Treatment decision

My spouse was recently diagnosed with prostate cancer. We consulted a local well regarded urologist. We also traveled to the Mayo Clinic in Rochester. Both urologist recommend robotic prostatectomy. Based on the number of procedures done by the surgeon at Mayo (about 300 per year compared to 50 per year for the local surgeon), we have decided on making the half day drive to Mayo. The surgery is scheduled for early fall.

We did not consider radiation. From all of the experience on this forum, would you say we are on the right track?

Age 60
PSA Nov. 2016 7.56
PSA April 2017 6.36
PSA May 2017 7.17
PSA June 2017 7.13
Biopsy Results:
12 samples - 7 benign
Right apex medial, Gleason 3+4=7 (Grade group 2) involving 20% of one core
Right mid medial Geason 3+3=6 (Grade group 1) involving 3% of one core
Left apex medial, Gleason 3+3=6 (Grade group 1) involving 3% of one core
Left mid medial, Gleason 3+3=6 (Grade group 1) involving 3% of one core
Left base medial, Geason 3+3=6 (Grade group 1) involving 2% of one core.

Your spouse may be a great candidate for radiation therapy. You may on the right track, or you may not be, but you won't know until you consult a radiation oncologist. After doing that weight all the side effects from both routes against eachother, because the cure rates will be almost identical. And please consider potential side effects that surgeons don't bring up voluntarily.

Hello and welcome to our exclusive club. I had my slides sent to John Hopkins for a second look and they were downgraded to what you see in my signature. After many visits with top surgeons and top radiation oncologists and absorbing all the knowledge from this wonderful site I chose cyberknife SBRT and never looked back. Its a personal educated decision that you must make yourself. Once that is made it feels like a ton of bricks are off your shoulders. But please explore all your options.Good Luck,John

Kocour-

No, you are not on the right track. I don't mean that surgery is a bad choice- it isn't- and Karnes is excellent. What puts you on the wrong track is failing to understand what your options are and taking the time, and making the effort to do that. You deserve a more thorough investigation, and you're worth the time and effort. There is no rush.

Kocour said...

We did not consider radiation. From all of the experience on this forum, would you say we are on the right track?

Maybe, maybe not. You won't know until you complete your education. My recommendation is similar to what others have told you namely (1) get another opinion on your biopsy slides from Dr. Epstein and (2) take the time to visit doctors who specialize in LDR Brachy, HDR Brachy and SBRT. Until you do that you have not done your homework IMHO.

The radiation options offer you better odds of avoiding the side effects of incontinence and ED. If that is important to you guys then it's worth the time to investigate those options.

Jim

Kocour, Good Morning, From my signature you can see that I was 60 when diagnosed and 61 when I had surgery at the Mayo in Rochester I also live about 5 hrs away in Northern MN there's a couple of other guys on the forum here that also had surgery at the Mayo. I was very happy with my operation and am very thankful for the good surgeon I had Dr. Boorjan because in 3 months I had just about 95% control of my continence. I had both seminal vessels and one nerve bundle removed probably will have ed issues the rest of my life. I was one of the unfortunate ones in the 30 to 50 percent group that the darn cancer is still there and am looking at radiation and possibly Lupron down at the mayo starting in Oct. So like Tall Allen says you don't have to make your decision today do your homework lots and lots of study's out there. I like the Journal of Clinical Oncology for one lots of info there read the definitions on the 1st page of this forum also. Whatever you decide embrace it and go for it. If you go for surgery email me I can pass along a couple of tips that might help you. Best of luck to you guys!

Larry

Your husband appears to be very low risk/low grade. While surgery can probably be curative, it is in a case like this to be determined to be over-treatment. That is because there are other equally curative treatments that routinely present fewer and less significant side effects.

You need to see a few different radiation oncologists for their assessments and suggestions. These should include external beam radiation, preferably SBRT/CyberKnife and Brachytherapy, preferably High Dose Rate and also permanent seeds. But to get the true information you must see the specialists that perform these services. Do not rely on any urologist for this information as none of them are the experts. Also do not rely on the radiation oncologists for advice on surgery.

These radiation based procedures provide for the same or better cancer cure and control as surgery. They also present far less significant side effects. Why? No cutting. The very act of surgery causes damage and side effects. Couple that with the very intricate methods necessary to remove the prostate (due to it's position and surrounding nerve bundles) and it is no wonder that for such a common procedure it results in such significant and potentially life changing side effects when compared to other surgeries. My wife had a double masectomy and has significantly less life style side effects as many of my friends that had their prostates removed.

Do some more research as you have barely scraped the surface. To move to surgery now would be, in my opinion and that of most experts, a mistake. To answer your original question, without more specific consideration of other treatment options you are not on the correct course. Learn about the other viable treatment choices and select the one that presents most men with the least significant side effects.

As you can see from my signature, I used a combination of two radiation based treatment methods because I was much higher risk than you. Nearly seven years later I remain cancer free and have no negative side effects. All my urinary, bowel and sexual functions are just fine and I have no scars or surgical adhesions. My urologist-surgeon would not operate on me and I am glad he forced me to look at non-surgical options. I continue to see him every three months for a checkup and PSA test and always tell him that the single most valuable aspect of his treatment was his requirement to seek other professional advice before determining on a treatment method.

I am partial to HDR brachytherapy. I chose that after much research and have been wonderfully well served by it. To learn more please see the website www.cetmc.com. This is by the father of HDR-BT, Dr. Jeffrey Demanes. He has used HDR-BT since 1981 and has been the head of the department at the UCLA Medical Center. There is also a very good explanation of permanent seeds at www.prostrcision.com. This is the website of Dr. Frank Critz here in Atlanta. He and his clinic have used seeds since the mid 1970's very successfully. I met with them and have several friends that have been successfully treated by them. Tall Allen and others that have used SBRT can also provide specific advice based on their actual experience. I would not, however, consider traditional IMRT/IGRT that require upwards of 40 days of treatment. It certainly works and is low side effects, but it has been supplanted by the 5 or six treatment days of SBRT; and the 1 or 2 treatment days of brachytherapy.

Thus, look to the treatment that presents the very least in the way of significant side effects and is most convenient to your life during and after treatment. You are very low risk and do not need to be introducing high risk of treatment side effects that are not necessary to treat the cancer.

I'll pile on also. When I discussed treatment options with my urologist at MD Anderson, I was well aware of radiation -or- surgery as options. Then I could have an informed discussion with him and ask appropriate questions. Both are good options and you need to carefully consider both.

Thanks everyone for your comments and suggestions. We will look into radiation treatment. We have done some reading. The Gleason score of 3+4=7 motivates us to aggressive treatment. Our goals being: 1. to be cancer free, 2. minimize incontinence and 3. minimize erectile disfunction (although important not our top priority).

We were told by both surgeons that if radical prostatectomy does not eliminate cancer, radiation is a second option. But if radiation fails, surgery is not a good option.

Will try to consult with an oncologist about radiation therapy. But at this point, my spouse is pretty confident in his decision to go with robotic prostatectomy at the Mayo Clinic. His work schedule is such that he does not want to take any more time to deal with this. His father had open prostatectomy when he was in his late 60s and lived until he was 91 with minimal to no incontinence issues. That gives my spouse some confidence that a radical prostatectomy is the best course for him.

Kocour, please tell hubby that folks on this forum are not trying to talk him into anything except getting educated and reviewing his options. Yes, reviewing options and seeing doctors takes up a lot of time. But -- THIS IS A POTENTIALLY LIFE CHANGING DECISION -- and you both may have to live with potentially severe consequences for a long time.

As PeterDA pointed out, this "can't do surgery after radiation" is a bogus argument. There are plenty of options for salvage treatment after radiation. You are not likely to hear about them from a surgeon but you are likely to discover them by reading/getting educated or visiting with a variety of radiation experts.

BTW, your goals are pretty much the same as all of us who have had this disease and his inclinations about "getting it out" are also pretty typical after we have only met with a urologist. He may still decide upon surgery after doing his homework but at least will go in with his eyes open about the alternatives. Please encourage him not to be lazy or impatient about the study of various treatments. This is critically important if you want to get it right.

Also BTW, I can tell you that my wife also had the strong inclination for me to have surgery ("get it out"). Nine years post treatment without significant side effects have made her VERY happy we took the time to look at all of the options.

Jim

Kocour.....you are now headed in the right direction. Do research about other options, but DON'T cancel your valuable Mayo surgery slot. You can do that later, if you and your husband have a change of heart.

Not only physicians are biased. We patients are as well, especially if we've had successful treatment. Most importantly, given the stats you posted, you have time, and shouldn't be pressured.

It is not insignificant that your husband seems to be predisposed toward surgery....for whatever reason. It's a better choice than some would have you believe. All the treatments discussed have their pros and cons, none are significantly better or worse, there is NO one size fits all, and only you and your husband can make the choice.

Best of luck; you can't do better than Mayo!