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Surgery vs. Radiation Therapy in Chicago

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Posted 1/25/2019 2:39 AM (GMT 0)
Hello Forum, I was recently diagnosed with Intermediate risk PCa and I'm trying to decide upon Surgery versus Radiation Therapy.

Details: I am 58 and in good shape. Gleason Score of 7 (3+4). 18 of 20 cores positive with some at a high percentage. There is perineurial invasion in some of the cores. PSA is 9.5. Ultrasound during biopsy said prostate volume was 30.6 cubit cm. Seminal vesicles appeared normal. The margins of the prostate appeared normal. Urologist(Catalona) believes I am T1c.

Question: I am trying to decide upon open Surgery with Dr. Catalona of NorthWestern Medical or Radiation Therapy with Dr. Moran of the Chicago Prostate Cancer Center. Dr. Catalona made the argument that he thought Surgery is better than RT and that open surgery is better than Robotic (Da Vinci) surgery. He cited studies about Robotic surgery that are beginning to show it may not be as effective as an experienced surgeon. He has down 7000+ himself and I believe that may be the most of any doctor... In comparing to RT he weighed the pros/cons of the two and was generally fair but did mention the uncommon risk of getting rectal or bladder cancer in 7+ years from the radiation. He argued that surgery offered the best chance of a complete cure. However, generally the prospects of surgery are scary to me and the higher risk of incontinence really scares me. Plus ED risk seems a lot higher. Next steps with Dr. Catalona are to get MRI and Bone scan to help with my decision making. I figure I can use them for either choice. Dr. Moran suggested a multi-modal treatment of IMRT with Brachytherapy starting with Casodex to "soften up" the prostate. Based on a DRE and my Path report he felt I looked more like a T2 although, to be fair, he did not have the ultrasound report. He argued the side effects, especially incontinence, are much lower with RT.

I would appreciate any and all wisdom from this forum on which way to go. Any insights on surgery vs. RT or Catalona vs. Moran would be much appreciated.

PS: my forum handle is Cyclingthe50 because my wife and I have set a goal to road cycle all 50 US states for at least 20 miles. We are up to 18 of 50 and have another 32 to go. So, its important for me to beat this PCa thing so I can reach my goal.... smile

Post Edited (Cyclingthe50) : 1/24/2019 7:42:28 PM (GMT-7)

Posted 1/25/2019 4:15 AM (GMT 0)
Surgeons recommend surgery, that's their business. Did he also tell you that surgery has a recurrence rate of about 32 percent (studies range from 25-40 percent)? Those men then need radiation, which leaves them with the side effects of both treatments.

I would suggest that you also consult with a radiation oncologist. about equal numbers of men are now choosing surgery or radiation. The more advanced forms of radiation, such as SBRT and protons have recent studies showing recurrence rates of less than 10 percent for your pathology.

Whatever you decide, good luck to you.
Posted 1/25/2019 4:21 AM (GMT 0)
One more note. The triple play combo of IMRT, Brachytherapy, and ADT has been shown to be the most effective therapy for high risk cases. I'm not sure that that your pathology requires that level of treatment. ADT has many effects, and can significantly impact your sexuality. Please do research before agreeing that you need ADT.
Posted 1/25/2019 4:57 AM (GMT 0)
Welcome to HW,

AS has given you some great suggestions. Either RT or surgery would work for you. Talk to a RO.

Like you I didn't want surgery and went the IMRT way. Worked great. These days, I would have chosen SBRT as it's got a great record - 5 treatments and done.

Andrew
Posted 1/25/2019 12:15 PM (GMT 0)
I don't know about Dr. Catalona but I do know about Dr. Moran - I had brachytherapy done by him six years ago and am doing great. My choice, based on what we knew from the biopsy, came down to: why have surgery if I might need radiation afterward? Why have the side effects of both? I reasoned that if the cancer had not already escaped, nuclear medicine would eliminate it. I've no problems with continence and no problems with sexual potency.
Posted 1/25/2019 12:29 PM (GMT 0)
There a few of us on here that went with Moran, I'm one of them, take a look at my signature and you will find I'm pretty darn close to your specs. Do a search on my handle and you will find my journey during the past year.
Next Friday marks three months post Brachy, and the only things I'm experiencing is a 50% loss of seminal fluid and a weaker urine stream. After Brachy with Moran I haven't had to take Flomax or anything for that matter besides my supplements.
Now, who the heck knows what's in store for me later down the road, but I cant wait for the 6 month post brachy date to arrive where the seeds have pretty much died off radiation wise and my body can start healing (I hope).
I can not comment on surgery, that's up to others. But if you want any info. on my experience with imrt/brachy after reading my posts, ask away.

Post Edited (ldog) : 1/25/2019 5:32:22 AM (GMT-7)

Posted 1/25/2019 12:37 PM (GMT 0)
Cyclingthe50 I would continue to try to understand my PC a little better prior to selecting a treatment. This might include a second opinion on your biopsy, John Hopkins is good, covered by insurance or $250. Also a T3MRI will give you the big picture. Here is a good article on that: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32401-1/fulltext I had a couple of genetic tests which I think were very useful. There are a lot to choose from. It sounds like you have a great surgeon. If he can do any nerve sparing you might be able to get on the road quicker than ADT and radiation. Of course, you will have a little incontinence, but it should go away. if you qualify for the shorter SBRT or AS that would be great too. However, if you need ADT and a traditional EBRT I can tell you it will take a while to get your energy back. You want to make sure you kill the cancer as recurrence happens 10 years down the road if you don't. The decision making is yours and you will need to take your time. I also recommend you read as much as you can including recent studies. The Key to Prostate Cancer https://www.amazon.com/Key-Prostate-Cancer-Experts-Explain-ebook/dp/B07C65VVNH It is well written and includes different views. Good Luck!

69 yrs., marathon runner, 44 3D-CRT/IMRT Radiation delivered via 3D-CRT in 1.8 Gy minimum dose fractions to a total of 79.2 Gy., 10.5.18. PSA .012, 8.12.18, 1.42 June 18, 2018 (Lupron 5.21.18 & 8.15.18), 12.7 May 2018, 13.7 Jan. 2018, 2.1 May 2012. SpaceOar 9.6.18, testosterone <.7, 8.15.18, Tot Mayo 19 ng .17 testosterone Free 6.18.18, Gleason 3+4=7 involving 15% of the right apex and 15% of the right mid, 3+3=6 prostate cancer involving 5% of the left base. Pathology interpretations by John Hopkins, UNM Cancer, and SF Path 3+4=7 or 4+3=7 MD Anderson Proton Center w/o %. T3 MRI w/ contrast 1.8 lesion left side 5P, Neg. Bone Scan. Prolaris test 3.5 consistent with intermediate and a PTEN test negative. Father PC age 78 RT & ADT now 94 yrs. Neurogenic bladder due to lumbar disk disease and recurrent bladder neck contracture with urinary retention man. 20 years doing catheterizations. TURP & scaring 2003, Finasteride 5 milligrams daily since 2002.
Posted 1/25/2019 2:49 PM (GMT 0)
I would second SantaZia’s recommendations since I just went through a similar decision process. You will start a war by asking which method is “best” and may not be a whole lot smarter at the end, just more confused. One question: do you have a PSA history other then the 9.5?

Knowing what I now know after surgery, I might have been inclined to go the radiation route if I could do it over. However, that is based on becoming smarter after surgery from additional testing, etc and the surgery itself.

I found the surgery recovery a little more taxing than advertised but then I was 66. I was not in as good as shape as an avid cycler but good for my age as they kept telling me. You do not just return to normal life after 2-3 weeks, 6 - 8 weeks seems to be more reasonable time frame to start feeling more “normal” again.

My “unqualified as a doctor” recommendation would be to get the MRI (hard to believe that was not done by such noted doctors), have genomic testing done on a biopsy sample, and send the pathology slides for a 2nd opinion from JH or other respected group. This will fill in all possible information for decision making and possibly one of the new items will make the decision more clear for you.

I also had the dreaded G7 biopsy diagnosis which sucks for making decisions. It is very easy to become 4+3 or worse with a second look or better biopsy sampling. You can’t really let it go but the treatment is not obvious. I felt that both methods would get me to the same place with similar side effect risks thus it was not an easy decision. My urologist was very experienced and provided statistics that claimed better results than the averages with continence and ED. I think this is valid as everyone will agree that experience is very important for good surgery results. It was difficult to find any similar experience testimonial for a specific radiologist in my limited experience with one RO, maybe it exists with some of the bigger names in RO as you would think some have better results than others.

Good luck and enjoy the comments you will be receiving.
Posted 1/25/2019 3:15 PM (GMT 0)
Good advice above - definitely talk with a RO to get both perspectives and take advantage of any second opinions (and any advanced scans you can get). My original diagnosis was similar to yours and I went with RALP, but afterwards learned the PCa was in adjacent lymph nodes so EBRT and ADT needed too. Had the scan detected the lymph nodes earlier I would have likely avoided the surgery. I would add that the surgery side effects were tough for a few weeks, but I was back to 98% on all counts within 8 weeks. Had it been ‘successful’ I would have been very happy with the decision.
Posted 1/25/2019 5:11 PM (GMT 0)
PG & BB - Does Dr. Moran qualify as a radiation oncologist or is his background too directed towards brachytherapy? If not principally a RO, a dedicated RO should be consulted for an opinion without that bias if possible as suggested.

Not saying that brachytherapy is right or wrong in this case but bias is obvious with the urologists but not as easy to see between the different radiation camps. If you have the time, you can not see too many doctors nor ask too many questions to arrive at this difficult decision.
Posted 1/25/2019 5:24 PM (GMT 0)
Mumbo Dr. Moran is a radiation oncologist.
Posted 1/25/2019 10:27 PM (GMT 0)

Buddy Blank said...
Mumbo Dr. Moran is a radiation oncologist.

Yes. . . BUT.

An RO is not unbiased, either. Each of them fully believes in those treatments that they can offer a patient, and only in those treatments. If you want to learn about ANY of the radiological treatments, you MUST speak with a practitioner who offers that particular treatment. A doc who specializes in brachy will not be able to fully discuss IMRT; an IMRT specialist will not be able to fully discuss SBRT, etc.

So, my advice is to do some research here and identify any or all radiation treatments that could be appropriate for your pathology )which is probably most of them). Then do some reading about them and choose which might be of interest to you personally. Then meet with a practitioner who offers that specific mode of treatment and ask about their success rates, side effects, etc.

You don't mention where around Chicago you are located, but I could tell you the names of two SBRT (CyberKnife) RO's in the northwest suburbs. I met with both, chose one, and have been quite happy with the whole process and its results.

Also, if your pathology remains as a G3+4=7, I don't believe that the Standard of Care normally includes ADT. I'm not a doc, though, so there could be special cases where it is applied. . . but I am not aware of any.
Posted 1/25/2019 10:54 PM (GMT 0)
I had surgery because of urinary issues, which radiation can worsen. Otherwise I favor radiation because I think surgery is more of a threat to sexual function. But there a plenty of guys here who did just fine with surgery. The risk of secondary cancers from radiation are sometimes overemphasized and I wouldn’t let that factor in my personal decision.

Do your research, get multiple opinions on various treatments from practitioners in those fields, then decide. Do NOT rush. You have time for an informed decision.

Keep us posted.
Posted 1/25/2019 11:00 PM (GMT 0)
Paxton - I forgot about the CyberKnife RO’s, they tend be biased as well. The oncology group that I went to has all the radiation options available except for photon. The RO I visited seemed to be conversant in all of the methods but probably has a favorite also. Can’t eliminate all bias but you can try.
Posted 1/25/2019 11:03 PM (GMT 0)
Cyclingthe50, I was diagnosed at a 4+3 by two labs. I did some research and decided for surgery. Once that decision was made I also decided that regardless of what happened or what more I learned I wouldn't 2nd guess my choice and live with regrets. The followup decision was where to have it done and I went to Cleveland Clinic. I live in the largest city in Montana but it is still a small town. A friend who is a doctor at the hospital went out of state for his RALP and told me that he didn't feel like they had enough experience here. My uro was OK with that.

As for recovery from RALP, I'm a runner and it was at least 3 month before I could get back to running due to some slow healing of the anastomosis but at the 6 month point I was back up to my weekly 8-miler.

I haven't been on my bike since before the surgery, only because once I felt like could the weather changed. I have read that 6 months is about the time it takes before bike riding is recommended. That area tend to be sensitive for a while.
Posted 1/26/2019 1:13 AM (GMT 0)

ASAdvocate said...
The more advanced forms of radiation, such as SBRT and protons have recent studies showing recurrence rates of less than 10 percent for your pathology.

Whatever you decide, good luck to you.

Also take note of what the authors of these studies do for a living. That doesn’t get a lot of press. And who knows, maybe it doesn’t need to.

Personal life circumstances can also influence one’s decision. It did mine. Had I had a crystal ball showing me what surgery had in store for me, I’d have chosen proton. There’s a proton place right near me.

I think you’ll be ok with your cycling goals no matter what you choose. One man’s opinion.

Good luck to ya man.
Posted 1/26/2019 11:55 AM (GMT 0)
Check out this thread about cycling after surgery. Most people don't have to wait 6 months to get back on the bike.

https://www.healingwell.com/community/default.aspx?f=35&m=3756713

Post Edited (fiddlecanoe) : 1/26/2019 4:58:47 AM (GMT-7)

Posted 1/26/2019 2:14 PM (GMT 0)
I posted a while back about cycling after surgery. Just turned 64 in 4/13 when I had RP. Spend all of May walking, then cycling in june. Flew off to Munich July 4th for a 2 month cycle tour. We spent 55nights straight in a tent with no problems. 3800kms/40,000m vertical. Easy peasy.

If you are in good shape before your treatment, healing will not be a problem.

Dave
Posted 1/26/2019 3:21 PM (GMT 0)
I third, (or whatever we're up to) Santa Zia. PC is a killer but a very slow killer. This is not time to rush.

My Johns Hopkins biospy pathology report came back slightly more favorable than the original path. I had FOCAL HIFU in 5/2017. Just had MRI and was told no need for a biopsy, just PSA every 3 months and another MRI next year. But the radiologist at North Shore had a very different opinion than the radiologist at UCLA. If I followed the first MRI radiologist report I was looking at re-treatment, radiation or surgery.

Take your time and get all the info first.


SantaZia said...
Cyclingthe50 I would continue to try to understand my PC a little better prior to selecting a treatment. This might include a second opinion on your biopsy, John Hopkins is good, covered by insurance or $250. Also a T3MRI will give you the big picture. Here is a good article on that: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32401-1/fulltext I had a couple of genetic tests which I think were very useful. There are a lot to choose from. It sounds like you have a great surgeon. If he can do any nerve sparing you might be able to get on the road quicker than ADT and radiation. Of course, you will have a little incontinence, but it should go away. if you qualify for the shorter SBRT or AS that would be great too. However, if you need ADT and a traditional EBRT I can tell you it will take a while to get your energy back. You want to make sure you kill the cancer as recurrence happens 10 years down the road if you don't. The decision making is yours and you will need to take your time. I also recommend you read as much as you can including recent studies. The Key to Prostate Cancer https://www.amazon.com/Key-Prostate-Cancer-Experts-Explain-ebook/dp/B07C65VVNH It is well written and includes different views. Good Luck!

Posted 1/26/2019 5:22 PM (GMT 0)

Mumbo said...
Paxton - I forgot about the CyberKnife RO’s, they tend be biased as well. The oncology group that I went to has all the radiation options available except for photon. The RO I visited seemed to be conversant in all of the methods but probably has a favorite also. Can’t eliminate all bias but you can try.

Too true. I was unusually lucky in that the RO I chose could, in the same clinic, offer IMRT, Tomotherapy, SBRT and even could refer to a clinic for brachytherapy.

As I mentioned, if you are interested in northwestern suburban RO's, I can share names.

IIRC, Northwestern does not offer SBRT themselves, but they have a referral link to another RO downtown who has some capability - just not the AccuRay Cyberknife brand. I chose CyberKnife because I loved the RO, because they had a referral relationship with my uro, and it was convenient for me to get there for treatment.
Posted 1/27/2019 4:29 AM (GMT 0)
If you chose surgeory, I would chose RALP over open.

Dr Catalona, is probably one of the best open surgeons and is probably best known for being part of the team that discovered PSA but I feel RALP is superior and recovery is faster.

I can say that in Chicago area based on my research Dr Edward Schaefer is one of the best in the chicago area ( he performed Ben Stiller’s RALP) - he is the chair of NW urology.
Posted 1/27/2019 4:37 AM (GMT 0)
Both of your doctors are well known and are considered experts in their fields. You couldN't have picked better doctors. Now you have to pick one. Surgery and brachytherapy are almost equal, but brachytherapy should have less short and long term side effects. The best for cancer control would be combo brachytherapy and External radiation with or without HT.
Posted 1/30/2019 11:44 PM (GMT 0)
Folks, I'm blown away by how helpful everyone's comments have been. This is truly a great resource and I am deeply thankful to everyone for sharing your very insightful thoughts. I was particularly encouraged to see that Ben Stiller went through the same thing as we all did.... smile

Very interesting comments on RALP. Dr. Catalona provided me a packet of materials disparaging robotic (Da Vinci) surgery. I suppose that since he is a strong believer in open surgery by very skilled surgeons that open is better in his mind. That said, Dr. Moran (my RO) actually mentioned that if I was going to consider surgery that I might want to talk to Dr. Schaefer at NW (whom ddyss suggested). So, that is helpful and actually makes me appreciate Dr. Moran's objectivity.

I appreciate the thoughts on getting a 2nd opinion of my biopsy. A number of folks have suggested that I send it to Epstein's lab at Johns Hopkins. However, the pathologist that completed my biopsy is Jimmy (Ximing) Yang who trained under Dr. Epstein and is known to be very competent.

My next step is MRI and a Bone Scan at Northwestern to get some more information to help with my decision making.

Dr. Moran's recommended treatment is a multi-modal treatment of IMRT combined with Bracy seeds. He would put me on the Casodex only for a couple months to soften up the prostate before radiation treatments and my understanding is that Casodex is not as severe as other forms of HT and it would be a short window that I would be on it. So, I'm currently leaning this way depending on what my MRI & Bone Scans show. I'm thinking that rather than endure surgery, if there is a question that any of the cancer has escaped the prostate the multi-model approach would be better anyway and I can mitigate some of the more concerning side effects of Surgery.....
Posted 1/30/2019 11:54 PM (GMT 0)
Cycling,

Great job of investigating, and listening to posters who have been through it. Not all of the new people coming through here take the time to explore their options. Somewhere down the line I think you’ll be glad you did.

Good luck
Posted 1/30/2019 11:55 PM (GMT 0)
It's always good to get to pairs of eyes on a biopsy sample, but Epstein trained is very good.

I didn't want surgery because of heart/lung risks and did IMRT. Worked for me and likely you'd be fine going that way. The combo is really a big hit at the PC. As long as everything is contained in the prostate bed - this method will get it all.

Keep us updated,
Andrew
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