HealingWell
Search Close Search
☰

Which Treatment Is Best ?

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
1 23 4
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 6/22/2013 7:33 PM (GMT 0)
A surgeon tried to sell me on the "if surgery fails you can have radiation" but I wasn't convinced by his argument.

And, "if you are concerned about having a plan B then you should have radiation as it is both plan A and plan B and you avoid the SE's of Plan A" is exactly how I thought about it when deciding.

Why have potential side effects from both surgery and radiation?
Posted 6/22/2013 7:44 PM (GMT 0)
The point about using radiation as a Plan B sure resonated with me...especially when I was told you couldn't do surgery after radiation. But as I learned more I realized that if my brachy and IMRT failed, it was pretty unlikely that the cancer was still in the prostate...instead it was our there floating around and there wouldn't really be much of a reason why I would have even wanted to try surgery at that point.

I also totally agree with davidg's point: there is no "best" treatment for prostate cancer, only a treatment that is best for each individual depending on their staging and personal preference regarding recovery and potential side effects.
Posted 6/22/2013 7:46 PM (GMT 0)
davidg,
Dattoli published results of 1400 consecutive high risk cases treated with a combo treatment. There were zero local failures (confirmed by biopsies) and all failures were systemic (already in the blood stream at time of treatment). The probability of having a local failure after a combo treatment is extremely rare; I've never heard of one.
Posted 6/22/2013 7:57 PM (GMT 0)
Okay, I found the paper with citations:

onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10827.x/pdf

Not many surgical studies included for the low-risk patients. This is not surprising because most published surgical studies do not include stratification by clinical stage. The effect may have been to exclude studies by surgeons with better outcomes from the comparison.

Post Edited (njs) : 6/22/2013 2:28:11 PM (GMT-6)

Posted 6/22/2013 8:25 PM (GMT 0)

John T said...

This is why I don't understand Doctor's telling their patients that surgery gives them a plan B of salvage radiation if the surgery doesn't work. I just heard your doctor say this on TV yesterday. If salvage radiation will work as a plan B then it stands to reason it would have worked as a plan A the first time. Either the doctors are being disingenuous or that phrase has been repeated so many times it is just accepted as fact without thinking it through. Having a plan B sounds good, but once you think it through it's telling you the exact opposite; if you are concerned about having a plan B then you should have radiation as it is both plan A and plan B and you avoid the SE's of Plan A.

Buddy Blank said...
"if you are concerned about having a plan B then you should have radiation as it is both plan A and plan B and you avoid the SE's of Plan A" is exactly how I thought about it when deciding.

Why have potential side effects from both surgery and radiation?

A few key points you guys seem to be missing:

  • By leaving radiation as a backup, its unique side effects (in particular the potential to cause other cancers down the road) can be completely avoided by a large fraction of patients (around 90 percent of low risk patients according to the data in this study).
  • Radiation does not completely ablate benign prostate tissue so after radiation you are left with a lot of prostate tissue that may give rise to new tumors down the road after which you cannot have any more radiation and surgery is very difficult. (I know this is the case for external beam; not sure to what extent it holds for BT, but I'd guess that at least some prostate tissue bordering on critical structures cannot be fully ablated by BT either).
  • To be effective radiation protocols must be scaled by risk (e.g. adding neoadjuvant HT and/or external beam to BT for higher risk patients) but as primary therapy the protocol has to be chosen based somewhat on guess work (c-stage, PSA, biopsy and imaging) whereas with a surgical specimen you have much better information on whether SRT is even required and, if so, how and where.
The first two may not be significant concerns for older patients but should be for younger ones...

Post Edited (njs) : 6/22/2013 7:20:21 PM (GMT-6)

Posted 6/22/2013 8:52 PM (GMT 0)
njs,
The number of surgery patients is significant, 7150 low risk, 4000 intermediate risk and 5300 high risk patients included in the studies.
A couple of points about your comments:
All studies have shown no significant risk of secondary cancer with BT and about a 1% risk for IMRT at 20 years. This compares rather favorably to the 1% mortality rate 30 days after surgery due to complications.
Radiation leaves the prostate tissue fallow and it is very unlikely to develop new tumors in a radiated prostate.
Reseeding, either HDR or LDR brachy is common for either failed seeding or failed IMRT. A different isotope is used.
Surgery does have the advantage of a post op pathology, but 50% of low risk positive margins never progress and there are many reoccurrence with negative margins. With the exception of major positive margins in high risk patients, rising psa after surgery is still the standard used to identify reoccurrence in the vast majority of surgical patients. So unless one is ready to immediately jump into adjuvant RT based on post op pathology a rising PSA and not the post op pathology determines if a patient will have SRT.
The reasons for locally failed radiation are: Too low a dose for the tumor volume,(common when the dose was 61 gy). The rare resistance to the isotope used. Seeds not properly dispersed, leaving dead spots.
Posted 6/22/2013 9:02 PM (GMT 0)
Here is my recollection of this study as it has been discussed on HW.  I believe that JT first brought it to our attention and it created a bit of a firestorm here (well not as much as ODOT but still some sparks).  There was outrage from the folks who wanted to argue for surgery as the gold standard and it appeared to be blasphemy that this study actually showed brachytherapy as the better treatment.

Fast forward some years and Yooper discovered the same study and I recall that it was somewhat influential in his decision to have brachytherapy.  Yoop bought the full study and has been kind enough to email it to folks who want to read and dissect it.

My take is this.  While this particular study shows radiation as superior, I can also find studies that show the superiority of surgery.  My conclusion is that there is enough long term evidence to demonstrate that either radiation (incl. brachy) or surgery will provide excellent cure rates for prostate cancer.  The sea change at the HW forum is that it appears most of the long term members here believe the same thing and, rather than focus on which is "better", accept the fact that both are equally good and encourage new patients to explore various good options -- rather than shouting to "get it out" or "burn it out".  I think that is a positive development for our forum over the years and was one of the reasons I was so adamant in encouraging the "big tent" approach that allows for sharing of papers and studies that aid in our PCa education.

Beyond this, it's no secret that I have been an advocate for brachytherapy because of the QOL issues.  However, knowing what I know today from this forum, if I was diagnosed today I would also be considering focal therapy, HDR brachy and Cyberknife along with the LDR brachy, IMRT and surgery that I considered 5 years ago.  I would still eliminate HIFU (no FDA approval). cyrotherapy (total ED) and PBT (no long term advantage over brachy) rather quickly.

Of course not everyone is suited for brachy, either physically or psychologically.  If I had been early 40's like davidg or TonyC, I might well have opted for surgery at that young age to be quite honest.  However, I still personally believe that many of the more senior guys are well served by brachytherapy because of the less invasiveness, the quicker recovery, the ease of the procedure and the liklihood of better QOL re urinary and sexual functions.  Of course the really big deal is to choose an "artist" (credits to JT) whatever the choice of treatment.

Jim

Posted 6/22/2013 9:08 PM (GMT 0)
JohnT,

I understand the selection criteria and am not accusing them of tendentiousness in formulating them, but the fact remains that very few studies were included for surgery and a number of surgeons have trouble reconciling the results of the study with their experience.
Posted 6/22/2013 9:12 PM (GMT 0)
 Word of the Day: tendentiousness -- marked by a tendency in favor of a particular point of view : biased

 

Posted 6/22/2013 9:16 PM (GMT 0)
Are there published numbers showing the percentage use of each treatment?
Posted 6/22/2013 9:21 PM (GMT 0)
Jim:

Excellent summary that I agree with fully.


For the record, I too agreed with a big tent approach. What I personally didn't like was activism and recruitment on a constant basis by a select group, whatever the cause was and whoever fit the group. That was my only issue.

I think that as a group here at HW we all respect all forms of treatment to a large extent and understand different treatments are suitable to different situations, including good thorough management solutions.
Posted 6/22/2013 9:22 PM (GMT 0)
njs if my brachy failed they can go in there with another isotope 1-2-3 and it is a myth that you can't have surgery post-radiation.
Posted 6/22/2013 9:27 PM (GMT 0)
it's very difficult to have surgery after radiation. Very few surgeons do (mine has). It's not something that you want to plan on.
Posted 6/22/2013 9:28 PM (GMT 0)
You make some good points John assuming you are correct on the incidence of radiation side effects and new PCa tumors arising in unablated prostate tissue.

To clarify two of my points...

My concern is not with the number of surgical patients in the comparison but with the number of surgeons. Regardless of the number of patients, if they are from a handful of surgeons with mediocre surgical outcomes that would impact the comparison. In my research of surgical outcomes I was struck by the substantial variability and the prevalence of mediocre surgical margin rates from some high volume academic institutions.

My point about the advantage of post-op pathology was not that you would initiate SRT based on it but rather that you could often refrain from radiation if the pathology turns out favorable (organ-confined disease) despite higher risk pre-op parameters that might have caused more extensive radiation as a primary therapy.

That said, as a GS6 on biopsy I really wanted to know if that would hold up post op to inform how vigilant and aggressive I might need to be down the road. I would not have been very comfortable assuming from two biopsy cores that I had nothing worse than pattern 3 and being treated with the GS6 radiation protocol (e.g. no neoadjuvant HT) and hoping for the best.
Posted 6/22/2013 9:58 PM (GMT 0)
Njs and Tud,
All excellent points. It's good to have a discussion with out it getting out of hand or personal. I do believe that surgery has advantages in some circumstances, especially for younger patients. There are good reasons to choose surgery and they should stand on their own. It's the bogus reasons, like there is no plan B for radiation, that are untrue, but often given by doctors that I really disagree with and makes me question their motivation.
Posted 6/22/2013 11:16 PM (GMT 0)

njs said...

A few key points you guys seem to be missing:
..

How refreshing to see reality expressed as it is, in this dark place where the line seems to be towed.... or at least, apparently ..

Searching folk, desperate folk... they come and go... but the dark place remains.

We are all different , and our conditions different but reality remains.
Doctors specialise, and want to do their OWN thing..
Cutters cut, burners burn, chemists poison.......skull ....... confused

I do NOT know a single male for whom life after PC was the same.
If radiation was the choice, minimal change was the norm for a time, and then after the meat was fully cooked, they ended the same. Same as the cut...
But NEVER certain of anything..

I do wonder why my experience is so different to what I read on here, and one BBC Knowledge presentation from Australia, seemed to be realistic and I think they quoted 30% of men as having minimal change after treatment.
I was told 80% chance of a normal life.. mad

Ironically, I do wonder how much of that 30% figure is bravardo.

Why do men think they are any different to women, when it comes to cancer.
We don't want it, and did not ask for it, but have to live or die with it.
We all likely should have thought about how we may have reduced our risk of getting it, but why, why would we, as it would not happen to us..
Those of my circle who got cut, are alive and well, but boy, the sex life has changed..
Not One boasts to having a real love life.. few will ever even talk, because there is LITTLE they can do.. at best men confirm all is not well, with no added comment... nono

Old friends who were burnt, seemed to be basically "in remission".. nothing more or less.
They burn the older, as the likelihood of suffering worse induced cancers, is less, because their time card has already been punched.
Not Strangely, they would not agree ....'.... shocked

The one opinion that I hear consistently , from those that were cut, is that they are happier living with an expectation that the CANCER is GONE... BUT
oh boy, do we miss it yeah

Then we sign off from here and (almost ) never return.. forgotten... smurf

Three years Cancer Free.. turn PTL n PTP

So, my silly advice if you are new here , is to suggest ---" understand that ALL uros want to get you through the next five years. "
If they get you that far, then they have done a good job.. but if you think that you are worth more than five years, forget the JiggyJiggy, and think about how many years you are really worth.
Think about who will miss you most.. your family or the URO .. wink

If the hand you are dealt, is not a flush, then take whatever steps you can to survive as long as you can and as comfortably as you can.. our prayers go with you.

Oh so many here in this place, can't boast "comfort ".. idea
..
:

Post Edited (BuiDoi) : 6/22/2013 5:21:00 PM (GMT-6)

Posted 6/22/2013 11:31 PM (GMT 0)
Bui.

I was 40. My #1 goal was to try and maintain something similar to what me pre-cancer perception of longevity was. Because I had a wife I enjoy very much, two young kids I adore, and because I was enjoying life (even if I didn't admit it).

The plan my urologists and my surgeon and the oncologists I spoke to focused precisely on trying to regain that perception of longevity.

There was no talk of 5 years. There was only talk of beating it and moving on.That was goal #1 and the only ultimate non-negotiable goal. Don't know where you get 5 years, according to MSK I'm 97% good for 15 years. They don't have longer term studies than that. I want to be good for 40 years.

As for sex, no bravado on this forum from what I can tell. Just honest and intimate exchanges. At this point 2.5 years out I'm back exactly where I was pre surgery minus the dry orgasms. If you ask my wife, that's a bonus. At first I was fully functional with pills and I would have signed off on that too. I felt fortunate those were working a month out. As for intimacy itself, sex is better now because of those 15 or so months rehab which were fun!

Believe it or not, that is a genuine story and there are many many more. They might not all be the same, but they mostly all successful in one way or another.
Posted 6/22/2013 11:45 PM (GMT 0)
Bui you said, "I do NOT know a single male for whom life after PC was the same."  Of course nothing is EXACTLY the same but...there are many, many men on HW for whom life is ESSENTIALLY the same after treatment.  Davidg is one after surgery.  So is TonyC after surgery and radiation.  So is JohnT after radiation.  So am I after brachytherapy.  And many more.

Is is very sad that many men suffer terrible SE's after their treatment.  But to paint such a dark picture of post-PC life is just plain wrong in many cases.  Just my opinion.

Jim

Posted 6/23/2013 12:06 AM (GMT 0)
There's really no way to answer that question as posed. It takes lots of individual assessment of staging and grade, age, other existing medical issues, personal preferences, and on, and on. Pass the popcorn.... this thread is likely to drag on mainly by everyone sharing their biases based on what part of the elephant each is touching (old story).

I've selected my plan based on everything I could learn and weigh out, including opinions of the doctors I liked (urology, radiology, medical oncology). Am I right? Well, I sure think so for me, or I wouldn't be doing it. Is it right for someone else with my similar diagnosis? Well, that can only be determined by that person.

I suppose the good news is there are lots of options. There are many diseases that have extremely limited choices of treatment.
Posted 6/23/2013 12:14 AM (GMT 0)
John's clear logic was why I chose HDR BT and IMRT rather than surgery. Actually my urologist said surgery would be foolish given my risk status. He does more HDR BT than surgery as he believes in most cases it is better.
Posted 6/23/2013 2:25 AM (GMT 0)
Bui,

Why are you painting such a bleak, drab picture? It's not all bad in the PC world. There are many success stories even here among our group.

I have a lot of collateral damage, but not directly because of the cancer (at least not at this point), but because of a very flawed Salvage Radiation that went very wrong.

I am one of the fortunate ones, no ED issues, ever. Not even after all I went through. No real incontinence issues to speak of. Sex life is as good if not better than before, except, as davidg said, the dry orgasm part. Wife likes that part too, can lead to some interesting situations. With the length and intensity of the "new" orgasms, wouldn't trade back for the old ones even if I could.

Some journeys are great, others are bad, buts its not all good or all bad, each guy's story and journey is different. Most are thankful to be in situations where they appear to be cured, and they very well may be for the rest of their natural lives. For others, with advanced cancer, the battle goes on, and the jury is still out.

Perhaps you would care to share what is really bothering you at the personal level, perhaps we can help.

A lot of it has to do with attitude, stamina, and being in it for the long haul, and never, ever giving up hope.

To share Bro. Sonny's infamous words, "Every day is a bonus". Lot of truth to that.

Hope you feel better about things in general, life is good. I am happy to still be alive, and when its my time to go, I will be ready for that as well. The circle of life and death is as constant as the tides, so I try to enjoy what I have, not regret what I don't have.

david
Posted 6/23/2013 2:31 AM (GMT 0)
Going back to the start of this thread, "What treatment is best?"

I thought the one thing we basically agreed upon, that there is no one best treatment. That it depended what was best for each man, based on his stats, circumstances, and medical history.

I don't think many anymore simply believe that surgery is the "gold standard". For those with G6 cancers, most have the full spectrum of primary choices, and some among them could embrace AS, and stay clear of the risk of side effects and periphery issues for years.

I honestly don't see one particular treatment as being better than another in general, depends on too many things. However (and saying this as a surgery guy, then later radiation), surgery will always come with more risks of negative issues, just comes with that turf, and a person choosing surgery will have to understand those risks are real, and that you can't predict your outcome or results ahead of time, so that is something to strongly think about.

david
Posted 6/23/2013 3:04 AM (GMT 0)

JNF said...
John's clear logic was why I chose HDR BT and IMRT rather than surgery. Actually my urologist said surgery would be foolish given my risk status. He does more HDR BT than surgery as he believes in most cases it is better.


My urologist oncologist is one of those thousands-of-surgeries guys. He was pretty soft on whether surgery would be a good idea for me, and was leaning more toward radiation due to my factors. While he stopped short of actual recommendation, for the super-surgeon to favor radiation spoke volumes. He said surgery was possible, but it would be a "WIDE" excision, without possibility of the, as he put it, "luxury" items, like nerve-sparing and so on. Even though the evidence of ECE is strong but can't be perfectly clear from available data, a lot of arrows align that way. My RO is a big brachy type, but he didn't consider it worth including for me, since it has its own side effects and again wouldn't add much beyond the level of IGRT available now. Even the widely-accepted ADT I'm on is coming into question with the radiation dose-levels available with today's machines.

Anyway, I'm in the same situation - what's the "best" treatment? Surgery just is not likely enough to be curative to be worth the risks and side effects for the very high probability of needing adjuvant IGRT and ADT anyway. With ADT and IGRT as primary therapy in my high risk case, it seems like the best tradeoff of risk, side effects, and effectiveness. Perfect? Hell no, nothing in this whole situation is close to perfect.

So many of the old studies used radiation protocols short of today's methods. The present dose levels and accuracy have capability they didn't have even 10 or 15 years ago. And neoadjuvant ADT with long term continuation, sucky as it is (like 30+ hot flashes a day!), has shown itself as distinctly worthwhile for us G9 types. Yippee.

I'm actually excited about the possibility of a really good outcome. Untreated large-volume G9 has frighteningly low 10 year survival rates. Treated, it is WAY better, with something like a 50/50 shot at a durable remission (the word "cure" isn't used a lot in G9-10 cases apparently; near as I can tell it's because there's such a high likelihood of undetectable micrometastasis.).

At 55, I have to say 65 now seems pretty young to me so I'm really aware of those 10 year projections!
Posted 6/23/2013 3:12 AM (GMT 0)
redwing:

I would say the way you are looking at things for yourself and your case makes perfect sense. Sounds like your best shot to get that 10 years you are looking for, and hopefully more.

david
Posted 6/23/2013 4:03 AM (GMT 0)
BuiDoi wow, you're a cheerful one.
✚ New Topic ✚ Reply
1234