RALP or Radiation? CA/WA surgeons?

After 3+3 1 core T1c diagnosis in 2015 & 2016, I elected to get a 12 core biopsy Oct 2019- after seeing my PSA increase. Biopsy 3+4 in 1 core, cribriforming pattern 4; 4mm length. Pathology suggests small tumor on one side with in the Left medial base with no extensions, lymph nodes, METs. MRI says confined to 74ml prostate. So, after a 4 year AS, my SD Uro says I should be looking at treatment in 3-6 mos, but says radiation with maybe a short interval of hormonal therapy, has the same cure rate.

I read that surgery is the gold standard for small organ confined tumors. Apparently my prostate is too large for brachy right now and I am not sure I want to shrink it to under 60ml - if it takes too much time. I want a long term fix and to treat it early enough so that "one and done" is a real possibility, without eliminating other treatment methods down the road if need be.

Given my age 63, I think it's time to get off the AS train and take action.

Except for recent renal cell carcinoma nephrectomy Stage 2 in April 2019, and resulting kidney disease GFR-CKD 3 that requires being more food conscious, I'm healthy. Heart & circulatory are near perfect w/o meds, no hx of treatment, no smoke, normal Ht and Wt. Active lifestyle. BPH affects urine flow, urgency and frequency about 30%. No prostate treatment other than flomax for 5 years. Tried proscar but hated loss of libido and some ED issue so gave it up.

Family longevity is crap: Father had kidney cancer early 60's, morbidly obese, died of heart attack age 71. Mother died from phen fen diet drug induced pulmonary hypertension Age 64. Very small family with 1 sister died A49 of unexplained sepsis, other 2 siblings fairly healthy w/no cancer. Prior gen of relatives are few in number with -50% living to 80+ and 50% dying before age 65.

I have a great wife who would support any decision. We both agree treatment is best and think RALP based on my age, small tumor. I have read that Radiation is usually done on older patients which I believe is because doing a RALP first allows for radiation whereas radiation first, makes a secondary prostatectomy more difficult and unlikely. I am interested in what other members experiences are here.

Finally, my adult kids are in San Diego as is my current well known Uro surgeon. He is skilled with a lot (2000+) RALPs to date. Regardless, a second opinion in the CA region is of interest. Who should I contact?

Lots of good doctors in CA. Can’t help much since I don’t live or been treated there.

I can attest that surgery can help with urinary problems with the principal caveat being that sometimes it helps too much thus the continence issues you read about. I can also attest to the surgery being a little more rigorous than advertised for me. I had the catheter out at 10 days, was continent right away, and met with my Uro about 10 days later. I told him that I did not think I had significant urinary issues previously but was peeing much better after surgery. He said he hears that from many older patients. Mine was just over 60g if that helps any.

Tough decision for you. The main stated reason for radiation over surgery over 70 is that surgery gets more risky the older you are whereas radiation is a pretty constant risk. Some surgeons just stop at age 70 as a matter of policy. The flip side is that radiation can aggravate existing prostate issues so that should be considered. Both should “cure” the PCa you appear to have but no guarantees with PCa.

Welcome to HW.

You should consult with an RO to discuss your options for beam radiation - SBRT might be something to look at. UCLA has a great program (Docs mentioned above).

Either surgery or RT should be curative in the first instance for you. The choice of treatment should be based solely on what will work the best and be curative in with the first treatment. Don't worry too much about backup plans right now.

Surgery is sometimes better if you're having flow issues, but it's difficult if you have other medical issue that might complicate surgery. There's a lot of cutting with procedure and healing can take time. There will be side effects. Most go away in a few months, but some can hang on for a long time.

Radiation avoids the trauma of surgery. It has its own less than fun side effects, but is often tolerated well. In your case some kind of beam radiation should be doable. RT is also slower in showing results. In the event of failed RT, there are salvage backup methods (surgery isn't one of them), but you don't hear of a lot of failed RT.

and remember that surgeons recommend surgery and ROs recommend radiation. Don't listen to a surgeon about RT or an RO about surgery. Get opinions from a couple of docs and you'll have to decide on your own what to do.

I suspect that you'll find it difficult to find clear objective reasons to pick one over the other and that even the docs will disagree. In the end it often comes down to what you feel the best choice for you is (or what you feel most comfortable doing).

I wanted to avoid surgery as I have some heart/lung issues that would have made surgery difficult for me. I ended up doing IMRT radiation and the long term effects have been some bowel issues and urgency. You'll hear similar stories from the surgery guys.

Do your research and keep us updated on your progress,
Andrew

MichaelT said "Nor is radiation just for older patients, although older patients generally aren't as well suited for radiation."
I wonder if he meant to say older patients aren't as well suited for Surgery?

All great observations from previous posters. I would just add that for many/most patients it may seem intuitive that surgical removal of the tumor would be more effective than showering it with mysterious radiation beams. Not so. Either method will kill it dead.

Good luck with whatever you choose!

mattam...thanks for pointing that out. I fixed it!

I'm waiting for biopsy results but according to the MRI, I have a RAD 4 lesion so more then likely it is PC. I would like to have surgery but I'm 74 so not sure if he will do it. Two months of radiation scares me. If I can, I will go with surgery and take my chances with side effects.

62gal...I'd like to encourage you to start your own thread since I think you'll get more replies than being part of this thread. And hopefully you don't actually have PCa. Regarding your comments, 74 is typically older than most for surgery, but we've had some guys here that were in their 70s. As to radiation, there are treatments much shorter than two months. SBRT is five days and brachytherapy is generally one day. Wishing you luck while you wait for the biopsy results!

Suggest you gather up your records and make an appointment with Dr. Chris King at UCLA. He's a radiation oncologist, and will give you as good advise as possible about all treatments. As good as they come!

https://www.uclahealth.org/christopher-king

Aloha,
I really think this platform is superb and appreciate all of your thoughtful replies. Thank you all. I am learning a lot by reading your personal journeys and replies.

I've thought about this a lot after reading some really good books on the subject, first and foremost "Surviving Prostate Cancer" by Patrick Walsh.

Some more observations and thoughts:
Given my renal cell carcinoma (Stage 2- organ contained) was removed March 2019, I am aware that despite the 85% 5 year survival rate for this Sx, it could come back. The last thing I want is to wait on my PCa as I don't want to fight two fires at the same time.

My enlarged prostate has no doubt been the cause of my BPH-urinary issues (mainly frequency) for 6-7 years. Radiation wouldn't resolve this would it? Would Radiation require that I deal with this with first-how?

Also, the Partin tables in the aforementioned book surprised me. Based on my PSA 6.8, T1c, G3+4, the retro study of 5700 patient pathology study, I have only a chance of 59% of the tumor being organ confined, 32% chance of an extraprostatic extension. 8% Seminal vesicle involvement, 1% Lymph nodes. I went on AS with 3+3, PSA under 5 for 4 years. It is simply amazing how once the G score goes from 3+3 to 3+4, how quickly these percentages decrease. My MRI said no extraprostatic extension but I am not counting on anything.

I'm definitely going to get an RO opinion/reco (ask about HDR brachy) despite leaning toward surgery right now. And I will make a call to UCLA & UCSF- get them my MRI and and pathology dx for a second opinion. Asking the surgeon how many RALP sx he/she has done, how his RALP patients are doing 3-4 years later, how often are the surgeons margins positive, and how often his/her patients require radiation tx after surgery are some of the questions I have.

Then decide. I can only address problems that exist.

With surgery the side effects are immediate. Better know what happens if you can't get erections. Dr said I was organ confined (City of Hope) during surgery removed all my nerves. Shrinkage starts immediately without nocturnal erections. Nothing is better than a blood filled erection. If you don't enjoy them, have at it with surgery. Injections may work for you but they caused a bend at midship to the right, so had to stop them and go to implant. Implants are not that great. Guys that have them for plain ed still have gland engorgment. With nerves gone you have a 3/8 inch inflatable garden hose inside a piece of dead meat. Plus side is, it does look good when flaccid. Not much feeling though. Oh, I forgot , urine leakage at time of orgasm. That is a real turn on for your mate.

>>Also, the Partin tables in the aforementioned book surprised me. Based on my PSA 6.8, T1c, G3+4, the retro study of 5700 patient pathology study, I have only a chance of 59% of the tumor being organ confined,<<

our numbers were similar. I had a 60% chance that the cancer was out of capsule so my urologist recommended against surgery and I am in my ninth year of remission. I have never been incontinent and I get full erections with the aid of Cialis.

Although I have no personal experience (not with treatment for this cancer anyway) several guys in my local support group have gone to Dr. King at UCLA and think he's tops. If you want to speak to a very experienced surgeon I'd recommend Dr. Clayton Lau. He's the top guy at City of Hope and I had a consult with him last summer and think highly of him.

Hello KB. Sorry I missed you when you first appeared several days ago but I want to welcome you and wish you the best as you make this critical decision. First of all, please allow me to debunk a few myths that were in your original post:

1. Myth #1. Surgery is the "gold standard". That was true at one time but is true no longer. Modern radiation techniques provide equal opportunities for cure but with a lower chance of the onerous side effects of ED and incontinence. Noted prostate oncologist, Dr. Mark Scholz says of this gold standard issue, "Thank God we are off that gold standard".

2. Myth #2. Your prostate is too large for brachy. That is true for LDR Brachytherapy unless you want to take the time to shrink it. However, that is not true of HDR Brachytherapy which has been shown to be effective in treating PCa in patients with large prostates. Others have also mentioned SBRT which would seem to be an excellent option for you as well.

3. Myth #3. Radiation is for older patients. That was true many years in the past when it was thought that surgery in men over 70 was problematical so radiation was the only choice. With today's radiation choices many "younger" men choose it as well both for the curative effects as well as the chances of fewer side effects than surgery.

4. Myth #4. There is no additional treatment after a failed radiation, i.e. you can't have surgery after radiation but you can have radiation after surgery. It is true that surgery after radiation is problematical but...there are additional potential treatments after a failed radiation that are equally successful as radiation after a failed surgery. Get info on this from an experienced RO not your urologist.

Having said that, you mentioned getting Dr. Walsh's book and that's a good idea albeit mostly info from a surgical perspective. For balance I can suggest Dr. Scholz' book, "Invasion of the Prostate Snatchers" or his newer book, "The Key to Prostate Cancer".

Anyway, I seem you are now committed to getting opinions from RO's and assessing those options. That's a great idea. Please remember that RO's tend to be specialists so you may need to an HDR Brachy doc as well as an SBRT doc to get the full picture.

Finally, I will just stress that you need to clearly understand your own priorities as you make your decision. If "getting it out" and getting an immediate and clear understanding of your pathology is critical to you then perhaps surgery is the right choice. If quality of life is a high priority then one of the radiation options may be right for you. With your pathology, cure should be a given so make sure your decision considers the other variables.

Good luck and remember we are here to help however we can.

Jim