Treatment Selection Close

My sweet wife and I met with Dr Debra Freeman at the Cyberknife center in Tampa FL last Thursday. Dr Freeman was so thorough and answered all my questions. She and her team including her physicist have been involved with SBRT almost since the treatment was originated and have refined their technique over the years to where it is today. I was really impressed with Dr Freeman and hope to initiate treatment with her soon. I have to get a multiparametric MRI and a bone scan done first. I just read about that type of MRI..... Sounds like fun... Anyway, I am really excited to be approaching a final plan although after reading about all the determined and courageous people on this site, my process almost seems mundane. I know all prostate cancer is very serious but I really admire the folks on here who are dealing successfully with this nasty disease, and particularly those with more aggressive disease. You guys are truly prostate cancer heroes.

It is great.....I just wish I could hurry it along and get on the other side. It is so difficult to even get to this point with this process, particularly since there are so many viable options for treatment. I guess I always expected that if and when I did have to fight a difficult disease, the choice of treatment would pretty much be a given. Obviously, with prostate cancer, that is just not the case. So much of the education that one acquires when confronted with the diagnosis, is specifically to help with the treatment choice. It is so different from many other diseases where the treatment choices are limited and often a standard protocol.

It is such a relief to move from the research phase to the 'get 'er done' phase of our disease. Best of luck with the treatments.

Thanks, John. Actually, until I get the results from the scans and they are clear, I won't know for sure that I will be able to proceed with this plan. But, the Drs think I will be ok so I'm thinking positively. If the scans are negative, then I will able to proceed with the fiducial markers and I will be on the way to treatment a week or so later.

I'm surprised she's asking for a bone scan with your diagnosis. I'm also surprised that she wants an mpMRI and not just an ordinary MRI -- why?

Unfortunately, that's exactly the problem with bone scans. They pick up old injuries, arthritis, etc., causing unnecessary worry and further investigative diagnostics. Less than 1% of men with favorable risk PC has a true met, and it would seldom be detectable with PSA this low, yet most of them will be worried by it. And that is even without mentioning the unnecessary cost (which we should all be sensitive to - even if insurance covers it, it raises insurance rates for all of us.)

Since 97% of favorable risk men are cured by this therapy, there is little chance that a future bone scan is in the cards. If there is a recurrence down the line, it would be diagnosed with a PET scan anyway. The idea of a "baseline" bone scan for favorable risk men is bogus. It is not standard of care and all professional organizations recommend against it.

I wasn't accusing you or anyone else. It is my opinion that a "baseline" bone scan on an intermediate risk man is bogus. What I mean by "bogus" is that there is no evidence to justify such an action, and a lot of evidence against it.

I am a big fan of Dr Freeman's (in fact I recommended her to the OP), but that doesn't mean that I have to find merit in every single one of her actions. Perhaps she can justify it -- but as empowered patients we don't just accept everything we're told, we ask questions, and reasonably expect answers.

As for the mpMRI - perhaps she does simultaneous integrated boosts (SIB). As a patient, I'd want to know that. And if she believes higher doses are necessary to kill evident cancer, why that dose is not used throughout. If she doesn't use SIB, why is she asking the patient to endure an hour in a machine (rather than 15 minutes at a much lower cost) for a procedure that will not change how the patient is treated? Again, there is no evidence that an mpMRI rather than an MRI leads to better outcomes or changes radiation treatments.

As patients, we should be encouraged to ask such questions of our doctors. They may have good reasons, maybe not.

Why are you saying "easy"? You were the one who said "bogus" should not be ascribed to anything Dr Freeman does. Does this unquestioning apply to others? Patrick Walsh? Snuffy Myers? What I'm saying is that your attitude does not really serve you well - the patient can and should question what he does not understand. Just a difference in our philosophies, I guess. I, for one, would be delighted to discuss any of this with Dr Freeman, and my guess is that she would be delighted to answer my questions.

I have some questions for you:
1. What did an mp MRI tell you that a T1 MRI would not have that made a difference in the SpaceOAR gel?
2. What dose are you being given on the basis of a Decipher score? What dose would you have gotten without it? I did read one study where biopsy cores were used to predict metastases, but I've never seen a correlation study with dose. This is an entirely new use, so I'm very curious. Is there any data behind it?

Your showing a tell..you won't like with a clearer mind...TA...As I told someone else once...quit while you are behind....Keep in mind ...She is the patients doctor...you are... "Allen-not an MD"...member??

To paraphrase Ralph Waldo Emerson 'the universe has a non arguable system of balance'...Its not tipping your way on this one.... Hopefully you will not take your belongings and leave...You are respected and knowledgeable...but not to be worshipped...and that does give me comfort...for your sake..

I just had an opportunity to read all the above discussion and I actually find differences of opinion refreshing and thought-provoking. No agitation or issue with me at all and definitely no apologies needed. There is merit from my perspective to both TA and SteveinErie's position on the bone scan and the mpMRI. Clearly, one must advocate for oneself throughout all the stages of this journey for ultimately Drs., while many are very experienced, qualified, and possibly even brilliant in their field, are still just people who are prone to habits, common protocols, occasional mistakes, and of course the influence of $$$. However, idiosyncrasies of a particular doctor could also be ascribed to years of personal experience, which may not always square with the majority of professional published opinions but may have been good medical practice for the particular doctor's specific and unique patients. Having said that, now that I have read the above posts, I will definitely address the bone scan and mpMRI questions to Dr. Freeman and we will see what her reasoning is. I remember her specifically mentioning the baseline idea of the bonescan for future purposes but I didn't question that any further. We'll see what the good Dr. says and I will post that information when I have it. Thanks to all for taking the time and expending the mental energy necessary to bring forth issues that need to be addressed. Without these discussions, people like me who are largely ignorant about the science of prostate cancer treatment, would not have a clue what to ask a doctor and ultimately would be making treatment decisions based on faulty or incomplete information.

Thank you for that encouragement, IO. I am making my way along the road to what I believe will be the best route for me. Things could change but at this point I doubt that will be the case. Some steps in the annual treatment plan may vary but we'll see. As is evidenced by the animated discussion earlier in this thread, there are different ways of viewing treatment issues but without those conversations, treatment decisions would be made with alot less informed patients.

19 - I'll take the thread back on-track and give you the history of my fiducial marker implants. I originally asked Dr. Hirsch if they could do mine transrectally, as I knew that a transrectal procedure with the nerve block was, for me, a non-issue. She advised me that their labs were not equipped to do the trans-rectal procedure, so if I wanted that process I would need to arrange to have the markers implanted across the street in the main hospital. This would greatly complicate things from the administrative perspective, and I just wanted to stay on schedule, so I accepted the trans-perineal procedure.

The trans-perineal procedure was a lot less "fun." The advance prep included a laxative and an enema, along with a couple of Norco tabs, a couple of lorazepam tabs and liberal application of a topical lidocaine cream the couple of hours prior to the procedure. You can't see what they're doing, but I guarantee you can feel it. It probably feels like what a biopsy would feel like with those meds. For me, it was 10-15 minutes of breathing and talking through clenched teeth. It did hurt, but as soon as they were finished, the pain ended completely. They only had to insert two "strings" of two markers per string. I had even less after effects than I had from the trans-rectal biopsy. 15 minutes of discomfort, then back to your normally-scheduled life (other than the precautions after taking the Norco, like don't operate machinery, etc.).

After the procedure, I talked with Dr. Hirsch and she said that she was personally glad that I opted for the trans-perineal procedure. She said that they have much better control over where the markers are placed with this approach, and they have never had to repeat any of their implants. With some of the local uro's doing implants trans-rectally, they have, on occasion, had to repeat the implant procedure due to mis-placed or migrated markers.

I will also admit that for a couple of days post-implant, although I had no "internal" pain or after-effects, I was quite sore from the ultrasound probe inserted into the rectum during the marker placement. This probe must have been a larger model than the one used for the biopsy, as I was sore "down there." It was easily remedied using over-the counter cream like Preparation H, so I really don't even count it as any sort of after effect.

Truthfully, as strange as it may seem, I feared this procedure more than the treatment itself. As it turned out, it was easily manageable and didn't result in anything worse than 15 minutes of discomfort. Not "10 of 10" pain, just something like "5 of 10." Now that this is history for me, if they said I needed to do it again, I would just ask "Where and when?"

On with the show! You'll do fine, then you'll start the treatments.

I will definitely pass on your greeting and comment to her, SiE. We will be having some communication this week for sure.Thanks for all your thoughts.