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Posted 3/18/2015 7:04 PM (GMT 0)
I am 52 years old and was diagnosed with Prostate cancer last month. I am "intermediate risk" and am awaiting the results of a Prolaris test to find out how aggressive the cancer is. I live in the Chicago area and have consulted with 2 surgeons and an oncologist. I understand that surgery and radiation (combination brachy/external beam) are both good options, but I am leaning towards surgery because I feel it offers a better "Plan B" if the first line of treatment fails. Is that a sound rationale for making my decision?
Posted 3/18/2015 7:23 PM (GMT 0)
There is a "Plan B" for my HDR Brachytherapy in the unlikely chance it fails me.

More will opine, but no I don't think that's a good rationale for making the decision.

Surgery might very well be your best option, or not, but it should be for a different reason than "We can always do radiation if the surgery fails".

You could do radiation if radiation fails as well.  Other options, as well.

Posted 3/18/2015 7:28 PM (GMT 0)

Dewayne said...
There is a "Plan B" for my HDR Brachytherapy in the unlikely chance it fails me.
More will opine, but no I don't think that's a good rationale for making the decision.

Surgery might very well be your best option, or not, but it should be for a different reason than "We can always do radiation if the surgery fails".

You could do radiation if radiation fails as well. Other options, as well.

I'd say ditto to that. Look very hard at what the relative side effects of various treatments might be and how likely you are to have them. Odds are very good of you dieing of something other than PC no matter which treatment you choose, but those side effects can be with you a long time, even until death do you part. So pay real close attention to that.
Posted 3/18/2015 7:29 PM (GMT 0)
Heard this theory many times ("we can always do radiation if surgery fails") as an argument on why surgery is the Gold Standard for treatment. I believe that line of thinking is largely a myth. I don't believe it holds up to scrutiny.

From the Prostate Cancer Center of Seattle (granted, they do LDR brachytherapy but their reasoning is backed up):

Myth: Surgery can not be performed after brachytherapy
Fact: This is not true. However most surgeons are not trained to do this procedure and it must be done by an experienced surgeon who has performed it many times before. The likelihood that a brachytherapy patient will face a local recurrence is quite low, approximately 3% 6. In the rare cases when there is a local recurrence only surgery can be done successfully. However, a local recurrence can be associated with distant recurrence which would make the value of removing the prostate in this situation questionable. Of note is that Prostate Cancer Center of Seattle physicians have developed and are treating patients with local recurrence after external beam radiation or brachytherapy with focal , noninvasive treatments. See description on home page.

Myth: Immediately after surgery, the surgeon says, “We got it all”
Fact: Microscopic disease beyond the gland cannot be seen by the naked eye, so this statement is a statement of hope, not fact. Only after a pathologic review of the removed prostate and subsequent PSA readings over 3- 5 years can this statement be given reasonable credibility The cure rates are excellent for many different treatment options, especially in low risk disease but it is a myth that surgical removal results in 100% cure.


1.) Ho, AY et al. Young Men have Equivalent Biochemical Outcomes Compared to Older Men After Treatment With Prostate Brachytherapy Volume 69, Issue 3, Supplement, Pages S90-S91 (1 November 2007)
2.) Merrick, GS et al. Brachytherapy in men age less than or equal to 54 years with clinically localized prostate cancer. BJU Int’l (98), 324-328, 2006.
3.) Frank SJ, et al. An assessment of quality of life following radical prostatectomy, high dose external beam radiation therapy and brachytherapy iodine implantation as monotherapies for localized prostate cancer. J Urol, Jun 177(6), 2151-6, 2007.
4.) Sharkey J, et al. 103Pd brachytherapy versus radical prostatectomy in patients with clinically localized prostate cancer: a 12-year experience from a single group practice. Brachytherapy, 4(1): 34-44, 2005.
5.) Ganswindt U, et al. Adjuvant radiotherapy for patients with locally advanced prostate cancer-a new standard? Eur Urol, Jun 23, 2008
6.) Stone et al Int. . Radiation Oncology Biol. Phys. 76: p355-360 2010
7.) Burri, R et al. Young Men have equivalent Biochemical outcomes compared with older me after treatment with Brachytherapy for PCa Int. J. Rad Onc. Biol Phys 2009 (article in press)

www.prostatecancertreatmentcenter.com/faq/myths/
Posted 3/18/2015 7:46 PM (GMT 0)
Sounds good, but in reality is a poor reason to choose surgery for the reasons others have stated. Choose the best treatment for your current situation as any salvage treatment is bad.
The risk of a local reocurrence is much less likely with radiation as it treats 15mm of the prostate bed, seminal vesicles, and nerves, all areas where the chance of surgical failure is the highest.
Posted 3/18/2015 7:53 PM (GMT 0)

BuckeyeMan said...
e I feel it offers a better "Plan B" if the first line of treatment fails. Is that a sound rationale for making my decision?

Hi Buckeye and welcome to HW. My answer to your question is the same as you have received from others on this thread, i.e. "no, that is not a good reason". Surgery after radiation can be problematical but that is only PART of the story. There are as many options for salvage after a failed radiation treatment as there are for salvage after a failed surgery. So...that's a wash. Make your decision on different parameters.

Perhaps an oversimplification is this: Surgery and radiation provide equal chances of cure. So the decision should be made on other factors. The value proposition of surgery is immediate knowledge of the cancer pathology. The value proposition of radiation is generally fewer onerous urinary and sexual side effects. You have to decide what is important to you.

BTW, since you are in Chicago I would heartily recommend that you see Dr. Brian Moran at the Chicago Prostate Center. He has successfully treated a number of our members including AYooper who will likely be along soon on this thread.

Good luck.

Jim
Posted 3/18/2015 7:57 PM (GMT 0)
Welcome to HW, sorry you need to be here.

There's a plan B for everything. Sometimes follow up surgery, or addition modes of radiation. We've discussed the "you can't have surgery after radiation" a lot around here.

Pick a method that makes sense to you and you're comfortable with. All major treatment modes will work fine with a variation in side effects.

and frankly, I'd be surprised to find that your primary treatment method would fail for you.

Hang in there and keep us updated on your progress,
Andrew
Posted 3/18/2015 8:06 PM (GMT 0)
Well, I see everyone has already jumped on what I consider one of the misleading statements made in regard to prostate cancer treatments. I won't repeat my feelings on that since it's already been stated, but I will repeat that based on your diagnosis, both surgery and radiation are likely to cure you.

Unless the oncologist you spoke with specializes in prostate cancer, he's probably not as familiar as a radiation oncologist when it comes to current techniques. The referral to Dr Moran is a good one as I understand he's one of the best at brachytherapy.
Posted 3/18/2015 8:21 PM (GMT 0)
Welcome Buckeyeman-

Sorry to hear about your Dx. You would be classified into the "favorable intermediate risk" category, which means that any of the treatments that are good for low risk are good for you too. You could probably even get away with some very closely watched Active Surveillance for awhile, although the PNI makes that more problematic. All popular therapies - surgery, SBRT, HDR brachy and LDR brachy - in the hands of the right specialist have odds greater than 90% of being curative. They differ greatly in the expected side effects, and other things that may or may not be important to you.

I hope you've already read the sticky "for the newly diagnosed" and have followed the recommendation therein to have your biopsy slides sent to Bostwick or Epstein for a second opinion.

I hope too that you know that you can and should take your time in making this important and irrevocable decision. In our era of specialists, you will have to seek out and interview specialists in each of the therapies that are good for you. You should also assess what is most important to you other than cancer control:continence? erectile function? having a pathology report and undetectable PSAs? There may be comorbidities that affect your decision too; e.g., CV disease, diabetes, large prostate, urinary strictures, hernia, anatomic abnormalities, etc.

To directly answer your question about using salvage as the basis of your decision, I agree with the above posters that that is an absolutely horrible basis for making a decision. You may be interested in my recent post on the subject:

Why salvage radiation is bad

For all forms of radiation, salvage focal radiation with brachy or SBRT is possible, as is ablation. However, local failures only account for about 20% of radiation failures, and because radiation also treats an area outside of the prostate, salvage radiation after radiation is unlikely. Salvage anything increases side effects. Given that they are equally curative, choose the therapy most suited to you, and deal with the low probability of salvage only if you have to.

I don't know who told you that combination brachy+EBRT is a good therapy for your case, but to me it seems like overkill for favorable intermediate risk, and is likely to leave you with unnecessary side effects. Monotherapy, and certainly without hormone therapy, should be sufficient.

Here are the specialists I would talk to in the Chicago area:

• Surgery: Dr. Catalona at Northwestern
• LDR Brachy: Brian Moran at Chicago Prostate Cancer Center
• HDR Brachy: Alvaro Martinez in Detroit - he's worth the trip.
• SBRT: any of several CyberKnife centers in the Chi area.
Posted 3/18/2015 9:17 PM (GMT 0)
From what I've seen in here in the few months I've been around I've seen the following informed rationales for surgery (and I include myself):

Surgery does offer certainty of diagnosis because final pathology is possible.
Surgery offers peace of mind to those of us who don't like the idea of being irradiated.
Surgery offers a very high probability of immediate non-detectable PSA--a few weeks vs a few months

There is endless debate about long term (over 10 years out) side effects, and whether surgery is actually better/worse/or same as radiation. Fact is, there aren't a lot of longitudinal studies that go out that far.

At your dx level, you should get good results regardless of your treatment choice. In the end, it's your decision to make, based on whatever criteria you think are most important. It can even be a gut feeling you can't really explain...and that's ok.

Take your time, find the experts you want to be working on you, and make the decision that makes you most comfortable. Stay in touch here, there's a great group of guys (and a few gals too) here.
Posted 3/18/2015 9:38 PM (GMT 0)
Hi BuckeyeMan, 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. Please keep in mind that with your statistics in the "favorable intermediate" while I also believe you need treatment, you do have time - time to learn about PCa and the various treatment options - so don't panic or rush into anything!

Others have already asked about getting a 2nd read on your biopsy slides, and I agree that should be one of your next steps. Labs such as Bostwick and Epstein are two of the best and a 2nd opinion from an expert in this area is usually a good thing to add to your decision making tree.

Along with forums such as this where you can learn from people that have and are going through what you are, do as much internet research as you can. When I was at your point in my journey I encountered the "paralysis by analysis" syndrome as I was spending several hours a day doing all of the research and reading as much as I could - but that's o.k. as it will put you in a better place in terms of deciding your choice of treatment.

You will also want to 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.

Tudpock mentioned that I would chime in about Dr. Moran - he did my LDR BT implants and the whole experience capped by my results speak for themselves. I would strongly encourage you to include him on your list of professionals to reach out to. You will find Dr. Moran very accommodating to a visit/initial consultation and/or a phone conversation.

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 close 2nd. Be aware of this by doing your research and getting these 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 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 again 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.
Posted 3/18/2015 10:47 PM (GMT 0)
Buckeye man, I'm late to the conversation, and so I don't have much to add to the great advice that's already been given.

My experience with surgery was a positive one. I'm ten weeks post op and aside from the anxiety over upcoming PSA tests, and a small drip here and there on coughing or yawning, I wouldn't even know I had surgery. So I'm glad I did what I did.

But I'm one of the lucky ones, as others here can attest. So consider the possibilities.
What I did do, and what you should do, is what everyone said. Second opinion on biopsy slides, and meetings with EXPERTS in all of the treatment disciplines. Get educated, weigh your options, and whatever you choose as treatment, you won't ever look back and think about whether you made the right decision.

Good luck, and hang around here, it's a wealth of knowledge and experience.
Posted 3/19/2015 12:52 AM (GMT 0)
I invite you to come to the Prostate Cancer Support Group at the Chicago Prostate Center in Westmont, IL. We meet the first Wed. of every month at 7 p.m. at the CPC in Westmont. Make an appointment to see Dr. Brian Moran if you haven't already. He's the best IMHO. I usually never miss a meeting so I hope to see you there.
Posted 3/19/2015 3:21 AM (GMT 0)
Wow, I am overwhelmed by all your encouraging words and support. I truly appreciate your candid input - both from the veterans and newer members. All the information available out there has been a little overwhelming so your perspectives and sage advice are very helpful.

I did have the team at UofC take a 2nd look at the slides - unfortunately their answer came back G7 too. For those of you based in Chicagoland, any strong opinions regarding the urology groups at Northwestern vs UofC? TallAllen, it sounded like you might have some insights here?

I did meet with Dr Moran and agree he is incredibly helpful.

Fulltlt, thanks for the invite - I hope to be able to join the Support Group mtg in early April.
Posted 3/19/2015 3:57 AM (GMT 0)
BuckeyeMan-

I suggest you read the recent thread about second opinions:
www.healingwell.com/community/default.aspx?f=35&m=3353669

I apparently didn't make clear what I was saying to you about specialists. One doesn't go with a "urology group" (although a surgeon at a tertiary care hospital is preferable to one in private practice), one goes with a specific surgeon. The way to choose a surgeon is by his expertise. There's no one in the Chicago area who comes close to Dr. Catalona. He happens to prefer open surgery, but that matters little. He is easily in the top 10 in the world.

- Allen
Posted 3/19/2015 6:20 AM (GMT 0)
I went with Davinci surgery 11/2013. I liked the quick recovery, little pain managed with Tylenol for 4 days, having a pathology report based on a look under a microscope and a PSA of <.01 (zero) after surgery. I did not like the week with a catheter. I was driving the day after catheter removal and only missing 6 days of work due to Thanksgiving holiday. I was continent laying down the first night once the catheter was out. I wore the full depends briefs home from the catheter removal and never used them again. I used the pads in my Jockey briefs. They held a full bladder full a few times in the first two weeks. After that they were damp with a little weight to them for a few weeks with 2-3 changes a day. After a month it was one a day. By month 3 I was pad free. Never a leak or embarrassment. Like a women with Kotex, no one knew. I was G4/3 =7 at biopsy and bone scan, MRI, and CT were negative and 4/5=9 after surgery/pathology with positive margins, positive seminal duct, and 3 of 26 lymph nodes. For me knowing all of this was important. My 3 month PSAs were <.01, .01, .05, <.1, <.1, <.1. The first 3 were ultra-sensitive PSA test.

I didn't want to spend a year watching my PSA after RT to get a feeling of my condition. Post pathology we knew exactly what my prostate was. It goes without say there may be distant mets. Only time will till. We know some cancer was left so a rising PSA is no surprise, the slow rise suggests it is still local. Given my G9 T3b N1 M0 staging I have a high probability of reoccurrence so I start adjutant RT shortly. There is a merging thought that de-bulking high grade cancers even when RT/HT is planned may have benefit.

There are very good studies linking outcomes with the surgeons experience. My team had >1000 da Vinci procedures. A good surgeon is really important.

I'm not saying this is the best course for everyone, just it was for me.

Did I say I didn't like the catheter?
Posted 3/19/2015 6:26 AM (GMT 0)
Sorry for the typos like emerging, tell not till, etc. Touch pads and small screens.....
Posted 3/19/2015 10:37 AM (GMT 0)
Just because you're at a major medical center doesn't mean you'll have a top end, highly experienced surgeon. They show up at places you wouldn't think of. The example that comes to mind for me is Dr. Smith at Vanderbilt in Nashville. Last I heard he was >3000 Davinci procedures. I had mine in St. Louis at Barnes/Washington University and there are several surgeons there with 2000 or more each.

Like others have said, when you talk to your team lead, whether you go with surgery-open or Davinci; Radiation-external or brachy; or even AS, it's OK to ask them for their personal numbers. How many have they done? With patients similar to you, what kinds of SE's are they getting? It's vital to find someone who has done a lot of them with good results. Be willing to expand your search.
Posted 3/19/2015 10:54 AM (GMT 0)
Buckeye,
When I made the decision to have treatment, I was not concerned about any plan B. My goal was to have the best plan A available. I wanted a treatment that would not only rid me of the disease, but leave my quality of life intact. I had a one day treatment of LDR brachy. I missed 2 days of work and one week at the gym. My oncologist uses the 'cure' word, and my sex life has never been better. It was clearly one of the best decisions of my life, and I would have made it regardless of my age at dx. Incidentally I was 56 at dx...58 at treatment...currently 63.
Best to you, Brother.
Posted 3/19/2015 9:30 PM (GMT 0)
Hey everyone. Rather new to this. Diagnosed 3/16.

47 yrs old.
PSA Feb 2.9 Mar 2.6

Dr recommends robotic surgery to remove prostate. Meeting on 3/23. What questions should I be asking?
Thanks.
Posted 3/19/2015 9:37 PM (GMT 0)
Hi glof1967,

Sorry to hear about your diagnosis, particularly at a young age. It would be helpful if you could provide the specifics of your biopsy (Gleason score, number of cores that tested positive) and you can add that to your signature like you see in most of the other posts. (BTW, if you don't have that info, that's the first question you should ask your doctor.)

Also, I recommend that you start a new thread while you're at it so you get info tailored for you. (If you don't start your own thread, someone else will likely do it for you.)

We're here to help and with a bit more info we can.
Posted 3/20/2015 12:01 AM (GMT 0)
Buckeyeman,
Sorry you find yourself here, but you have received a lot of good input. I chose surgery with no consideration of plan B. I liked the idea of the pathology to understand better what I was dealing with. Unfortunately with this disease its a matter of probability and not assurances. I had pretty good post op pathology and now find myself doing SRT after 3+ years. Urinary continence and erectile dysfunction have not been major issues for me. Things are definitely different, but I dont regret the choice I made. Get as much information and opinions that you can and make your decision. IMO, the right decision is the decision you make. Good luck and I wish you well.
Posted 3/20/2015 1:48 AM (GMT 0)

halbert said...
Just because you're at a major medical center doesn't mean you'll have a top end, highly experienced surgeon. They show up at places you wouldn't think of. The example that comes to mind for me is Dr. Smith at Vanderbilt in Nashville. Last I heard he was >3000 Davinci procedures. I had mine in St. Louis at Barnes/Washington University and there are several surgeons there with 2000 or more each.

..........

Yep, he(Smith) did mine. At that time he had about 3000 RRPs which I believe followed about 3000 opens done during the development of the robotic approach. He is also quite the researcher and authority on the subjects of PC and kidney/bladder cancers.
Bill in MS
Posted 3/20/2015 3:05 AM (GMT 0)
Buckeye,

I've had surgery; but then again I am a G9'ner! They did mention "incontinence" and "ED" -- Quality of Life (QoL) issues; but given the danger of Cancer, QoL was given cursory attention at the time.

Having surgery at 52 could seriously affect Mr Floppy, sometimes permanently. What I miss most is that "white gob" I used to shoot; but then again my hard-on is back after almost 18 months, and my PSA < .01 (as at Friday 13/03/2015). (read my profile below)

There is a lot to think about and to consider. At the end of the day, you'll make the right decision for you! All the best!
.
Posted 3/20/2015 4:22 AM (GMT 0)
Hi halbert,

Your are right about major medical centers. The team I interviewed at BIDMC committed to being the guys with the knife and they were. They were very open about numbers, successes, and failures.

But during my selection process Boston's largest med center scared me away when I was handed down twice when I asked to meet the actual surgeon. Another mid sized outfit tried the old "you make an appointment with Dr X and find you are scheduled withDr Y". I canceled the appointment.

I'm glad to see Barnes /Washington held in high regard, my rad onc (Dr J Aronovitz) came from there.

Hamilton
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