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Posted 11/9/2016 12:44 PM (GMT 0)
Hi
I have recently had a transperineal biopsy and have been diagnosed with prostrate cancer. I am 61 years old and I am considering my options. I have consulted two urologists and have been told I am suitable for either surgery or radiation. I live in Scotland in the Uk and other options such as HIFU and Cryotherapy are not yet available. Having done as much research as possible into the potential outcomes and side effects etc, I have decided against surgery and I am trying to decide between IMRT and LDR Brachytherapy. Would I be suitable for LDR Brachytherapy on it's own with my stats or would I need to combine it with any other treatment. Apparently I have a small prostrate volume of 18mL instead of the average of around 40.
I would be grateful for advice from experienced members of the forum for any advice and guidance in helping me to choose the best route. My stats are the following:

PSA 6.2
Gleason 7 (3+4)
25 cores
Right anterior 3+4 -two out of five cores- 20% of the tissue core
Right posterior 3+4-one out of five cores- 5% of the tissue core
Left anterior 3+4-four out of 10 cores- 12% of the tissue core
Left posterior benign- 0% out of 5 cores

Thanks for taking the time to read this.

John G
Posted 11/9/2016 1:41 PM (GMT 0)
Hi, John, and welcome to the club nobody wanted to join. I'm sorry you have to be here, but this is the best online resource I've found, so you made a good choice to join. The folks here know a lot, have been through a lot, and are very open and sharing of their experiences.

I am fairly new here, too, so I am far from an expert. My pathology is not that different than your own, and I am just a few years older. I, too, chose radiation over surgery even though my urologist did say that in spite of my age he felt that I could be a good surgical candidate. I felt that as long as there are non-surgical first line treatments that have the same general disease control capabilities, I would stay out of the OR. I've had enough surgeries, don't want more unless that's the only way to save my life.

That said, and remembering that I am not an expert, I would believe that with your small prostate and with your relatively low-risk pathology, you could be a candidate for LDR Brachy monotherapy. I know several men in the US who have had that treatment, and with the newest imaging tools, it is quite effective. Had you asked that question 10 or 15 years ago, I might have cautioned against it, as the imaging tools used for seed positioning were nowhere near as precise as what we have now.

I also considered seeds, but my urologist told me that "they hardly ever do those any more." I later found out that there is a major center about 30 miles from my home where they to literally thousands of cases/year with seeds, so it depends upon your doctor's viewpoint. The only real caution against seeds that I hear these days is that if you have any urinary issues (weak stream, difficulty urinating, etc.), they caution against seeds in fear that if seeds are too close to the urethra, swelling may make your issues worse.

Others will be along soon, and probably some who have had LDR brachytherapy by itself to comment directly, so take a deep breath, relax a bit, and wait for the flurry of responses.
Posted 11/9/2016 2:52 PM (GMT 0)
Welcome to the forum. It was a little eerie reading your post because I am 61 and also John G. I don't live in Scotland but several of my ancestors are from Scotland.

25 cores! I guess your doctor hates false negatives. I had only 10 and by the end I was feeling kind of frazzled and extremely glad it was over. I'm curious why you have ruled out surgery. Is your doctor concerned that the cancer has spread too far?
Posted 11/9/2016 2:53 PM (GMT 0)
Welcome! Unfortunately there are far too many of us here already. The decision phase is very difficult and we've all been there - radiation or surgery. If radiation, what kind. Alphabet soup of letters to decipher.

My urologist at the world class MD Anderson facility in Houston, TX said I was a candidate for either radiation or surgery. He cautioned about seeds that the skill of the practitioner was particularly critical for success (and not everybody is a candidate for seeds due to pelvic bone structure.) I chose surgery because I wanted to know exactly what was in my prostate bed with the pathology report.

As it turned out, I was node positive so on to step two, hormone therapy and then SRT. I have zero regrets about the path I chose. So take your time and continue to perform your due diligence. Best of luck to you.
Posted 11/9/2016 3:13 PM (GMT 0)
Sorry about your diagnosis and that you have to join our club. But we should be able to be of help. Your diagnosis pretty much gives you option to have any treatment, including IMRT and LDR brachy as you mentioned.

Typically, with a Gleason 3+4 (favorable intermediate risk) you would have brachy as a mono therapy. It's generally the higher risk cases (like myself) where it's combined with IMRT and/or HT. Certainly one benefit of brachy over IMRT is that it takes much less time. That said, you might also want to look into SBRT, which is an external radiation technique that only requires five sessions. Effectiveness with your diagnosis of all these techniques should be comparable.

Good luck to you and you have every chance of doing very, very well!
Posted 11/9/2016 3:42 PM (GMT 0)
Welcome to HW, sorry you need to be here.

Thing that is going to drive you crazy is: both would work just fine in your case.

I'd go with the one you think will work.

Andrew
Posted 11/9/2016 5:05 PM (GMT 0)
First of all thank you all for amazingly quick replies and words of support and advice.

Michael T I haven't looked into SBRT and not sure if it is an option in our area. I'll check it out further. With SBRT do you know what the side effects of long term toxicity with urinary functions proctitis etc are compared to LDBRT. With only five sessions does it mean that you are given higher doses of radiation over a shorter period of time or is it a different method of radiation. Sorry if these are dumb questions but my head is frazzled trying to take everything in and trying to understand the different procedures.
John TX
I agree about the standard of the consultant being critical and i have been given the name of one of the UKs best Brachytherapy practioners who has carried out over 3000 procedures with results comparable to the top USA success rates. He would be the one that I would pursue if I decided on Brachytherapy.
Fiddle canoe
The reason I have ruled out surgery is I beleive the risk of incontinence is too high and that out of all the possible side effects is the one that terrifies me the most. I know of two people that live close by that have had surgery and that have had major urinary problems over an extended period of time. I also have a 55% blocked coronary artery and i am afraid that having surgery may be a risk not worth taking.
Paxton
I'm hoping that the urinary side of things won't be a problem as I do have a slightly weakened stream. At my initial medical assessment when testing for BPH it measured at a peak flow of 16.5 mls and an average flow of 9mls I understand that the average flow for a male aged 61 snould be around 12mls so I am about 75% of where I should be. I hope that this will not be problematic for my treatment choice.
In the shop.
Thanks for the welcome your right about the choices driving you crazy, my head is spinning.
I know we probably only get one chance at this and I want to make the best decision possible.

Thank you everyone for your input and hopefully more people will chip in with their thoughts.
John
Posted 11/9/2016 5:55 PM (GMT 0)
Yes, SBRT uses a higher dose of radiation. It's similar to the difference between LDR and HDR brachy. There are purportedly some benefits to how higher doses of radiation can more effectively kills PC cells, although I'm not one of those guys here that can pull studies and quote the science. And it may not make a difference to you as a Gleason 7.

But SBRT is also a different kind of radiation compared to IMRT, although my knowledge stops there. FYI, SBRT is sometime referred as CyberKnife in case you see that name. (Or are googling.)

In general, the SEs from the various treatments are similar. Mostly, short-term urinary issues, although longer-term issues are certainly possible.

In the US, you generally have to meet with someone that practices the various types of radiation to get good info. The learning curve can take some time, but PC is very slow growing and generally allows you the opportunity to get smart. And once you make a decision on a treatment option, you'll feel 100% better.
Posted 11/9/2016 10:22 PM (GMT 0)
Michael thanks for that, I'll try and research more info online regarding SBRT and find out if it's available in my area. I've heard of Cyberknife but again don't know much about it and again unsure if it's available here. I am trying to be patient to try and make an informed decision at the same time I am anxious to begin treating the cancer. I'm sure that the majority of people on this forum have been through the same dilemma. Thanks for your advice,
Posted 11/10/2016 1:52 AM (GMT 0)
ScotsJohn: Your stats are not that different from mine and Seeds were my ticket for treatment. My signature will speak to few and easy to manage SEs with a resumed sex life that is awesome with a about half the amount of ejaculate. I am not ashamed to sound biased and often wonder why everyone does not choose LDR. That said, SBRT, IMRT, HDR, and Surgery offer about and equal chance of cure. Talk to as many people as possible who have been through this journey, research like crazy, and continue to come to this board for advice and encouragement.
Posted 11/10/2016 2:00 AM (GMT 0)
Hi ScotsJohn, welcome to HW. You are on the right path, research and decision making time. As Michael stated with your pathology, you can do almost any treatment. All have some side effects, which can be short term and long term. Seems the skill of the doctor affects all of those so where to get treatment could be just as important as the treatment path you choose. You can gain a lot of info doing several consults with both Radiation Oncologist and Urologist. In the end, you have to go with your gut feeling on what is best for you. I wish you luck on your decision and this journey. Take care and keep us posted. -JR
Posted 11/10/2016 2:29 AM (GMT 0)
Welcome ScotsJohn ! I chose radiation with HT( 6 mo. lupron) since I`m a full time caregiver for my wife and didn`t want the down time with surgery. In my 4th week now and rolling along well. Had the markers put in and the Tomotherapy tube radiation. 3 1/2 minutes in the tube....45 fractions(sessions) 81 greys. This way of treatment is easy and has similar outcomes as the rest .......but in your case having a slightly less aggressive cancer than mine, the LDR mono may be the "way"...good luck to you and your decision...like the guys said , no rush ,take your time and know that you do have a very curable cancer...healing vibes sent across the pond !
Posted 11/10/2016 1:49 PM (GMT 0)
ScotsJohn - I don't remember if anyone has given you this advice, but initially this helped me to focus my research and aided my discernment process. Since virtually all of the mainstream primary therapies (all the types of surgery and all the types of radiation) will have similar disease control abilities for your "favorable intermediate risk" pathology, focus your evaluation on the side effects. For each type of treatment that you are considering, look at the specific side effects that are possible, their likelihood of occurrence, and your perceived level of difficulty in living with the effect should it hit you. What you are then doing is choosing your treatment mode based upon what your life will be like after treatment -- which was especially important to me because I plan to have a right long life after treatment!

Focus on your life after treatment. That's where you will spend the rest of your life!
Posted 11/10/2016 3:20 PM (GMT 0)
Hello John and welcome. You have already received some great advice and support on this thread so I'll try not to be too redundant.

I am a successful LDR Brachy patient myself - you can copy and paste my long winded journey in my signature if you want to see my story. The advice that many of us give newly diagnosed guys is to take your time/get educated, get a second opinion on your biopsy slides and seek out multiple opinions before selecting a treatment. As Paxton said, most any of the main line treatments will likely cure you so focusing on the side effects is good advice in my opinion.

Looking at your situation, i think the question of a second biopsy opinion comes into play. If those are your true stats then LDR Brachy is likely a great choice. But...if some of those 3 +4 samples are really 4 + 3 then your brachytherapist might well suggest a course of IMRT in addition to the brachy. In the USA there are several highly respected pathologists who specialize in prostate cancer - Bostwick and Epstein are two recommended frequently on this forum. I don't know if there is a similar specialist in the UK but you might want to check that out just to make sure you are confident in your diagnosis.

Good luck and let us know how we can help.

Jim
Posted 11/11/2016 7:42 AM (GMT 0)
Brown trout I agree with you there are so many different choices of treatment that offer similar rates of success for this condition, that's what makes it so different to most other illnesses and so difficult to choose the right one. Usually if you have a medical condition or illness there is a specific profesionaly recommended treatment path. With this condition we as non medical untrained individuals are expected to weigh up what are medically sophisticated procedures and to make the right choice for our individual condition.
Paxton I couldn't agree more about your point regarding living with the possible side effects.This is at the forefront of my mind and will affect my treatment choice heavily. The one side effect that worries me most is incontinence and that's why I have ruled out surgery as I feel that this is the procedure that carries the highest risk for this, I may well be wrong but it's how I feel.

CaliJR thanks for your input, I agree that choosing the right doctor and treatment venue are crucial. It's likely that I am going to have to travel down to the South of England from Scotland to get the best choices of treatment however I dont intend to let distance stop me from making the right choice.

FI Drifter thanks for your input and encouragement glad to hear that your treatment is going well. Hopefully I will be able to choose and qualify for a mono treatment with a high potential success rate.
Posted 11/11/2016 11:49 AM (GMT 0)
Hi, pleased to meet you. :-)

You are the proud owner of a batch of G4 cancer cells. Those scare me very badly, with reason.

While many describe a G7 (3+4 or 4+3) as "moderate risk", my personal experience is that G7 is "high risk". I am a firm believer in what is termed "de - bulking" a cancerous tumour by cutting it out and throwing it in the trash.

Yessir, all of the treatment side effects pretty much suck all around, but IMHO they are better than the alternative. skull

Just my opinion, however. Your mileage may vary. blush
Posted 11/11/2016 5:45 PM (GMT 0)
Jim (Tudpock) I logged on to read your personal journey and for some reason your previous post to me has disappeared. Me and computers don't get on. I'm delighted for you that your own personal journey and challenges have turned out so well. It's encouraging for me to see that LDR Brachatherapy can turn out so well as this is one of the treatments that I feel particularly drawn to. I have recently had a transperineal biopsy and the consultant explained that the procedure for placing the seeds is virtually the same. The difference being that instead of taking samples out they are putting the seeds in.

Your point about having my biopsy slides checked is worrying me. I thought that these results would be reliable.
In the UK we don't seem to have specialists that only read prostrate biopsies. Having said that the hospital and the team in Guildford Surrey where I had my biopsy done have one of the best reputations in the UK for prostrate cancer. The urologist that carried out my biopsy Professor Stephen Langley has performed over 3000 prostrate Brachatherapy procedures, I'm hoping that the pathology labs that they use are reliable and experienced in reading prostrate biopsy samples.

Prior to having my biopsy I was in Florida on holiday and I travelled to Partners Imaging in Sarasota to get a 3Tesla Multiparametric MRI scan.The scan was read by Dr Richard Goldberg who apparently is recognised as a top radiologist in prostrate scanning. The scan identified one of the tumours and graded it a Gleason 7 3+4 the same as the biopsies would later be graded as. The scan did not identify any of the other lesions that were picked up in my biopsy. Having queried that since, I was told that the Multiparametric MRI will only pick up lesions of 5mm or more. The largest of the other cancerous cores identified in the biopsies was 4mm. The scan report also stated the following:
No extraprostatic extension (EPE) of tumor. No seminal vesicle, bladder or rectal tumor invasion. No pelvic enlarged lymph nodes or suspicious bony lesions. Im hoping Jim that with the combined evidence of the specialist MRI scan and pathology report that they are both right. What do you think? Am I being too optimistic?
Jim I appreciate you taking the time to take an interest in my case and for sharing your knowledge and experience.
Posted 11/11/2016 5:59 PM (GMT 0)
here is my story
age 74
3+4 on 50%
choice of surgery or brachy.
had brach. studies say same outcome ,more or less.
who wants surgery anyways.
understood radiation therapy way back when.

psa 8.1 at brachy start
3 mos 1.8
3 more 1.3
last one. .9

make whatever choice you think right. it is your life
GOOD LUCK!
Posted 11/11/2016 6:49 PM (GMT 0)
John, my previous post is still there. Move slowly up the page and you will find it.

Also, I didn't mean to worry you. With the amount of testing and work that you have done I'm sure you will be fine with LDR Brachy. Just ask the question of your experienced RO as to why he didn't add IMRT to the Brachy. I predict he will tell you that it's because he feels the LDR Brachy alone will do the job and you don't want to add unnecessary unneeded radiation. That was the case with my 3 +4 case...

Jim
Posted 11/11/2016 7:17 PM (GMT 0)
Scotsjohn...some of the typical advice we give guys here is to have their biopsy slides read by someone that does nothing but read prostate biopsy slides. (Other pathologists--no matter how expert--read all sorts of tissue samples.) But I've learned that's more difficult to do for those in the UK.

If you can find someone that fits the bill in the UK, that's great. I'm not sure what the mechanics might be of trying to send them over to the US--I'm not familiar with anyone doing that.

And you should know that the majority of biopsies don't change on a second reading--so yours are probably right. But keep in mind that biopsies are never an exact science since they all depend on the particular "poke" and the tissue they draw out. Based on your last post, I will say the very, very good news is that the scan showed no EPE, which means your chance for a cure is very, very good.
Posted 11/11/2016 7:18 PM (GMT 0)
There are natural things you can do to fight against cancer. Diet is the most important thing. The body can heal itself if you give it what it needs. It needs the vitamins and minerals which are found in the fruits and vegetables. Here is an article which explains things you can do to fight your cancer.

http://www.naturopathic.org/content.asp?contentid=505
Posted 11/11/2016 7:58 PM (GMT 0)
John, diet is of course important but it is doubtful if it will cure your case of cancer. Beyond that I recommend that you make sure you discuss any and all supplements with your treating physician BEFORE taking them.

Jim
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