statistics and if they say they don't or are unwilling to share that would be a cause of concern for me. (Of course keep in mind that surgeons will recommend surgery, RO's will recommend radiation - simply goes with the territory.)

On a personal note, at my young age and excellent health, and with no symptoms or issues - while curing the cancer was / is my top priority, at the same time preserving my quality of life ran a very, very close 2nd. I simply was not willing to sacrifice that. Be aware of this by doing your research and getting the statistics from the practitioners/treatment modalities you may be considering going with. You only get one shot at this - one of the most important decisions we're likely to make in our lives. As Tall Allen mentioned and I fully embraced, no matter what modality you choose you'll be far better served by going with one of "the best."

To all of this I would also add that early on in my journey I made the decision that I would not allow geography or cost to get in the way of my decision making process of who and where to be treated; while not independently wealthy I simply drew the conclusion of - what is my life, and my quality of life, worth? That made it an easy call.

Based on all of my research then I went with LDR BT as it shows equal to or better results with far less potential for SE's. I also went with one of "the best" practitioners in the world, and am incredibly happy that I did. My PSA is where it needs to be, and I have NO SE's whatsoever.

As part of my journey to learn about the various treatment options I downloaded, purchased, and copied a number of studies and results that I would also be happy to share with you, so if you are interested shoot an e-mail my way and I'll reply right away.

We are all out here to help - my very best wishes to you in this journey.

Not surprising since Tall Allen was my mentor but I went all the way from FL to LA to have the 5 fractions of SBRT. There are only 3 radiaiton oncologists I am aware of that do the high Gleason SBRT and I chose Dr. Chris King at UCLA.

The other 2 are Dr. Allen Katz in NY and a group of doctors in Toronto, so substantial travel to get to any of the 3.

For 5 fractions over a week and a half logistics was not a major issue, and one of the costs of living in a rural area of Florida.

In your case G7 (3+4) as others have said you have a lot more option and all of them are good, so just go with personal preference after doing your due diligence, and go with the most experienced one in that field.

After my dx, I had several consultations with surgeons, radiation oncologists, and a medical oncologist. All concurred that I had too great a probability of surgery failing and they did not think it wise to add radiation on top of surgery for all the risk and side effect issues that have already been stated. They all also concurred that in my case they knew enough from my biopsy to direct the treatment and did not think a pathology would be beneficial enough to offset the risk. As Tall Allan reported, the argument of radiation after surgery but not vice versa is a red herring and should not influence the initial treatment decision. Personally, I would stay away from a surgeon that presented that incorrect reasoning in order to push surgery.

I then researched the radiation choices between HDR and LDR brachytherapy. IMRT was a given with as was HT. I chose HDR for it's better use of technology to improve cancer control and reduce side effects compared to LDR. At the time, I did not seriously research SBRT as I didn't find local practitioners with the experience that the HDR and LDR practitioners had and I didn't have Tall Alan to assist me! All has been fine since my treatment more than four years ago.

I concur and amplify what others have said about choosing the very best practitioner and clinic. If I could not have found a very experienced HDR practitioner, then I would have gone with LDR. Fortunately I had three of the best choices in the country here in Atlanta (two HDR and one LDR) and chose the HDR brachytherapy.