Father pondering Radiation or Surgery

Hi John:

You're certainly welcome over here in our forum but sorry you need to be here. To answer your questions properly we need to know a little more about your dad's case. The pros and cons as well as the odds are somewhat dependent on the severity of his diagnosis. And, has he really been on "watchful waiting" or has he been in a true "active surveillance" program? The difference is huge and is largely in the "active" part of the equation.

So, if you can come back with some more specifics we have some great folks here you can give you some great information. Please tell us anything you can about his PSA history, specifics on the biopsy (e.g. Gleason score, number of cores cancerous, % cancer in the cores), what other tests he made have had (PHI, MRI's, bone scans) and the results of those, etc. We will be glad to help and the more specific you can be the better the info/response you will get.

In general however, both radiation and surgery are equally likely to provide a cure if the cancer is fully contained in the prostate capsule. Surgery will give exact post-procedure pathology and give the if-needed satisfaction of "getting it out". Successful radiation will give slower knowledge of success but with a generally lesser chance of onerous side effects like incontinence or ED. The odds of those occurring are somewhat dependent on the nature of the cancer and the extent of treatment needed. For example, if a surgeon needs to "cut wide" and take the nerves, then the chances of ED are very high.

Anyway, please get back to us with some more specifics and we will be happy to help.

Jim

First decision level is his health status to see if surgery is a viable option. It is major surgery with differing recovery profiles. At his age there is a trend to recommend RT. Another consideration for him is quality of life vs quantity. Third point is he comfortable with where he has been going for treatment. From the limited info given it may be too early to be comparing option and side effects. But that’s me.

“Surgery is not possible after radiation but radiation is possible after surgery.”

That statement is misleading by omission. Yes, surgery after radiation is very difficult, but that is hardly relevant because they are several other proven salvage treatments in the case of a failure of primary radiation. And, Proton Beam therapy is also being used since this article was written
In 2017.

https://prostatecancerinfolink.net/2017/09/05/salvage-focal-ablation-for-radio-recurrent-prostate-cancer/amp/

We assume he is seeing a urologist, who will order the diagnostic tests for him. At a PSA of nearly 17, and showing the slow steady rise, a new biopsy appears to be in order--unless they did one in the last few months.

After that, we do have a useful sticky at the top 'to the newly diagnosed'. It suggests the steps to take after a positive biopsy. How to get a second opinion on the pathology. How to get in to see the specialists--and you certainly want him to see multiple experts: don't ask a surgeon about radiation and vice versa--and urologists, by definition, are surgeons, and invariably recommend surgery.

Not watchful waiting, watching the PSA rise like that.
My vote, depending on the biopsy result is a 5 treatment SBRT radiation type treatment.

I vote radiation with HT - have him see an RO for an opinion.

Andrew

Ipoop,

I think all of us are shocked that an observant urologist would stand aside with a steadily rising PSA over a period of 4 years to the levels that are being reported. Please do find out what the biopsy results were. To give you a brief primer on Gleason Scoring, it is usually expressed as a sum of 2 numbers, with a total. Each cell pattern seen in a slide is given a score, and the sum comes from the two dominant scores in a sample, with the most common reported first. So, a "3+4 =7" means there is more type 3 than type 4 in the sample. These nuances are important--and so is the expertise of the pathologist, which is why we generally recommend having the slides sent out for a second opinion to Johns Hopkins--Dr. Epstein there has devoted his career to prostate cancer pathology--that is all he does--and he is considered the best there is.

While PSA is not a cancer test per se, steady rises, as opposed to dramatic swings up and down, usually are indicative of the presence of PC--and the higher the score, the higher the probability. At 70, 'normal' PSA is usually in the 4-5 range, so the almost 17 is a real concern.

It's also important to know what, if anything, the doctor felt with a DRE exam. Lumps, puffiness, hard spots, notches, all are significant.

We hope the best for him.

I agree the the other folks expressing unhappiness with the urologist. It is not important to act quickly, but he needs to do research, and see more doctors. If I were him, I would find a new urologist and also see a radiation oncologist. And he needs new tests to see how advanced the cancer is before initiating any treatment.

He needs a current biopsy. When was his last one done? Until you get a current biopsy, scans, and clinical staging there should be no speculation as to treatment methods to pursue. You have to confirm what the cancer is and where it is before you start deciding on a treatment method. At age 70 fewer doctors will operate, the most renowned PCa surgeon Patrick Walsh used 70 as a firm cutoff for surgery. Not all docs follow that, however. .

This rush to bash iPoop's father's urologist as incompetent belies some misunderstanding over the difference between Active Surveillance and Watchful Waiting. Watchful Waiting is a decision of the patient who has decided that treatment of the cancer will likely be to control it rather than to cure it. Generally, it is used for older patients or those with health problems. iPoop says that his father is healthy and relatively young at 70, but it would be useful to know why he chose WW rather than AS. AS on the other hand is much more proactive and with careful monitoring, and to initiate curative treatment once there is a change.

Both AS and WW may be offered to patients with G6 cancer where PSA is < 10. You typically exit an AS protocol when your PSA rises over 10 and for other reasons such as change to Gleason 7 or volume. However, with WW, the guidelines I've seen are PSA > 20 before further treatment is initiated. As most patients on WW desire to control rather than cure the cancer, further treatment might just be hormone therapy. Hence, iPoop's father's urologist was well within the guidelines of WW protocol. Of course, iPoop's father could change his mind and opt for curative treatment at this point.

Hey guys, forgive me if I got some terminology wrong and caused confusion. Total beginner here (i think watchful waiting was wrongly stated by me). All i know is they were watching his psa. Now it's high enough for action. They're considering him for surgery or radiation. He's been talking with both docs for each.

Dad just had an MRI, had a surgery consult, and met with a radiation oncologist. He did tell me that the cancer is confined to the prostate, which is good news. Said the cancer is on the bottom part of his prostate where it forms into a tube that goes down towards his weiner. Seems limited in extent. For surgery they use laparoscopic, robot-assist.

They said his gleason was 3. I asked for clarity and he was unsure, said two numbers were not given. I'm guessing it was a gleason group value of 3. Or perhaps a regular gleason score of 3 3 (which would make him a group of 3). He said he was middle of the road.

He said the surgeon said his case was unique (how I do not know). But the radiation oncologist, surgeon, and his urologist docs are all talking together on which is best route for him.

He's leaning toward radiation. Surgeon told him no excercise for 3 months which (dad's words) would kill him. And he was worried about peeing and pooping into bags after surgery (which they said he might have to do).

Sorry I do not have all of the information you had asked for. Not going to the doctors apts with him to ask in person (he lives about 4 hours away). He lives on the New Hampshire seacoast.

I do appreciate all you've said thus far. If you have more to add based on the newer info above, let me know.

That sounds like a low risk PC and radiation would be good route for him.

Surgery at that age is a little more recovery time than for a younger person.

Do keep us updated on his progress.
Andrew