Is surgery ever the right choice even for aggressive PC?

Now before you guys shoot me I do realize and accept that it is the right choice for quite a number of us, most especially the luckier among us. That is, you ( like me ) chose surgery, and even if you got the **** end of the stick when it came to SEs, it is still the choice that was right for you and your needs and psyche going with the information you had at the time. OTOH, if you came out on the lucky end, and still have a sex pleasurable sex life and dry pants to boot, along with a post op path that virtually guarantees a long term cure, you might even be deliriously happy with how right your choice- made under duress- worked out for you. So the title of this thread is not to challenge whether or not surgery was right for you, it was, period.

OTOH, there are guys like me who sort of felt they were making the wrong decision ( just not sure at all but time seemed to be a wastin) what with a G9, rapidly rising PSA( most recently from 8.1 to 10.9 while awaiting appointment with Uro) and a negative DRE, I felt like I better decide on something. In the end, I could not go against the advice of the massively published department head at Vanderbilt(Joseph Smith) who said he thought, at least in my case, surgery was a slam dunk. Because:
1: After he dis another DRE, he felt my tumor was tiny and there was a good chance despite my G9, I was still contained, and if I was contained he could offer me a cure and
2: If I had RT, and had already spread out to the lymph nodes, RT would not get the job done and it might be quite a while before we knew that for sure.
3: If I was not contained, we would probably know it by the path report and be primed to take additional action if needed, plus there were some studies out there indicating that even men who were not contained often did better with the main tumor removed.

I think that was the gist of it. And though I dreaded surgery because of the likely SEs plus feared I would need RT anyway, in the end I went with his advice.

So when the path report showed that though my nodes were clear, I was not contained and had SV+ and margin+, and I was now very likely to need RT to go with all my surgery SEs, I just felt like I would have been better treated with RT which would have gotten the margins, though we still would not know about the lymph nodes. Then when I had bad incontinence for most of a year, and realized my sex life was kaput most likely forever, I simply was no fan of surgery under any circumstances, not for me, but too dang late.

However, in the next post, I am copying Bobby Mac's post from the thread about nerve sparing by JayMot. He may be the very patient my surgeon was talking about.

You'll probably get some responses that say that not only is surgery never good for high risk cases, that it's rarely good for anyone. (But you knew that before you started).

I can think of several reasons why primary surgery for high risk cases might be a good idea:

1. If the patient lives in an area where long term radiation treatment is going to be challenging for various reasons--such as distance to the treatment center makes weeks of treatment difficult.

2. If the diagnostic tools suggest a high probability that the tumor is well contained and that a combination of surgery + HT/chemo could be curative.

3. There have been cases mentioned in here about 'debulking' surgery as an adjunct to HT/RT for certain special cases that warranted that direction of treatment.

4. The patient and the treatment team feel that surgery + adjuvant treatment is the best choice for the individual and his circumstances for other reasons.

Here is Bobby Mac's post that got me thinking his was the exact situation my surgeon was referring to:

Bobby Mac said...
Jay-

7 weeks post RP tomorrow- one pair of Depends underwear gets me through the day - no extra pad. Keep doing the Kegels, as they do help. Of course, since my surgery failed to get all the cancer I want to be continent before starting RT. Meet with the RO today and will receive my first pot op uPSA result.

I had non-nerve sparing, so can't comment on the ED. Although, I may at some point consider a penile implant.

Bobby Mac

Age: 69, 69 at PC dx, PSA 6.7 Avodart (6.7 x 2.3 = 15.5)
Biopsy: 2/16 13 of 14 Positive, 2-99%, GL 8, 2nd look GL 7 (4+3)
RALP 4/20/16
Post OP Pathology:
Non-Focal EPE, 2 positive margins, Gleason 4+3=7, involving 50% of gland, prostate weight 31.5 g, Stage pT3a N1 Lymph node involvement: 2/10, right side positive, Diameter of largest N Metastisis 2 mm

OK, so only a G7, but with the post op path we find out that, yes, he is indeed a G7(more aggressive version), however, he is NOT contained and has positive margins and nodes.

So, let's say he had chosen brachy or RT. Brachy would not have been adequate for either the margins and for sure not the nodes. Rt would have missed the nodes. And it might have been awhile before he knew that he had these positive margins and nodes.

Now, considering the fact that some claim that you are better off without the main tumor in the prostate even if you are not contained, plus the fact that at least he knows there is something that will probably need treating and he would not have known with out the surgery path report, is it reasonable to say that for Bobby Mac surgery was the obvious correct choice? That his type situation is what my surgeon meant when he said surgery was a slam dunk for me?

Or is there still an argument to be made that he would have been better off with some form of RT?

Q: Is surgery ever the right choice even for aggressive PC

A: It depends



Do you really want to know when it's appropriate, or are you just making up things to talk about online because you are bored? There have been lots of threads on this topic, including a number of good ones. Use the HW search tool.

Surgery - FOR ME - was the right choice, big time. I am absolutely convinced that I would be dead now if my wife and Dr hadn't almost slapped me and said, "Wake up, we have to do something now!" (I was hoping to finish coaching my soccer team before surgery - ha-ha). I had aggressive cancer, was probably within weeks or months of a breakout, and it saved my life. * * Surgery is not the answer for everybody in every case, but it was for me. (Incontinence was a big problem for me for about 6 months, I still wear one pad a day. And the sex life is good - not exactly the same - but good enough.)

Wishing everybody all the best,

kcragman

island time said...


A bigger part if this whole equation is the mindset of the patient. If it's one of...."I gotta get this outta me. No more discussion", then yeah...go ahead give 'em the placebo. Mental mindset is no small part of QOL. (It could be argued it's more important than physical reality). That's quoted as a major reason for surgery as well. People want to know their pathology. Bobby mac said it. That and 2 bucks'll get ya a cup of coffee. But it gets you more than that. It's QOL for the mind...

There's a whole lot more drives people's thinking when it comes to this stuff other than the physical.

Island Time, well said. It's a point that I sometimes don't understand how some people cannot get.
I would take IT's comment a step further, Billybob, and add that if a man's made a decision to move forward with surgery, then it's the right choice for that man, no matter the pathology, or the science. I would say the same thing about SBRT, LDR, HDR and AS.

The objective of treatment is a cure with as few side effects as possible.

If I was younger, I might have had surgery. If I had a Gleason 7, I might have had surgery.

I chose HT and Radiation. On May 13, I finished the last part of my treatment plan. I have a follow up appointment with my RO tomorrow. I have a follow up with my urologist in August
for a PSA test. Another appointment for a PSA test in November. At that point, I'll find out for sure if I chose wisely.

I feel okay, a bit tired, I can urinate (flow rate is sometimes low), my libido is low, erections are weaker than I'd like, and I've gained 5 lbs of belly fat. I've got some work to do for sure.

Avoid surgery on a Friday or major federal holidays...

Bobby Mac said...
Unfortunately, in my case, the pathology report gave me the information below in my signature, but did not answer all the questions I need to know.

BINGO

I don't know why this myth keeps getting repeated, but thanks for busting it...again. The value of having a pathology report in hand is a false security. Period.


But the silliest comment in this thread was this one:

Island time said...
"Debulking" is for a term used by surgeons who operated on a patient that probably should not have been operated on.

"Silly" understates the degree of cluelessness. That's a truly dangerous quote to be making here by someone who doesn't know or understand what debulking is or the purpose of it. You clearly don't understand medical studies--by your own word--but how about a medical dictionary, Dr Island.

In the seven years I have been observing PCa cases, it appears there has been quite a shift away from surgery and brachytherapy. I attribute this to an increased awareness of AS, new imaging and testing technologies and improved external beam radiation technology. (If anybody has numbers concerning the trend that I think I see I would appreciate seeing them). I remember when my PCa doc told me that he would perform open surgery on me if I wanted, but he was doing very few .... patients were voting with their feet and going to The DaVinci surgeon. Times and procedures change.

My point is, it appears to me that the situations where surgery is appropriate (including high G cases) has shrunk in the recent past, and will likely continue to decline. Indeed, I am guessing that the number of men treated for PCa has decreased recently based on increased AS protocols and imaging and testing technologies.

Hopefully, someday soon a high tech wand (pill/procedure?) can defeat PCa.

Wow, took a post about surgery for high risk PCa G8 - G10, and turned it into another AS for all G6 (low risk) discussion.
Well, G6s don't get it. You likely won't die and so maybe AS is best for you. I don't care. Honestly, for your sakes I wish they would reclassify G6 as pre-cancerous or not cancerous.
So it really has nothing to do with this thread.

If I hadn't had surgery we wouldn't have known I am really a G9 not a G8. Wouldn't know it had escaped the capsule. Wouldn't have known of the seminal vesicle invasion. Wouldn't have known of + margins. And wouldn't have known about my positive lymph nodes.

So, I had surgery, found all this useful information and am being properly treated for it.
In my case surgery was very much helpful.

Based on my research and own experience, I am biased toward radiation, especially in high risk situations.

My uro would not operate due to my high risk because the tables and his experience showed I would no doubt also need radiation. He would operate only when the probability of cure is very high. And he says, many of those cases are low risk and he wouldn't operate on low risk until AS has proven ineffective. Two other uro-surgeons and a MO agreed. Of course, my uro has a partner who performs more DaVincis than anyone in Atlanta who gladly would operate if I had wanted surgery.

In my case a pathology report would not have changed anything for a treatment direction. I think most high risk situations would be the same. Just how different would the treatment direction be for a 4+4 vs a 4+5? Or a 5+4 vs a 4+5 or 5+3? Rarely we se a G7 upgraded to a G9 with pathology. But a G7 knows going in that the risk of recurrance is significant regardless of the initial treatment method.

Compared to surgery the HDR brachytherapy easily covered a much larger area than the surgery could and included the seminal vesicles, which appeared enlarged on the CT scan. The IMRT redoubled the treatment and included the lymph nodes. All better cancer control than surgery with much less significant side effects.

The facts also show that radiation is more effective than surgery for high risk cases and that many of the high risk surgeries fail and result in SRT being needed. Look at all the intermediate and high risk men on this board that have needed SRT. This is a piling on of treatment risk and side effects that in my opinion doesn't not produce better cancer control or improved quality of life.

I have a simple philosophy; avoid surgery when other treatments can be as effective and stay out of hospitals. Surgery is by definition damaging. A stay in a hospital today is by definition higher risk for infections than a stay at home. Surgery and hospital stays should be avoided if we are looking to lower treatment risk and reduce side effects. There are situations where surgery is the best or only option and I have had two of those in the past three years. Thankfully, they went well and fairly well solved the issue, but I do have permanent side effects and in one case (my knee) it wasn't curative.

It remains that most the men who report they chose surgery simply did not investigate and research alternative treatments with the same gusto as they used for surgery. Plus, surgery was the first and often only recommendation by the specialist that discovered the cancer. I assume that in most of the cases their uro-surgeon did not require them to get other opinion regarding non-surgical treatments. Mine did, and that was what placed him in my highest esteem. We now see that on this board many more men are seriously considering different treatments and it seems that many more are choosing AS or radiation over surgery than when I first joined nearly six years ago. That is anecdotal, but important. My docs report they are doing twice as many HDR Brachytherapy procedures as they did five years ago. They now do more than a dozen a week. My uro has stopped prostate surgery altogether, though he treats nearly twice as many prostate cases as he did five years ago.

That more low risk men are not rushing to treatment (surgery or radiation) is a good thing for them. That more intermediate and high risk men are seriously considering non-surgical treatments is also a good thing for lower risk and side effects. That medical advancements are improving treatment efficacy and reducing dependence on surgery in many other areas is also very good. In the advanced society depicted in Star Trek, just how often did Dr. Bones McKoy operate? Ah, the promise of technology.

JackH said...

Bobby Mac said...
Unfortunately, in my case, the pathology report gave me the information below in my signature, but did not answer all the questions I need to know.

BINGO

I don't know why this myth keeps getting repeated, but thanks for busting it...again. The value of having a pathology report in hand is a false security. Period.


But the silliest comment in this thread was this one:

Island time said...
"Debulking" is for a term used by surgeons who operated on a patient that probably should not have been operated on.

"Silly" understates the degree of cluelessness. That's a truly dangerous quote to be making here by someone who doesn't know or understand what debulking is or the purpose of it. You clearly don't understand medical studies--by your own word--but how about a medical dictionary, Dr Island.

JacK, I am amazed how consistently abrasive you can be to a lot of different folks here over time, or at least how you come across in internet language. As in earlier when, before I was able to get the full purpose for my thread posted here(got the old 90 second delay then got side tracked) you wanted to know if I posted this thread just because I was bored and needed some one to talk with. Followed by a condescending suggestion I do a search on that subject. Plus, you seem to think you have a level of understanding far above any other member here, putting you in rare company on this board. But, maybe you are actually not that much of a horses behind, and it just seems that way as you are not communicating face to face with folks and we are lacking all of those non-verbal clues? If so, I apologize for even asking those questions.

But as for your claim "I don't know why this myth keeps getting repeated, but thanks for busting it...again. The value of having a pathology report in hand is a false security. Period. ", I think I've got to call BS on that one. You seem to be arguing that it is of no benefit for Bobby Mac to know that not only does he have positive margins, but that he has LN+? Is that your claim? If it is, please provide your thinking on how that is useless info and maybe I can retract the BS call. Personally, if I had positive nodes - call me crazy- I would want to know.

Post Edited (BillyBob@388) : 6/8/2016 11:39:59 AM (GMT-6)