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Posted 3/20/2016 5:21 AM (GMT 0)
Hi all - Aussie 66 years young here. Active lifestyle, retired.
Getting close to committing to RALP.
Grid biopsy completed 10 days ago. Final consultation to come.

BPH 5 years+. Current size=67cc's.
PSA: Aug '15 8.2, Nov '15 7.1

T3 MRI last Feb. Showed:
9mm lesion in left mid gland level.
Score T2W:4
SV's seem normal.

Dr briefly summarised after biopsy results received:
Relatively small tumor
Gleason=7
option 1 Active Surveillance - for 8 to 9 years.
option 2 RALP - 90% probability of being cancer free. Right side nerve is spared. Left side nerve ?. For incontinent & impotence I think he said 60% chance of normal.
option 3 Brachy - 85% probability of being cancer free (?).

I was hoping, for 90% probability for everything being good.
Now I'm not sure I want to spend the $$'s for top nerve sparing robotic surgeon (the extra cost of robotic is not cover by Medicare or health insurance).
It would appear I could get a similar 60% result in our public health care system (Australia).

Summary
Thinking of RALP with a sizeable out of pocket cost.
Disappointed with predicted RALP outcomes for incontinent & impotence (<70%)
Also thinking a skilled surgeon with 'lesser status' may achieve the same result for much lower cost.

Opinions & advice sought.

Post Edited (shudderingThud) : 3/21/2016 3:14:38 PM (GMT-6)

Posted 3/20/2016 7:50 AM (GMT 0)
In my opinion, I want the best surgeon possible cutting on me but to each his or her own.
Posted 3/20/2016 11:17 AM (GMT 0)
shudderingthud (I like that handle, by the way),

With a single G7 core, even with PNI, your chances of cure with either surgery or radiation are very high. Either way, you'll be getting regular PSA tests for a long time to come. Here in the US, the standard protocol is every 3 months for 1-2 years, then every 6 months for another 1-2 years, before going to annual tests, and this applies to both surgery and radiation patients.

AS is the only protocol that has nearly zero side effects. Yes, it's (literally) a pain in the ass to get another biopsy in 18 months, but that's the 'active' part of AS. I note also that you're 61. If you made 8-9 years (as predicted by your doc), then you'd be 70, and moving out of the typical age block for surgery anyway.

You've got time to explore your options and make an informed and rational decision. Here in the US, most docs would tell you that you likely have up to six months to make a treatment decision.
Posted 3/20/2016 11:44 AM (GMT 0)
Finally an honest surgeon who is being up front about the risk and side effects of surgery.

Your brachytherapy doesn't need another biopsy in the future, just PSA monitoring. Also the cancer control is improved by adding external beam radiation. The result at you stage is actually better cancer control and much less side effects than surgery. I had the combination and I am side effect free after five years and PSA is undetectable.

Have you actually met with the brachytherapy radiation oncologist? Do not rely on the urologist to provide the specifics of another method, rely on the actual specialist that will do the work.

You have plenty of time to seek additional opinions.
Posted 3/20/2016 11:49 AM (GMT 0)
My main concern 5 years ago was impotence which is why I went with LDR brachy.
Best decision I ever made. It would be wise to explore this (and other non surgical options) before making a final decision.
Best to you.
Posted 3/20/2016 3:55 PM (GMT 0)
Wellcome to the forum Thud!
Paying for a top surgeon could be well spent money. Both erection and continence depends heavily on how many RALP procedures that have been done by the surgeon. Takes 1000 - 1500 to learn the job! I fortunately got THE european top surgeon. Did one side nerve sparing RALP and satisfied with zero incontinence and 80% erection at 18 months.
Posted 3/20/2016 4:12 PM (GMT 0)
Read a recent article, perhaps Tall Allen can comment, that AS is now a recommended option for favorable intermediate PC.
Posted 3/20/2016 4:17 PM (GMT 0)
Thud, If, as your doctor noted, there is only one small tumor, you may wish to also look at some of the focal therapies. These would include HIFU, Focal Laser Ablation, and focal cryotherapy.

Now, these are only alternatives to the forms of surgery and radiation mentioned above. But, they all promise fewer side effects, and are considered by some to be a middle ground between active surveillance and surgery or radiation.
Posted 3/20/2016 6:11 PM (GMT 0)
shuddering Thud,

You've got to slow it down. If your urologist is telling you that you're good with AS for 8-9 years, that should give you a clue that you do not need to act immediately. You've got a bunch of information you need to acquire before making an informed decision. I assume you were diagnosed with a small amount of GS 3+4, stage T2a, and PSA of 7.1. That puts you in the "favorable intermediate risk" category. This means that outcomes are pretty much the same as for low risk PC.

1. Read the sticky for the newly diagnosed.

2. Have the biopsy slides sent to a prostate pathologist for a second opinion. There must be a go-to specialist in OZ for this.

3. Make appointments with top specialists. You cannot assume your uro knows much of anything about treatments outside of his specialty. If you decide on AS, it seems your current facility may have a good program because of their mpMRI capability. Specialists you ought to talk to - other than AS and surgery - include HDR brachytherapy and LDR brachytherapy (as monotherapies - there's no need for external beam radiation with those), and SBRT/CyberKnife. All of them have much higher rates of potency preservation than surgery, and incontinence is almost never an issue with them. And no transperineal biopsy is required. All of them have 90+% cure rates for men at your risk level.

4. Talk to Phillip Stricker at the St. Vincent Prostate Cancer Centre in Sydney. He is working on a new kind of focal ablation called "irreversible electroporation," which you might be an ideal candidate for. This is very new and experimental, but you may want to learn about it. You can read more about it at the following link:

NanoKnife or irreversible electroporation treatment as a potential focal ablation therapy

5. If you decide on surgery, go to the most experienced surgeon you can find. open or robotic doesn't matter much, but experience does. Be sure to find one who does intraoperative frozen sections, as that may spare more of the nerve bundles (see the questions to ask doctors at the end of the sticky).
Posted 3/20/2016 7:18 PM (GMT 0)
Sorry you have to be here, but hopefully the comments have already been helpful. PC has so many potential treatments and a lot of well-intentioned misinformation that makes it tough to make a decision. But as mentioned by Allen, it generally does give you a generous amount of time to talk to experts to learn as much as you can. There are no do-overs, so I'd urge you to seek out those experts to the extent that the medical system in Australia allows you to do so.

Responding to what you were told, I don't how/why your doc put brachy success at 85% and surgery at 90%. Generally, they would be regarded as equal in success--sometimes the brachy can be higher since it treats an area slightly beyond the prostate. And as had mentioned, brachy doesn't require a follow-up biopsy. I suspect you would get better info on the brachy question from an RO that specializes in that.

Re surgery and the cost question, that's obviously a very personal decision to make. While I don't know your situation, I'd be concerned about choosing a "lesser surgeon"--at least here in the states the best surgeons generally have the best outcomes.

I would say that based on what you said about your diagnosis, you have an excellent chance of a cure no matter what treatment you choose. So I'd urge you to think about SEs--that's what can have a profound effect on your QOL and given an active lifestyle could impact you for quite some time. AS, of course, is the only protocol without SEs.

Good luck to you and I hope we can help as you sift through everything.
Posted 3/20/2016 8:45 PM (GMT 0)
Thanks everyone for your advice.
The % stats may not be recorded correctly as it was from a telephone converstaion. I see the surgeon tonight for a better explanation but I don't want to be pressured into signing up for a RALP tonight. Wife could be a problem there ;)

Thanks for highlighting Brachytherapy. It was offered, only because the lesion is on one side. Dr said with BPH - a large prostate can preclude it. There were reservations about future options if Pc returns in later years. And BPH could get worse (don't want a TURP).

If I recall correctly, the Uro surgeon said he would do the procedure (brachy) & the cost would be similar to RALP. No mention of a radiation oncologist - I'll ask that tonight.

My GP (family doctor) supported RALP - maybe because I was favouring it.

ahhh - decisions, decisions .....lots of phone calls to make today, & detailed information to come tonight.

edit: can't delete emoticon in header, should be in text

Post Edited (shudderingThud) : 3/20/2016 3:33:35 PM (GMT-6)

Posted 3/20/2016 10:22 PM (GMT 0)
Your urologist would do the LDR brachytherapy (seeds)??? That's unheard of in the US and Europe. Here, a radiation oncologist who is board-certified in giving brachytherapy does it. It is a very specialized discipline, and only those with a LOT of experience with it get good results (just as with surgery) - no wonder he was quoting you such low numbers. Here are the specialists in OZ I've seen in the literature:

HDR brachytherapy: George Hruby - Chris O'Brien Lifehouse, (02) 9515 8057 (Phillip Stricker may do this as well).
SBRT: Northern Sydney Cancer Centre offers it 02 9463 1300 (I don't know which Radiation Oncologist - call and ask.)
LDR brachytherapy: I think St Vincent's offers it as well - ask Phillip Stricker
Posted 3/20/2016 11:37 PM (GMT 0)
You are getting some poor information from your doc. Never have a non specialist do Brachy. It is an experienced skill done by a radiologist who only does Brachy.
You can easily reduce the size of your prostate by 50% using Casodex for a couple of months.
Radiation also reduces the size of your prostate so BPH will no longer be an issue. My prostate was 60 cc before Brachy and is now 25 cc and has been for 7 years.
The reoccurrence rate for Brachy is the lowest for any treatments and salvage treatments are a very rare occurrence it is unfortunate you are receiving poor information, and this is the reason you must be your own advocate and do your own research.
Posted 3/21/2016 5:30 AM (GMT 0)
Thud, fellow Aussie here. I can't stress enough, as most others here have said, don't rush into treatment without very careful consideration.

I am one of those who did and I now really regret that. I have some very significant permanent side effects which may not have happened if I had taken a different course, either in terms of treatment administered, or Drs chosen. I can't say I would be fine if I had gone a different route, but I do know I wish I had spent more time considering options.

Don't know where you are in Oz, but one Dr you should consult is Phillip Stricker, the guy Tall Allen has recommended. Even if only as a phone consult. You can even get an opinion from him via his web site. I tried that, but unfortunately he was overseas and took a couple of weeks to get back to me (which he did by phone). By then I had committed to surgery by a local Uro here in Canberra - I was too panicked to wait, (an unnecessary panic). Stricker was great on the phone, very patient and understanding, and he didn't try to talk me out of my surgery, but I definitely got the sense, just from his tone, that he was disappointed that I was jumping so quickly.

He has a great reputation and has operated on a number of very high profile clients from the media and politics.

I would also consider the Chris O'Brien LifeHouse in Sydney. They are cancer specialists, and I think that is where I will be looking when/if I need a dedicated medical oncologist.

I wish you all the best and strongly urge you not to over commit yourself at this stage. Even if you only wait another week you can gather a lot of info in that time and I assure you that you will not regret it in the long term. Don't end up in my situation.

Chas
Posted 3/21/2016 10:19 AM (GMT 0)
Coincidentally, I have a third opinion coming up this week with a surgeon from LifeHouse. Will definitely ask about oncology radiology at LifeHouse and George Hruby.
I have earlier read about Phillip Stricker and his Nano Knife (IEF) trials. Spoke briefly with my Dr on it at our first meeting.

I forgot to confirm with the Dr tonight if he does the Brachy implant, but will be seeing him again next week. I think he ranked brachy a slightly lower cure in the long term, as there may be still undetected lesions in the prostate that show up in future years. Whereas they would be removed if surgery now.

We spent most of the time discussing the grid biopsy as it did find a second small cancer very close to nerve. The 3T MRI did not show it. (So 3+4 and 4+3 - Mid & Top).

@Gemlin & JohnT - those results sound good.

Thanks all, for the time taken in providing advice.
I need to keep reading all this for a while - for it to sink in!

Post Edited (shudderingThud) : 3/21/2016 4:26:22 PM (GMT-6)

Posted 3/22/2016 6:10 AM (GMT 0)
Thud, please keep us advised of your experience at Lifehouse. One of the disadvantages of being in Oz and on this forum is that we don't have many guys able to make recommendations for high quality specialists. That is just a consequence of the smaller participation by Aussie guys. The more experiences we can share, the better for all of us.

I find it a bit ironic that Tall Allen in the US is able to suggest names here in Oz. Just goes to show the excellent contacts and breadth of experience he has. Thanks for helping out TA!

Chas
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