Gleason 9 is surgery an option?

Hi Ted,

This is the right place to ask these questions. I'm not going to say that surgery is a bad idea, but you should be wary of anyone who says that surgery is clearly the right option for you. You definitely need to look at different forms of radiation therapy, and see a radiation oncologist asap. No one should say they are confident that your cancer is organ-contained. Have you read the stickies at the top of the list of topics here? They are very good. More people will be along soon with more thoughts on your case.

FC

Sure it is an option. The appropriate question should be is it the best option for you?

Among the last people I would get such advice from would be my GP. Go to the several different specialists in the field including a few urologists and radiation oncologists for their in-depth assessments. Only then should you make a treatment decision.

Many studies have shown that for high risk cases like yours that the radiation treatments are better at cancer control and present less significant negative treatment side effects. At all cost you should avoid surgery followed by radiation as the is the highest risk and most damaging treatment sequence for most men.

Hi Ted... I'm just speaking from my own experience as a g-9 who had surgery. My first suggestion would be to find a great team from a cancer center, hospital, university hospital, such as MSK, Mayo,
Sloan Kettering and many other great ones. You have to be your own advocate and as a G-9 guy PCA is definitely going to change what is a normal life not for the bad but different new kind of normal. It will impact your family also so make sure to include the spouse in your team! The big thing is don't make a decision overnite you have some time and I'm sure other guys will come along and advise you the same advice. There are so many treatments available to you including surgery but make sure you check out all the possibilities and the SE's that go along with each treatment. As a G-9 there is a chance you will have to have ADT and Radiation down the road after surgery. Read the notes on the forum about newly diagnosed and also you can read The ADT and SRT journey thread as there are lots of G-9 guys on there that have surgery then later ADT and SRT and also some guys that have chosen Radiation as first treatment so gives you a little insight as to what guys have gone thru. Wishing you the best in whatever treatment you decide keep us up to date as to how your doing. Have a great Memorial Weekend!

Larry

Another G9er here...surgery certainly is an option and that's what my urologist recommended for me. But as I learned more, it felt like there was a decent chance that I would need radiation after surgery and rather than have the side effects of both radiation and surgery, I cut to the chase and had radiation. (In my case, IMRT + brachy + hormone therapy.)

In general, you are unlikely to get a recommendation for radiation from a urologist, who is a surgeon by training. And even with radiation, there are so many types that and most ROs have a particular type they practice, so you may need to meet with multiple experts. Good luck to you and I hope we can help you work through everything.

PS I'm doing fine as a G9 four years after treatment, in case you want something positive to focus on!

Ted - You are fortunate that your cancer was diagnosed before it progressed any further, but very unfortunate that it is high grade and high risk. And apparently it is advancing quickly. You likely need to act very soon if it is indeed still organ confined.

Mine also appeared on the MRI to be contained, but once the surgeon got in there, found that it had already spread to the seminal vesicles and said that he had to "remove a lot of tissue" to get it out. The result was near total incontinence, hormone therapy and more surgery so that I could undergo follow up radiation.

This is the same scenario as several others have already mentioned above. I should mention that I did consult with two radiation oncologists prior to surgery as I was very interested in the five treatment Cyberknife, but was not eligible due to my high risk status (which was elevated to very high risk post-op).

Surgery was chosen for expediency as there were numerous other complicating factors at the time. If I had been granted the gift of time to research treatments I might have chosen differently, but the ONLY regret I have at this point is not being more aggressive early on and acting sooner.

Several other guys I know went into surgery with clinical Gleason 7 and following post-op pathology were found to have G9 tumors that were missed in the biopsy. In general they had to follow the same trifecta of treatments that I had. It hasn't been terrible, but at this point my PSA is 0.00 and it appears that I may be cancer free. And so it might be with you.

I'm not saying that surgery is a bad idea, but you might be better off going straight to radiation. It is not a cakewalk and there are side effects. You will need to be armed with knowledge of those beforehand. I recommend that you thoroughly research pelvic radiation side effects, as you are a young man and will potentially have to live with those side effects for a many years.

Good luck with whatever you choose. It is never easy.

I'm another G-9 and I chose surgery even though my Urologist / Surgeon thought that radiation might be better for me..He gave surgery a 50-50 shot at curing my cancer..(Gleason 9 is tough) ..While surgery has not changed much in the last 10 years, radiation has. Radiation is FAR more effective with fewer side-effects than it was 10 years ago..Combination treatments that use both brachytherapy and beam radiation can deliver better results than surgery in high-risk cases..Anyway, my surgeon was right, surgery did not cure me and I'm still battling the monster 9 years later..

Ted, welcome to our reluctant brotherhood. If I were you I’d probbly think long and hard before choosing surgery, knowing chances are high you’ll need adjuvant radiation when it’s done. But I say that with a big caveat that I’m not that knowledgeable when it comes to Gleason 9 cases, the other guys here are way ahead of me in that knowledge.

Go into this with eyes wide open. When speaking with practitioners of the various treat,nets, trust, but verify. PC is big business, sad to say.

No matter what the outcome of your primary treatment, always remind yourself that Prostate Cancer today, even ggressive cases, is most often treated as a chronic disease and you can hve a very long life of joy and happiness while “co-existing” with this disease. Life will be different, but it will still be good.

Good luck in your decision making.

Hi Ted . Sorry you had to find us yet very glad that you did. This is a great place to find strength and information. A great place to hear others share their experiences as they go through their journeys. You have just started your journey and every one here knows pretty much how you feel.


If you look at my signature you will see that we have very similar Dx. I had 6 cores G9 on the one side also. I did have 2 cores G7 on the other side as the only difference.


I will only give my experience as to what and how my treatment plan transpired. I first wanted to just get it out. Surgery was what I wanted so I tried to find the best surgeon I could find that was from a respected facility. My plans from the beginning rapidly started changing. The surgeon told me I wasn't a good candidate for RP, for other reasons.... so I had a consult with radiation oncologist and the plan was to do ADT (hormone deprivation) +IMRT (external beam radiation ) and then Brachy therapy (seed implant).
This is known as the triple play , which by the way has been proven as a very good way to approach G9 confined PC.

After having that plan and team in place it was determined that I wasn't a good candidate for Brachy therapy as I had to many urinary issues. So I ended up doing IMRT + ADT. Down the line I chose to do Chemo but that was a choice I made. (not a lot of us here do the chemo)

So.... not to go on and on and make things too complicated for you I would take the advice that others have already given and seek the experience of those that are also G9 guys.

I will say I'm very glad that I didn't have surgery as I've seen to many G9 guys do surgery then end up having to go through radiatin and HT anyway. (Double the side effects) The only thing that I can see is that would be a possitive with surgery would be that you would then have a patholigy report that would give you a much clearer view of what your Dx is. (not a good enough reason for me)


Keep reporting back and keep asking questions and know that knowledge is your best bet to getting the treatment that will be best for you. It enables you to be your own advocate.


Battle On Brothers!


The Artistic One - Mark

Ted, in your shoes and knowing what I know now, I'd be looking very hard at the radiation/hormone option.

I say this as a guy who biopsied at G-7 (the "unfavorable" 4-3 variant) but then got the unpleasant surprise of an upgrade to G-9 after surgery at Johns Hopkins.

Granted, I was "lucky" in that pathology indicated the cancer was "organ-confined," and my first (and so far only) PSA after the operation was undetectable. Moreover, the standard side effects of surgery were short-lived -- due I think to the exceptional skill and experience of the surgeon.

The problem is, with G-9, my chances of maintaining that undetectable for the long term are 50-50 at best. And I emphasize "at best."

I'm good with my choice because it was entirely reasonable and justified, based on what I knew before surgery -- plus the fact that so far things have worked out quite well for me.

But there is more than one study out there now to suggest that with "high-risk" and "very high-risk" prostate cancer, such as yours is, radiation and hormone therapy are the preferred courses.

That's not to say radiation is a walk in the park. Far from it. And the hormone therapy will likely be long-term, which increases the challenge (and potential side-effects) considerably.

However, you really want to avoid a scenario where you have surgery and then find yourself immediately looking at the need for radiation. That would be the worst of all worlds. And honestly, with your numbers -- the PSA quite high and the biopsy with so much G-9 -- that would be a very distinct possibility.

Truthfully, you can throw out what the GP said: A) because there's no way he can know or even reasonably predict that the cancer is organ-confined; and B) because being a GP, he's not an expert in prostate cancer.

Another thing to mention: the technology and methodology of radiation these days is far advanced from how things used to be, say, 20 (or even 10) years ago. It's night and day.

But you do need to find a radiation oncologist who has extensive experience in the treatment of prostate cancer. As others have mentioned, cancer centers of excellence are sprinkled around the country. These are the places you need.

Bottom line: surgery certainly wouldn't be crazy, but it would be a gamble. And unless you found a high-class surgeon, it would frankly be a bad idea.

As a surgery guy myself, I don't mean to push radiation, and I'm content with the choice I made. But based on your description of the situation and what I've learned through research, radiation might be the better option for you.

I say "might" because it seems that so many choices with this crappy disease amount to a crapshoot.

I wish you the best of luck -- and Godspeed. I've always believed that in the end, it's in the hands of a Higher Authority. That's given me a lot of comfort as I've groped my way through the bewildering maze of prostate cancer.

Hello Ted and welcome. I think you have your answer...surgery is an option but is likely not your best option. Let us know if we can help you find a good radiation oncologist in your area who can provide radiation brachy boost therapy.

Good luck.

Jim

I had G9 prostate cancer and had surgery. Whether it was the right decision we will never know. I can tell you that surgery completely took away my ability to have an active sex life. I don't get into vacuum pumps or pills so my wife and I have had to create a new relationship that is really super good. But then again she's a great woman. My final pathology showed a prostate that was filled with cancer and shortly after surgery (about 9 months) my PSA began to rise again. Many treatments later I am undetectable but will likely never be cured. So was it a good idea? For me, I think so.

I don't know what the right decision is for you. You need to understand the pros and cons of each treatment and decide what is best for you. Wish I could be more help to you but this is a very personal decision and one that shouldn't not be entered into lightly. Wishing you all the best. Take care.

I am a G9 and am considering a clinical trial, my doctors told me my next option might be a clinical trial..
3 years ago in the beginning my psa was 203 with distant bone mets so I realize my PC is different.
My first MO treated all types of cancer but now my doctor at md anderson treats only advanced PC, he knows much more about PC.
Stay active and learn all you can about PC.
Larry E