HealingWell
Search Close Search
☰

Brachytherapy - Robotic surgery, maybe Cyberknife _HELP !!

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 1/22/2010 8:53 PM (GMT 0)
hello - 1st time posting here -
diagnosed 4 months ago - PSA - 7.3 - Gleason 3+4

12 samples taken - 9 positive
59 years old
very active - play hockey weekly etc - 5'10" 168 lbs -
no illnesses at all
1st Dr recommened -nomal surgery - he said not a good candidate for radiation - would require hormones etc
2nd Dr a Ct Dr that specialized in Robotics says - do the Robotics - not a good candiate for radiation
3rd Dr a radiation specialists say I'm a perfect canditate for radiation
25 treatments over 5 weeks - 2 weeks off then the seed implant
Now I'm more confused - So i am going to see Dr Cardinale in New
Haven for a 4th consultation. they do everything there. I am especially interested in the Cyberknife after reading about it .
Any thoughts or opinons on what I have written - I was originally going to go with robitics but now it appears i have other options and maybe non surgical

Thanks allot...

Post Edited (dbros9) : 1/22/2010 2:19:58 PM (GMT-7)

Posted 1/22/2010 9:08 PM (GMT 0)
Dbros,

Not sure of all your stats, such as how many samples taken and how many positive for cancer.You might want to add those to your signature. I still enjoy athletics and run and Mtn. Bike so I chose Robotic surgery due to the possible quick recovery time. My surgery didn't go that well so it was a couple of months before I could exercise and I probably could have taken another route. However, I knew I wanted the prostate gone due to enlargement and so I chose surgery. You will hear a lot from people telling you to educate yourself to the fullest and I will be the first to say that is exactly what you want to do. Some of the old timers know some good books to read. My urologist gave me one that helped me look at all of the variables before making a choice. In the end I thought I did what was right for me and it was with another Dr. since my urologist did not do robotic surgery. Good luck and keep us posted and hope your back to playing hockey quickly.

Michael

Posted 1/22/2010 9:17 PM (GMT 0)
Did your doctors tell you why you were not a good candidate for radiation? There are only two reasons I can think of; 1. you have current urinary issues that radiation would make worse or 2. that the pc is already beyond the margin, and in that case surgery would not work either.
Either surgery or radiation would be a good choice, since their cure rates are equal, you have to concentrate on what side affects you are willing to accept.
Cyberknife would not be recommended as it is designed for very small tumors in hard to get at places where the tumor can clearly be seen through imaging. It has no proven results in treating prostate cancer as you are usuall dealing with a large tumor or tumors in many places throughout the prostate.
JohnT
Posted 1/22/2010 9:19 PM (GMT 0)
Dbros:

You might want to check out protonbob.com, read Marckini's book and possibly contact him.  Best of luck.

Dutch

Posted 1/22/2010 9:21 PM (GMT 0)
Sorry to hear about your diagnosis. The bright side is that you have found this place, which is full of knowledgeable and helpful people. I am pretty new here, but I have already learned a lot. (I do not have prostate cancer but I am interested because my father died of the disease and I have some high risk factors -- in the process I have read several books and a couple of hundred articles about various aspects of the disease, and I generally try to keep abreast of research developments). One thing you might consider is to consult with a medical oncologist who specializes in prostate cancer. There are fewer of those than you might think, but all you need is one really good one. People here can give you some names (or I can), if you tell us where you are located. Naturally (I suppose) surgeons tend to like surgery, radiation oncologists tend to like radiation, the hospital that just spend a ton of money on a cyberknife machine likes cyberknife, etc. Some of that is, of course, about money, but it is also about people believing in what they do for a living. In any event, medical oncologists may be more neutral between initial treatments, since they generally don't do surgery or radiation oncology. So you can get a less biased view. Of course, "unbiased" is only good if it comes along with great knowledge, which is why I suggest going to one of the medical oncologists who specializes in prostate cancer. Another option that some hospitals offer (particularly leading academic medical centers) is a panel of experts, where your case would be reviewed by a medical oncologist, a radiation onco, and a urologist - and often a pathologist too - and they would meet jointly with you and offer a joint recommendation -- which can help with the "everyone is telling me a different thing" problem you are facing (which, by the way, is very common). Your good physical condition should help you in recovery and dealing with whatever treatments you decide on. You might want to consider a good diet, if you are not already doing that. There is some evidence that diet can have an impact on the progression of p ca. That evidence is not as clear as some of us would like it to be, but there is enough evidence that it is worthwhile, in my opinion.


I wish you the best.
Posted 1/22/2010 9:24 PM (GMT 0)
the 1st doctor (specialized in regular surgery)is the one who did the biopsy - and he said my #'s were too high and i would need hormone shots etc for radiology/seeds -  the robotic dr basically said the same thing - the 3rd who specializes in radiologhy/seeds said no hormone shots and i was a good candidate - the 3 dr's were from totally different firms...
Posted 1/22/2010 9:28 PM (GMT 0)

thanks for al the comments so quickly - and yes if anyone has names of good medical oncologist's who specializes in prostate cancer that would be great. I live in southern Ct about 50 miles from NYC

thanks

Posted 1/22/2010 9:56 PM (GMT 0)
WIth 3/4 ths of your cores being positive, your current PSA, and being a Gleason 7 (and that's assuming you don't get upgraded), and factoring your age, I would reccomend surgery first. Then you will still have radiation available to you as a secondary curative treatment if needed. open or robotic, its all about the experience and skill level of your surgeon. You do have to factor in side effects and quality of life issues with any treatment you choose. All of them come with a price, no free ride.

David in SC
Posted 1/23/2010 3:50 AM (GMT 0)
Which Dr Cardinale will you be seeing? Dr Joseph Cardinal did my husbands seeding back in July of 08 and so far so good other than getting up at night more frequently in the past two months. He will take the time to talk to you and answer any questions you may have. We went armed with a list of things and our hour long appointment turned into 2 1/2 hours, he was very patient with us and answered everything we asked. He also gave us the option of talking to some of his past patients. At that time I believe he said he had 6 patients doing the cyberknife treatment for prostate cancer and did not recommend it for my husband due to his age which was 54 at the time. He said there wasn't enough data out there for him to recommend it but if it's what my husband wanted he would do it. We really liked him and told us to call him at anytime and we even had his cell number. Also, he did not push for radiation he simply gave us the facts on it.  

We also consulted with Dr Jonathan Bernie who is Chief of Robotic Surgery at Norwalk hospital. We liked him as well as he didn't push robotic surgery but did go over the pros and cons of it.  Do your homework and ask questions. Most people will tell you an urologist will push for surgery, that was not the case with us. We didn't feel pushed in any direction by any of the doctors.  We also had the slides sent to Jonathan Esptein at John Hopkins. I wish you well on whatever you choose to do.

                    

Posted 1/23/2010 4:53 AM (GMT 0)
Hello dbros9:

Five months ago I was about where you are now --  confronted with a difficult choice and getting varied opinions from solid professionals.  In all, I met with three surgeons, one radiation oncologist, my primary care physician, and a general medical oncologist.  The medical oncologist summarized his role as "not having a horse in this race", and I find that approach helpful as I discussed my options with him. In the end I settled on robotic surgery, which occurred in November and went well (so far at least). Essentially, there is no sure thing in any of this, and the ultimate and mosr important outcome  (to not die of prostate cancer) will  not be known for many years. 

Of all the materials I reviewed while considering my course of action  the referenced study and article below from the New England Journal of Medicine was by far the most helpful to me.

 

The study followed 1200+ men and their partners for two years.  Interviews were conducted before surgery, and at 2, 6, 12, and 24 months.  Respondents were asked to guage their "degree of satisfaction" with "Changes in Quality of Life After Primary Care Treatment" in five areas, including Sexual Satisfaction and Urinary Incontinence.  The results are graphed out nicely in Figure 1 in the article referenced below;  you can keep clicking on Figure 1 it to get it to readable size.

 

I found the results more than interesting, and not that surprising from what I had learned anecdotally on this Board and other locations. 

 

For example, the men undergoing Prostatectomy were divided into Nerve-Sparing and Non- Nerve Sparing groups.  After two years, 40% of the Nerve-Sparing group reported they were sexually satisfied; only around 20% of the Non-sparing group reported satisfaction.  The two groups were much closer on satisfaction with urinary continenece, roughly 80% and 70% were satisfied.

 

My personal choices, because of my situation, came down to Non- Nerve Sparing Prostatectomy (one bundle removed and told by all three surgeons that is what they would do)  or a combination of Radiotherapy + NHT (hormones) for six months.  Surprisingly (at least to me), the Radiotherapy + NHT group reported about the same level of sexual satisfaction as the Non- Nerve Sparing prostatactomy group (roughly 20%).  That helped tilt things for me towards surgery as I decided radiation had its own problems, hormones reportedly are not much fun, and either way the sexual  recovery part was going to be tough for me at best.  Better to know before hand.

 

Well, here is the article.  I found, and still find, the data fascinating if not exactly what I would have liked to read.

 

Best wishes in a difficult time.

 

 

http://content.nejm.org/cgi/content/full/358/12/1250

 

 

NewsPaper Lover

 

Age 66

PSA:  6.0  on 07/31/09 having risen from 4.2 on 12/02/08.  Free PSA 23.5%.Other PSA History: 4.3 on 05/01/08; 3.3 on 11/15/07; 3.1 on 05/20/07; 4.0 on 11/30/06; 3.40 on 09/01/05.

 

Biopsy:  09/04/09  13 snips;  two positive.  Right Mid  4+3 = 7 and 15% of the total volume.   Right Lateral Mid 4+3 = 7 and 20% of the total volume.

 

DaVinci robotic surgery:  11/05/09.  Post surgery pathology:  margins clean, no invasion of seminal vessels, no upgrade of the Gleason scores, no evidence of cancer outside the prostate capsule.

 

Cathether removed one week later:  11/12/09.  No incontinence.  Stopped pads after two days.  No problems at night.

 

Post surgery PSA:  Test scheduled early February.  That will tell a tale.

 

 

 

Posted 1/23/2010 4:59 AM (GMT 0)
I had 9 of 12 cores positive, all Gleason 4+3 or 3+4. Post surgery path was 4+5. DaVinci in Oct '09.

My urologist said do Robotic (DaVinci) because that is all he does. He offered an opinion from a partner who does only open. At that point the delta was pain and recovery time.
They sent me to a radiation oncologist who, after a $900 review, said I was a great long term hormone therapy + radiation candidate, and that they had a 70% success rate (with incredibly ugly side effects). Took about two seconds to write that off, reconsider, then make a final decision against it.
Now, with post-op multiple positive margins, it appears I chose DaVinci correctly. They took wider margins based on the on-site pathology - nerves too, so you won't see me on the ED threads
;-{
I still will have to do salvage radiation. but at least the biggest chunk is gone.
HIFU was not an option since my insurance does not cover it. They wouldn't even pay for a 12 core biopsy -
Posted 1/23/2010 12:48 PM (GMT 0)
I see over and over the positions of radiation first or surgery first on the forum. As a surgeon, I could not abide going for a non-surgical option, but that's just for me. I still do not see why anyone who ia a reasonable candidate for either option would not choose the surgical one first. That leaves radiation as a backup. The converse is not true without having a surgeon deal with the terrific desmoplastic reaction that radiation can cause. This increases surgical risk considerably and contributes to the radiation cystitis and/or colitis as side effects. Simply put: surgery is safer before radiation with that being left as an alternative measure if biochemical recurrence takes place. I feel much the same concerning robotics vs open. If one is a good candidate for either, why not go for the robot first understanding that all robotic surgeons also do open procedures if needed during the operation. The first thing I did in the RR was to feel what sort of bandage I had on my abdomen. When I found the band aid size, I knew things had gone well.

Just trying to learn the thinking here. The above assumes a fairly young man in good surgical risk category.
Posted 1/24/2010 3:15 AM (GMT 0)
There is a common misconception that there are no salvage techniques for failed brachy or failed external radiation. 1st the reoccurrance has to be local and not systemic for any salvage therapy to work.
There are salvage therapies available for localized radiation failure and their cure rate is exactly the same as salvage radiation after surgery.
Surgery is a poor option as a salvage therapy, but in the hand of a very experienced surgeon it can be done, but not recommended.
For failed Bracytherapy a patient can be reseeded with a different isotope than the original treatment. (Datttoli Cancer Center)
HDR Brachytherapy is established as a very good option for failed radiation.(PCRI website, search HDR Brachytherapy)
Cryosurgery is also an effective option as is HIFU.
All of the above salvage therapies are better options than salvage surgery.
The main reason that most patients choose Brachy or IMRT or Proton as a 1st line treatment rather than surgery is that the cure rates are similar or better than surgery (Prostate Cancer Study Group 2008) and the temporary and permanent side affects are much lower. This seems like a very resonable decision for many patients.
JohnT
Posted 1/24/2010 6:40 AM (GMT 0)

    DO THE SURGERY , YOUR YOUNG , AND YOU WANT AS MANY OPTONS AS POSSIBLE  KEEP THOSE OPTIONS open , YOU WONT BE SORRY

Posted 1/24/2010 1:25 PM (GMT 0)

Dear dbros:

Well, you have started to receive the surgery mantra from a number of well meaning posters but, please remember, this site is largely populated by surgery patients and you should not be surprised at their attempts to recruit you to their choice...each new surgery patient ratifies the decision they made.

While I seriously disagree with brainsurgeon's post on many levels, I do think his comments were helpful...he says, "As a surgeon, I could not abide going for a non-surgical option, but that's just for me. I still do not see why anyone who ia a reasonable candidate for either option would not choose the surgical one first."  I think this is ample evidence of the bias that exists in surgeons minds about the surgical choice and why you should not be surprised when your urologist-surgeon recommends surgery.  That is not true for all urologists, but many of them have this perspective.

As for cyberknife, I looked at that option and personally discarded it for the reasons listed in an earlier post on this thread plus the fact that there is not sufficient long term evidence of its rate of cure.

Also without seeing a more detailed look at your stats, it is hard for any of us to make an intelligent recommendation to you.  But, from with your G7 and number of positive cores, if you choose radiation the likely course of action is brachytherapy plus a course of external radiation.

Here is the deal.  Both surgery and radiation are likely to cure your cancer.  Both options have reasonable choices for backup if the orginal treatment fails.  The side effects of surgery are more onerous...IMHO...and that is why I chose radiation.  Qualify of life was important to me.  I also encourage you to read the NEJM article referenced by NewspaperLover.  He has conveniently summarized it as yielding pro-surgery conclusions.  I read it carefully before my procedure and reached a significantly different conclusion.

Good luck,

Tudpock

Posted 1/24/2010 1:47 PM (GMT 0)
Dbros, as you have learned, nothing is clear-cut when dealing with PCa. I don't envy anyone at the decision-making stage in their treatment.

As with almost any other cancer treatment, there are pros and cons. Some are obvious and some not so. Some will show up right away (as with surgery), and some may take years to develop (or not - depending on the person).

I found the attached article on Livestrong (Lance Armstrong's website) about the long-term effects of radiation treatment for prostate cancer. I have heard many say that radiation does not carry the same risks for incontinence and ED as surgery but the attached article has a different take. The difference in my mind is that surgery almost always has some degree of incontinence in that some men may leak for a few months, some may leak for years, and some many not leak at all. ED as a side effect of surgery may or may not happen, regardless of whether the surgery spared the nerves or not. Radiation, on the other hand, may have more subtle side effects down the road. Do not take this to mean that I am against radiation - it is an excellent and viable treatment option for many, many men. My husband was offered radiation as a treatment option but was cautioned against the long-term side effects. Even a radiation oncologist confessed that they simply don't know what radiation does the body over the long term.

A quick story to illustrate my point: I work for a children's charity - we deal with kids with cancer every day. We currently have a 17 year old boy who was treated for osteosarcoma (bone cancer) which had spread to his chest. He was treated out of a major cancer center in the northwest. Radiation was given to the chest area to kill the tumor - it worked. about four years later, this young man found out that he had AML (a form of leukemia) likely brought about by the radiation (he was told this by his oncologist). Now, does that mean that he shouldn't have had the radiation - no, of course not, as the metasticized osteosarcoma would have killed him.

Here's the link I promised...http://www.livestrong.com/article/52086-longterm-side-effects-prostate-radiation/
Posted 1/24/2010 2:53 PM (GMT 0)
In defense of the two urologists that I consulted, they both asked on multiple occasions if I wanted to consider non-surgical options. I made up my mind to have a visit with the robot as soon as my biospy report was in and was in no mood to consider otherwise. Other folks may not agree with this. To me, radiation would have made me very apprehensive to consider surgery as a salvage. Radiation makes tissues distorted and scarred. Operating through such tissues is fraught with dangers. Therefore, surgery first, then radiation as a salvage treatment second. The opposite is not a good idea. Radiation negates the possibility of a safe and complication free surgical treatment.
Posted 1/24/2010 3:42 PM (GMT 0)
As a non-surgeon and engineer, I agree whole-heartedly with brainsurgeon. In my work, I look for the "robust solution" - one that does not compromise the feasibility of a backup plan should it not work as well as I'd like. For PCa, the "robust solution" is surgery, as there is always the possibility of salvage radiation. Salvage surgery following radiation therapy may be possible, but its safety and effectiveness are not very well demonstrated.

None of this means that going rad first is wrong. Everyone needs to come up with his own solution, incorporating input from knowledgable people. Best wishes - my own decision seemed simple, but it's not so for everyone.
Posted 1/24/2010 6:09 PM (GMT 0)
<<and yes if anyone has names of good medical oncologist's who specializes in prostate cancer that would be great. I live in southern Ct about 50 miles from NYC>>

 

 

You could try Howard Scher at Sloan Kettering:

 

http://www.mskcc.org/prg/prg/bios/61.cfm

Or Daniel Petrylak at Columbia University Medical Center:

http://www.cumc.columbia.edu/dept/medicine/oncolhema/faculty/293.html

Posted 1/24/2010 6:10 PM (GMT 0)

Brainsurgeon and MaxBuck

I refer you to JohnT's post wherein he describes post radiation salvage treatments.  This myth that persists re that there is only back up treatment if you first have surgery is BS.

Tudpock

Posted 1/24/2010 6:15 PM (GMT 0)
BrainSurgeon and Max,

You continue to state that salvage surgery is not viable for failed radiation. That is true, but you are misssing the point. There are OTHER salvage techniques for failed radiation THAT ARE JUST AS EFFECTIVE AS SALVAGE RADIATION AFTER FAILED SURGERY. You are both implying that only surgery as a 1st line treatment gives you a 2nd chance and this is totally untrue and misleading.

As far as a robut solution: a combination of seeds and IMRT gives a total radiation dose of about 130gy,
(85gy for seeds and 45gy for IMRT). This compares to 65gy that was the standard for external radiation 10 years ago. The newer treatments with image guided technology, and sculpured rays are much more accurrate and precise and will treat margins up to 15mm and all the prostate tissue that a surgery would have left behind. The chances of a local reoccurrance are small and most reoccurrances are systemic.

There are a number of good reasons to have surgery, but to state that radiation is not a robust treatment and backup treatments are not available is entirely untrue and misleading to those who come here seeking factual information.
JT
Posted 1/24/2010 7:06 PM (GMT 0)
Still comes back to the degree of PC one is dealing with after their dx.

If the dx is real low grade, low core, low %, no family history kind of thing, then we know that intelligent AS can make perfects sense to some men that meet that framework.

When the criterea for Seeding along, or seeding with IMRT added, it is an excellent choice to consider, especially eliminating the trauma of surgery and the too hard to predict side effects and quality of life issues. Despite being a surgery and now a SRT guy, seeding still would have been my choice had my numbers been ther.

At still a higher level of cancer present, a stronger RT treatment can be effective, and can knock out the cancer. At the higher combined gys that JohnT mentioned, RT and/or seeds can still be a powerful methodology for cancer eradication.

But I feel that once you reach a strong Gleason 7 case, with lots of postive cores high % cores, that surgery, either robotic or open like I underwent, is the best way, while there is still hope that the cancer is contained. When it proves that it wasn't, i.e. a positive margin like I inherited after surgery, then having the option or RT or SRT as a possible curative means is still easily on the table.

If surgery is the best choice, the argument of having RT or SRT as a backup, secondary curative possible plan is not just small talk. For all practical purposes, its best to take salvage surgery off the table altogether. Most surgeons won't touch it, it's bound to leave the patient with all kinds of perm. quality of life issues, etc. Can it be done, yes, should it be done? Most surgeons would say know.

Then of course, once the curative treatments have been used and failed, then there is the entire HT route along with its cousins.

If the patient's mindset will be calm and logical, and one really looks at their total PC related history, there are correct choices in a good sequence of order to follow. I am all about freedom of choice, etc, but sometimes, our freedoms lead to poor choices or poor sequences just because we could do something, doesn't mean it makes the best medical sense.

David in SC
✚ New Topic ✚ Reply