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Posted 6/29/2019 3:13 PM (GMT 0)
I was diagnosed with Pc last week and my Urologist Oncologist explained to me that there were only two options in Colombia (south america): surgery and radiation therapy.
He explained both alternatives and gave approximately the same numbers and risks factors for both. Because of my age he recommended the surgery and told me that if there was a recurrence it could be treated with RT. He did explain that there was also Brachytherapy but that if there was a recurrence surgery would be out of the question. any thoughts on my journey? I just got a new job and would start on July 28. I am in a bind on making a decision. Is brachytherapy more precise and reliable today than 5 or 6 years ago?

Age 58 Psa 1/19 - 3.14 Psa 6/19 - 2.12
DRE abnormal(lump left side) lump grade from MRI PI_RADS 5
Gleason 6 on 6/12 cores positive %10 40 % 60 40 %70 30
prostatic volume 21cc

Post Edited (C.H.) : 7/4/2019 4:53:27 PM (GMT-6)

Posted 6/29/2019 3:27 PM (GMT 0)
I posted this to you in the other thread:

"CH my advice is take your time, see several doctors (surgeons and radiation oncologists, that specialize), and educate yourself on the various treatments available, then decide."
Posted 6/29/2019 4:23 PM (GMT 0)
I'm sorry to hear about your diagnosis. You were told exactly what I was told when I was diagnosed in 2012. What your urologist is saying is technically true, but also a bit misleading. First off, he's right that both surgery and brachy would have the same (excellent) chances of curing you as a Gleason 6. As for side effects, the side effects are typically different between the treatments--that's an area that you should research.

Here's the misleading part: yes, it's true that you can have radiation after surgery and not the other way around. But, there are other secondary treatments if brachytherapy were to fail--it's just that surgery is not one of them. In other words, you don't get two chance with surgery and only one chance with radiation. You get two chance with both. Also, as a Gleason 6, your chances of a cure are so good that you are quite unlikely to need secondary treatment anyway.

I agree with the comment above that you should talk to multiple specialists--PCa is very slow moving so you have lots of time to do so. My experience here is that after doing so most people are naturally drawn to one treatment or another. Also, there are two types of brachytherapy--low dose radiation (LDR), which uses implanted radioactive seeds and high dose radiation (HDR), in which the radiation is inserted and withdrawn. LDR is more common (but not necessarily better)--I don't know what options you have with that in Columbia. Good luck to you and I hope we can help!
Posted 6/29/2019 5:49 PM (GMT 0)
Michael T and Buddy Blank
Thanks for those soothing words. They help easy my mind from the doctor's recommendation talk(YOU HAVE TO DO IT SOON A MONTH OR TWO AT THE MOST!) for a decision.
I am partial to the LDR but I don't think it's available near where I live. So I will take my time and find a hospital in Colombia with experienced oncologist which offers brachytherapies. Thanks again.
Posted 6/29/2019 6:05 PM (GMT 0)
If you are a true Gleason 6, I don't think you have to do it in "a month or two at most" - but get a second opinion. This is your life, and the side effects from surgery can be brutal physically and mentally, with many men needing more treatment post-surgery. My thinking was why do surgery, and then perhaps need radiation, and hormone therapy, and suffer the side effects of all three.
Posted 6/29/2019 6:09 PM (GMT 0)
Also, if you decide on some form of radiation, and it is not available in Columbia, perhaps you can travel to have it done. Of course, I don't know your financial situation, or what kind of financial resources you have available, but, as I said, we are talking about your life here, and your quality of life post-treatment. The thought of impotence, incontinence, and perhaps both, was almost as scary as the diagnosis of cancer to me. Sexual potency is part of being a man, a big part.
Posted 6/29/2019 6:31 PM (GMT 0)
It is very important you check the experience of the surgeon/RO who is going to treat you. For instance, it is advisable your surgeon has already done about 1000 prostatectomies with the same technique. You will find good technical, though not professional, advice here, but you should also check locally, speak with other people who have been treated in the same place you plan to do, etc. Gleason 6 is the best possible diagnostic but it can be upgraded and the amount of PCa in the biopsy is not small. Maybe what your doctors say about treating you promptly is right. In any case, calma y mucha suerte.
Posted 6/29/2019 10:37 PM (GMT 0)
C.H. when you say surgery, do you mean Davinci robotic surgery or open surgery? I assume robotic but maybe that is not what your doctor is talking about. There is a very big difference.
Posted 6/30/2019 3:08 AM (GMT 0)

Argent said...
C.H. when you say surgery, do you mean Davinci robotic surgery or open surgery? I assume robotic but maybe that is not what your doctor is talking about. There is a very big difference.

No difference in outcome, though. Mine was open surgery. Catheter time shorter with robotic (1 week versus 2-3). Bigger scar with open. Usually zero concern, but scars don't all heal the same way, so smaller the better (robotic). There is an argument that open is better where they can see everything with their own eyes. I'd probably go for robotic if I had a do over,. But ONLY if surgeon is very experienced with it. I've heard of not-so-nice complications with robotic in public health scenes where the surgeon isn't particularly experienced with the method.
Posted 6/30/2019 3:50 AM (GMT 0)
So what if surgery is difficult or impossible after radiation? There are several other treatments available in the rare event of a failure of primary radiation.

https://prostatecancerinfolink.net/2017/09/05/salvage-focal-ablation-for-radio-recurrent-prostate-cancer/
Posted 6/30/2019 4:28 AM (GMT 0)

ASAdvocate said...
So what if surgery is difficult or impossible after radiation? There are several other treatments available in the rare event of a failure of primary radiation.

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

I wonder if those treatments are available to him? my preference would be a treatment that hits the prostate and the prostate bed but that's not one of the choices. I know he's G6 but is he really, and he has a 60% and a 70% core.
Posted 6/30/2019 10:28 AM (GMT 0)
CH, My suggestion is to find yourself the most experienced doctor and medical team you can get to, and go there. There are fine doctors all over the world, and I'm sure there are many in Colombia.

From and outcome perspective, brachytherapy and surgery would give you similar opportunities for cure, and at G6 or possibly G7, that's a basic point. Your odds of being what we call once and done are very high. If they are doing robotic surgery there, make sure the surgeon has done many procedures--there is a steep learning curve for learning the robotic method, and you don't want to be one of the patients the doctor is learning from.

Surgery probably creates a higher likelyhood for unpleasant side effects, the most dominant being ED and incontinence. Many men (I'm one) came out of surgery without significant issues....but there are some who end up with a lifetime of problems from the surgery. It's always good to ask the surgeon about his or her experience...most will share their personal statistics.

Regardless, get yourself to the best, most experienced doctors you can find. Come back and keep us involved, we are here to support you.
Posted 6/30/2019 12:37 PM (GMT 0)
Thank you all for your expertise in the matter. I am taking in all your advice and will try to find the best team possible. I've just read about the HIFU treatment and there two treatment centers in Ecuador. Maybe that's another alternative. My mind is all over the place. But as HALBERT points out, whatever treatment I choose should be done by experienced doctors. Here in Colombia, technological advancements and training from elsewhere in the world usually lag behind by 5 to 10 years and so my worries lie in the area of experienced doctors with the latest techniques and equipment. Have to wait to get bone scan on Tuesday since this Monday is another frigging holiday. (We had another one last Monday land will have one on July 20). I'll have to pay it because if I wait for my insurance it will take months for the results. Just like the pathologist results which took 1 month of calling and begging. thank you all for your support.
Posted 6/30/2019 1:32 PM (GMT 0)
HIFU has been used in Europe and elsewhere for awhile. It did not have approval in the US 4 yrs ago for prostate cancer treatment when I was treated, and I'm unclear if it does now. I think it is approved for treatment of some conditions in the US. Others more knowledgeable than me can chime in. The studies I saw of HIFU when I was researching treatments at the the time (which I would've needed to do outside the US at the time if I wanted that) did not seem to make it a clearly better choice than either radiation or surgery.

I go along with the post by Michael T. Comparable results seem expected from surgery and radiation, while radiation is less invasive and an easier recovery. Also thought radiation was better for side effects. And if you decide on radiation there is then figuring which form. LDR is found more readily in the US. HDR is available in fewer places, but it was what I decided on and had to travel for at the time.
Posted 6/30/2019 3:08 PM (GMT 0)
CH - There appears to some resources in Columbia from a quick internet search.

http://centrodecontroldecancer.com/radiation-oncology/

A quick read indicates that they are using current radiation technologies if that helps you.
Posted 6/30/2019 6:56 PM (GMT 0)
Why is PSA going down from 1/19 4.1 to 6/19 3.2 PSA ? I would do nothing till your biopsy slide are checked for a second opinion. Definitely with a GL 6 there is no hurry. I would be very suspect of the URO trying to hurry you. Get a second opinion on the slides first. Read the sticky thread at the top of our subject. You may be a candidate for AS.
Posted 6/30/2019 7:13 PM (GMT 0)
Oldbeek, thanks for your optimism. The URO did ask me to get a second opinion of the biopsy slide with a pathologist he recommended. As for being a candidate for AS, the URO did a DRE and looked at the MRI images on CD and showed me that the nodular lesion he felt was very close to the capsular lining. Lesion is category PI_RADS 5.
Posted 6/30/2019 9:53 PM (GMT 0)
My opinion is to find a best surgeon and go for the robotic removal. Good luck
Posted 7/3/2019 2:49 PM (GMT 0)
My advice is get BT at the best center you can afford. I had it one month ago, no SE's, and PSA is undetectable.
Posted 7/4/2019 10:52 PM (GMT 0)
Good afternoon everyone,
Today, I got a second opinion from my urologist from my health care provider(I had gone to a highly respected private Uro oncologist last week who recommended open surgery.) and he recommended active surveillance since he believes that at gleason 6 and psa at 2.1 it is better to wait and not deal with the SEs at my age. If there are any changes as it is monitored, then we would look at the different options. He suggested a board meeting with the other urologists in the hospital, so I could have everyone's input and make a decision. And I am getting a second opinion on the slides to take them to the board meeting. I was somewhat relieved since yesterday I had a meeting with the RO and he recommended to start today with HT (eligard 45Mg) so he could do BT and IMRT in December. info overload.
Posted 7/4/2019 11:43 PM (GMT 0)
CH,
It's good that you are G6, but you have a lot of positive cores, some with high volumes, and a palpable nodule - which probably precludes long term AS. You will likely need treatment eventually, but you seem well within the cure zone. Definitely have your biopsy verified. There is plenty of good news with your diagnosis.

At this point I like the doctor's advice who recommended holding off on treatment until you can get more information on your situation.

It is an information overload but you're doing a great job of going about this methodically. Take a deep breath and continue taking the time to get it right.

Good luck and keep us updated.
Posted 7/5/2019 12:14 AM (GMT 0)
C.H. - It sounds like everyone is in a hurry, maybe that is the Columbia medical way? My urologist told me to make a decision in a 3-4 months but not to delay it much more than that. Get the second opinion on the biopsy pathology as recommended then make you can make some decisions based on those results.

I think that the proposed "Triple Play" of HT, BT, and IMRT might be a little overkill for your current situation. Maybe some others here with more radiation experience can provide some comments. You may be able to use just 1 or 2 of the radiation treatments (also consider SBRT if available or look elsewhere) and skip HT. Just a guess on my part based on what I have read but your situation may not warrant "over treatment" at this point.
Posted 7/5/2019 9:20 AM (GMT 0)
With a PIRADS 5 and many cores in biopsy I would not try AS; Gleason 6 is many times upgraded. Either combo radiation or surgery would be OK. But your doctors can evaluate your particular situation much better than us.
Posted 7/5/2019 9:41 AM (GMT 0)
In the US, at least, there are clearly defined protocols for AS, and they include a follow up biopsy within a few months--usually a so -called saturation biopsy (where they take many more than the standard 12 cores), along with regular PSA and digital exams.

Based on what you've told us, your odds of staying on AS for very long are not great--but the AS community would say that even 6 months is a win. I would hope that proposing AS to you is not code for "we are going to save money by not treating you until it gets a LOT worse". I would suggest you try to get a written AS plan or the protocol they follow for AS there--just so you know what the actual steps and action points are.
Posted 7/5/2019 12:21 PM (GMT 0)

halbert said...
In the US, at least, there are clearly defined protocols for AS, and they include a follow up biopsy within a few months--usually a so -called saturation biopsy (where they take many more than the standard 12 cores), along with regular PSA and digital exams.

Those protocols for AS don't exist in Australia .... up to the patient/urologist ..., so may only be a US thing. Something for C.H to check and be sure on in Columbia if he goes this path.
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