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Anyone with experience using Kaiser Santa Clara for robotic radical prostatectomy ?

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Posted 9/16/2015 6:56 AM (GMT 0)
56 years old, recently diagnosed last week with prostate cancer.

Looking for any feedback.

Anyone with recent prostate cancer experience with other Kaiser locations, Stanford or UCSF would be appreciated also.


My biopsy ...

STAGE: T1c
Gleason Score: 3+4=7
PSA 4.4 08/10/2015
NUMBER OF CORES INVOLVED/TOTAL NUMBER OF CORES: 2 of 14.
TOTAL CARCINOMA LENGTH: 10 mm.
TOTAL TISSUE LENGTH: 192 mm.
PERCENT OF SAMPLED TISSUE WITH CARCINOMA: 5 %
F) PROSTATE, LEFT BASE, NEEDLE BIOPSY
-- ADENOCARCINOMA, GLEASON GRADE 3+4 = 7
-- ADENOCARCINOMA INVOLVES 2 OF 2 CORES AND 10 MM OF 30 MM
TOTAL SPECIMEN LENGTH (33%)
-- NO PERINEURAL INVASION IDENTIFIED
Posted 9/16/2015 12:55 PM (GMT 0)
Yes, I had my RALP done at Santa Clara by Dr Ahuja from the Santa Theresa office. The staff was great, the surgery went well except I had a positive focal margin. But, I'm still undetectable after 18 months.

I talked to a Radiation Oncologist before I went the surgery route, he also recommended surgery but also mentioned that Kaiser had assembled a good team of Dr's and that I should be in good hands.

As always do the research, how many surgeries, success rates, continence rates and so on...

Best of luck and I'll check back to see if you have further questions
Posted 9/16/2015 2:38 PM (GMT 0)
jronne-

As Patrick noted in his post, please take your time to review all of the options (including RALP) that are available to you. I'm sure you are doing this, but I think it bears repeating, as you DO have the time to consider all potential treatment options.

Ok, now, having said that, I had my RALP done by Dr. Thomas Hsu at Santa Clara Kaiser in May of 2014. I did quite a bit of research on the staff at Kaiser, aided by a good friend who is an ENT surgeon. We chose Dr. Hsu based on his experience with the procedure, his approach to my specific situation, and the third party references we were able to get from my friend's contacts at Stanford (where Dr. Hsu did his residency.)

I felt very well cared for by Dr. Hsu and his staff. He was also quite accommodating of my request to coordinate the removal of my gall bladder (separate issue that cropped up between my PCa Dx and RALP) during the same OR session (this involved a bit of both scheduling and OR coordination with the GI surgeon.) I will note that my wife was not as comfortable with Dr. Hsu. Her feelings were directly related to his bedside manner, which is very matter of fact, with little, to no, sugar coating. This particular trait did/does not bother me, as I wasn't there for small talk, I wanted the best guy on the "joystick"!

I'd be happy to discuss any specific questions that you might have about my experience with Dr. Hsu, and Kaiser in general (my Uro is in Redwood City, my MO is in Oakland, and my RO is in So San Francisco.) The short version is, though, that I have a great medical team at Kaiser.

All the best to you as you make your way through this journey. Again, don't hesitate to reach out to me (you can click on the "email link" below my screen name to the left.)

Rich
Posted 9/16/2015 4:26 PM (GMT 0)
Unfortunately Dr Hsu is currently on medical leave as I wanted to ideally get an opinion from him. I am working with Dr. Choi instead and was wondering if he is as proficient. I was wondering if you considered Dr Choi also ?

How do you think Santa Clara Kaiser rates compared to Stanford for the top surgeons (that would be likely be Dr. Choi at the current time) ?

With regards to your procedure was it open or robotic ?

Dr Hsu I think does both.

Were the positive margins a big issue / concern or a somewhat expected outcome given the extent of your biopsy ?

Curious as to how the initial biopsy pathology as compared to the actual cancer staging using the removed the actual prostate. My biopsy is concerning but not horrible I think.

I am also trying to gauge how quickly I need to act. What is your take given this biospy / PSA ?

STAGE: T1c
Gleason Score: 3+4=7
PSA 3.2 06/10/2015
PSA 4.4 08/10/2015
NUMBER OF CORES INVOLVED/TOTAL NUMBER OF CORES: 2 of 14.
TOTAL CARCINOMA LENGTH: 10 mm.
TOTAL TISSUE LENGTH: 192 mm.
PERCENT OF SAMPLED TISSUE WITH CARCINOMA: 5 %
F) PROSTATE, LEFT BASE, NEEDLE BIOPSY
-- ADENOCARCINOMA, GLEASON GRADE 3+4 = 7
-- ADENOCARCINOMA INVOLVES 2 OF 2 CORES AND 10 MM OF 30 MM
TOTAL SPECIMEN LENGTH (33%)
-- NO PERINEURAL INVASION IDENTIFIED
Posted 9/16/2015 4:44 PM (GMT 0)
Patrick -

Personally for me the bedside manner of the surgeon is secondary as surgical proficiency / skill is paramount. As long as the communication is accurate, efficient and clear that is all I require in the end.

Did you consider Kaiser Santa Clara ?

Did you look at Dr Hsu, Dr. Choi or anyone else there in Kaiser Santa Clara ?

How do you think Kaiser rates compared to Stanford / USCF for the top surgeons ?

Were the positive margins a big issue / concern or a somewhat expected outcome given the extent of your biopsy ?

Curious as to how the initial biopsy pathology as compared to the actual cancer staging using the removed the actual prostate. My biopsy is concerning but not horrible I think. How did your biopsy compare to mine ?

I am also trying to gauge how quickly I need to act. What is your take given this biospy / PSA ?

STAGE: T1c
Gleason Score: 3+4=7
PSA 3.2 6/10/2014
PSA 4.4 8/10/2015
NUMBER CORES INVOLVED/TOTAL NUMBER CORES: 2 / 14
TOTAL CARCINOMA LENGTH: 10 mm
TOTAL TISSUE LENGTH: 192 mm
PERCENT OF SAMPLED TISSUE WITH CARCINOMA: 5 %
F) PROSTATE, LEFT BASE
ADENOCARCINOMA, GLEASON GRADE 3+4 = 7
ADENOCARCINOMA INVOLVES 2 OF 2 CORES AND 10 MM OF 30 MM
TOTAL SPECIMEN LENGTH 33%
NO PERINEURAL INVASION IDENTIFIED
Posted 9/16/2015 4:57 PM (GMT 0)
• Peter Carroll at UCSF is among the top surgeons in the world.
• Al Taira in Mountain View is among the best LDR brachytherapists.
• At both Stanford and UCSF (Gottschalk), he can get SBRT. I think Kaiser North offers it but for some inexplicable reason, they only give it to low risk patients.
• I hope you got a second opinion from Bostwick or Epstein (only) on the biopsy slides.

I suggest you will interview all of the above doctors before coming to a decision.
Posted 9/16/2015 5:11 PM (GMT 0)
Allen -

Leaning heavily towards RALP surgery.
Was considering getting a 2nd opinion from Peter Carroll, contacted his office yesterday.
Is USCF better than Stanford if I go out of network for RALP ?

In terms of getting slides reread is UCSF fine or is Bostwick or Epstein (only) the definitive step ?

Do these slides ever get lost (as I can hand deliver them to UCSF to avoid this risk) ?

Post Edited (jronne) : 9/16/2015 1:17:57 PM (GMT-6)

Posted 9/16/2015 5:16 PM (GMT 0)
jronne:

I was not aware that Dr. Hsu was on medical leave. I haven't interacted with him at all since my procedure and follow up.

If the Dr. Choi you are referring to is Justin Choi, then he is the surgeon who removed my gall bladder. I only "interviewed" him with respect to the gall bladder procedure, as we had already chosen to have Dr. Hsu do my RALP prior to my gall bladder issue cropping up. My focus was so much on the PCa at that time, that I honestly don't have much recollection of Dr. Choi, other than I deemed him more than competent to perform the Cholystectomy.

I did not do a comparison of available surgeons between Kaiser and Stanford, so I don't have direct research to share with you on that subject. In general, since I've lived in the area for a long time, and know many physicians at both institutions (my dad trained at Stanford, and completed his medical career at Kaiser), you can/will find top practitioners at both. You will also find not-so-top practitioners at both. Advocating for one's self by doing the research is the only way to ensure that you are able to make an informed choice on your course of treatment, and the person who will perform/lead said treatment.

Due to the large volume of cancer, and it's position primarily on the right side of my prostate, Dr. Hsu was concerned about penile nerve involvement and margins from the get-go. We knew going into the surgery that it was possible that he would need to be more aggressive with removing tissue to ensure that we had the best odds for a curative outcome from surgery. I told Dr. Hsu that I wanted his focus to be on removal of the cancer over sparing of the nerves if the decision came to that once he had instruments inside to tell him what was really going on. Unfortunately, that meant that a decent portion of my nerve on the right side was removed, resulting in expected issues from a sexual function perspective. Dr. Hsu was able to achieve the clean surgical margins that we were looking for save for two spots of microscopic, focal involvement.

My pathology details are in my sig below. Biopsy pathology indicated 12 out of 14 cores positive, 4+3. Post-op pathology from Kaiser indicated 4+4 with focal EPE and LVI. Review of pathology slides by Epstein confirmed 4+4 adding in the bonus of tertiary 5.

With regard to how quickly you need to act, I'd say you have time to fully research your treatment options (RALP, Radiation, Brachy, etc.) I know very well (as does everyone here) the "get it out now" feeling that you very likely have with your very fresh diagnosis. However, with a slow moving disease like ours, "now" can be measured in months.

Again, I'm happy to connect with you directly to discuss any aspect of my disease or treatment. I'm pretty much an open book with respect to my PCa journey. I'm in Redwood City, btw.

Good luck!

Rich
Posted 9/16/2015 5:29 PM (GMT 0)
That's why I put the word (only) there. UCSF, as far as I know, does not have a pathologist who is solely dedicated to reading prostate biopsy slides like Bostwick or Epstein. Just tell your urologist to overnight it to them - it's a common practice.

As I said, Peter Carroll is world renowned. There may be surgeons at your local Kaiser who can do a great job as well.

As an empowered patient, I think you owe it to yourself to talk to the doctors I listed, and learn more about your alternatives. You have what is commonly called "favorable intermediate risk" prostate cancer, which means you have plenty of time to make a decision. You were just diagnosed just last week, so it is way too soon to be "leaning" one way or another. We have all gone through what is often called "cancer panic" with a natural reaction to "just cut it out." That may be exactly where you wind up later, but in the meantime, take your time and go through a reasonable assessment process. Read the sticky for the newly diagnosed and stay open to receiving as much information as you can. Don't rush this - you only get one chance to do it in the way that will be right for you.

BTW - I sometimes suggest to men in my support groups to change their insurance during open enrollment in order to expand their alternatives.
Posted 9/16/2015 5:41 PM (GMT 0)
jronne-

FWIW, I had no issues with getting the slides to Epstein (and back to Kaiser.)

Rich
Posted 9/16/2015 5:42 PM (GMT 0)
Hello Jronne and welcome. As Allen stated, it is critical that you get your slides read by an expert pathologist who focuses on prostate cancer readings. Drs. Epstein and Bostwick and their labs are two of the best. With your pathology you certainly have time to do this. Look at the sticky thread at the top of our forum and you will see info about sending your slides to these experts -- though your doctor should also know how to do this. Many slides are mis-read by non-expert pathologists. Given your stats, consider what happens if an expert reevaluates you to G6. Perhaps then you will choose Active Surveillance instead of a radical treatment.

Beyond this, I'll just tell you that many of us arrive here with a mentality of "get it out", i.e. get surgery. That may be your final choice but the reality is that almost any of the mainstream treatments is likely to cure you with a high degree of success. So, you really owe it to yourself and your family to do your due diligence. Seek out the opinions of the doctors that Allen recommended or others who are expert in LDR Brachy, HDR Brachy and SBRT. You have time and that's the smart and logical thing to do.

Good luck and let us know how you progress.

Jim
Posted 9/16/2015 5:56 PM (GMT 0)
I'll third the motion to slow down and explore all of your choices. You don't get any do-overs in this. Surgery is obviously a very valid treatment option and this isn't meant to talk you out of that, but since your diagnosis gives you the luxury of time it makes sense to use that. Many people don't since their initial diagnosis is by their urologist, who is a surgeon by training. (It would be equally bad if folks were diagnosed by radiation oncologists and never consulted a surgeon.)

There are lots of options for someone with your diagnosis, all of which will give you a very high chance of curing you. If indeed after you go through these and you ultimately decide to do surgery, you'll be going in from a position of strength knowing that you've investigated all of your options.

Most important, I do hope you do well no matter what you choose and let us know if we can help. Good luck and keep us posted!
Posted 9/16/2015 8:04 PM (GMT 0)
To add to the list...

I think Joe Hsu is the UCSF guy in charge of HDR brachy.

I should have mentioned focal therapy as a possibility as well - two small cores of no more than GS 3+4 should qualify you. There are probably some trials at UCSF and/or Stanford. Some AS programs might take you too.
Posted 9/17/2015 8:13 PM (GMT 0)
rich -

Dr Micheal Choi is the urologist I am considering for robotic surgery.

The question is how do his skills rank, the number of procedures done, and what is his level of experience in dealing with the reality when the actual prostate pathology is worse than the estimated biopsy pathology ?

https://mydoctor.kaiserpermanente.org/ncal/provider/michaelchoi
Posted 9/17/2015 8:47 PM (GMT 0)
I've have a couple of surgeries at Kaiser Santa Clara and found them to be very good. I've been surprised at how many of those doctors went med school at either Standford or UCSF. Likely, this is one of the best Kaiser locations. You'd be fine there. My brother had RP there (Hsu I think) and he's doing great.

But if you want better, UCSF is the place.

Andrew
Posted 9/18/2015 10:11 AM (GMT 0)
Hi
I was 2 out of 12 cores positive for g6 but upgraded after surgery. I had a few more tumors that the biopsy missed. The focal positive margin was not expected and it rattled me for a while. There is nothing I can do but wait and see. I started at Kaiser Santa Theresa under Dr Tsang who is the head of urology there, he's a good Dr and under his referral I went to Dr Ahuja. I did alot of reading and consulted one of the best radiation oncologist on the west coast, his recommendation was also surgery. It was a whirlwind few months from high PSA 14.7 to arranging surgery. I did all this before I found this board and rushed a bit to treatment. My first post here was the night before surgery... If I had to do it all over again I would have chosen the same path, I would have probably slowed it down a bit though.

In any case, you have received great feedback about exploring options.
Posted 9/18/2015 10:58 AM (GMT 0)
My initial biopsy was very similar to yours, and when I asked my diagnosing Uro how long I had to make a decision about treatment, he said, "six months, take your time". Which had the practical effect of giving me permission to do exactly that.

I did wind up G3+4 on post surgical pathology and I've had minimal side effects. I'd also encourage you to take your time to make your decision on treatment. As many have pointed out, you've only got one chance to get it right the first time. Backup/secondary/salvage treatments are almost always challenging and to be avoided if at all possible.
Posted 9/18/2015 2:58 PM (GMT 0)
jronne, I learned of my diagnosis on 8/4/15 and 6 weeks later I'm still learning about this disease and the treatment options. There's no way you or anyone else can have a handle of the key questions/issues in one week. Please slow down.

Unfortunately, there is much to learn and trying to do so under the stress of having just been diagnosed can confound things.

You are getting excellent advice here.

It is frustrating that none of us can go to one specialist and learn all there is to know, but that's the sad truth. So we need to make time to thoroughly investigate the options, of which there are many.

My 57 year old urologist, who has done over a thousand of daVinci and open procedures combined, said he's no longer recommending daVinci because he gets better results using his hands via the open procedure. But he also said he's seeing so much better results with radiation these days that it's hard for him to recommend surgery any more. He's says he's older, wiser and less concerned about making a living these day in the operating room.

You will find that not all radiation oncologists will be able to answer all of your questions because they tend to offer some therapies but not others. So it usually means seeing several of them to learn what's available, pros/cons, side effects, etc. (And considering that the various radiation machines cost a pretty penny, I guess we shouldn't be surprised that not all facilities offer all the radiation therapies.)
Posted 9/18/2015 3:05 PM (GMT 0)
jronne,

I had mine done in Sacramento at Kaiser South Sacramento - at the time the only location in Sacramento with the Da Vinci. No first hand experience with the bay area, but I can tell you this - the integrated treatment I have received from Kaiser has been top notch. My Doctor - Scott Troxell - has been and continues to be a great support. The way kaiser integrates all of the treatments I receive (I have epilepsy) so that I don't have any issues - well, it makes me feel very well taken care of.

Happy to offer more if you are interested.

Good luck

pat
Posted 9/18/2015 3:11 PM (GMT 0)
jronne-

If you want to seek the opinion of a Radiation Oncologist, I can HIGHLY recommend that you talk to Dr. Milan Patel (specifically Milan, there are two Dr. Patels in SoSF) at Kaiser's cancer treatment center in South San Francisco. I have found Dr. Patel to be extremely knowledgeable about treating PCa, he listens very well, and his explanations are quite good. When I was initially diagnosed, I consulted him prior to my surgery. After my surgery, he was part of my consult team as we decided whether to jump to ADT, or to monitor PSA and wait. Upon seeing three consecutive rises, I didn't hesitate to have Dr. Patel design and manage my IMRT (37 sessions.)

I'm pretty sure that Andrew (In The Shop) has had a similar positive experience with the cancer treatment center at Kaiser Santa Clara, and he could make a recommendation of someone for you to consult there, too.

Rich
Posted 9/18/2015 8:32 PM (GMT 0)
The RO I had there was Brian Missett. He's a great guy. Trained at both Standford and UCSF. He knew his stuff and went out of his way to make sure I knew what was going on. I remember at the first visit with him, my wife and I had brought in a written list of questions. Towards the end he asked if he could see our list and then proceeded to mark up the pathology report noting where our questions where answered so we could refer to it later.

Andrew
Posted 9/19/2015 1:46 AM (GMT 0)
i'm in the camp of acting sooner rather than later. if the disease gets away from you the conversation changes drastically. it sounds like any treatment should work for you. when I went for the big consultation I took three family members with me. my uro was against surgery. he instead recommended a combination treatment because the odds were my cancer was out of the capsule. that's what I did and I would do nothing differently.

ed
Posted 7/3/2016 8:43 PM (GMT 0)
Any experience with PC treatment is Southern California? Any recommended surgeons in Southern California Kaiser? How about outside Kaiser like UCLA? Any experience with SBRT? I appreciate any feedback.
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