A little guidance would be appreciated...

I've gone from having a PSA come back in 5/13 at a 7 to being dx'ed w/PC at the end of August.

Factoids: PSA was a 3.5 in 2010, didn't have one taken again until 5/13, which came back a 7. Went to a urologist, had a biopsy. 12 cores taken, 3 came back positive w/adenocarcinoma: one at 50%, one at 17%, one at 33%. All located at the right anterior quadrant. I was also told that at 26mm my prostate was about half the normal size. FYI: in between my initial urologist's consult and the scheduled biopsy, I ordered my own PSA/free PSA from another lab (I'm in the healthcare field). I know, standards may be different, but it came out about the same (5.6 with 8% free). I had the post-biopsy consult, and recommended was RP w/lympth node dissection via Leonardo. My urologist has done over 3000 of these, with over 1000 of those being da Vinci; he trained at Johns-Hopkins on da Vinci and is a da Vinci instructor there now.

I then got a second opinion. I was fortunate enough to come in contact and have a consult with one of the radiation oncologists at U of Penn via a friend. We discussed all options, including proton therapy, one of their specialties. His take was that given my age (54) and stage (Gleason 6) that surgery would be the first choice for the best outcome as the current standard of care.

So then, my question. It's a balance of quality of life vs. cure rate, if you will. I want this 100% gone. But, is surgery the only way? I've read a little about brachytherapy (much too little, I'll admit), however there seems to be less (anecdotal) side effects. Would I have the same cure rate with this vs. surgery for the stage that I'm in? Are there any white papers out there comparing surgery vs. other therapies' outcomes in low-risk recurrent patients? The surgery doesn't concern me, believe it or not, as I've been around this sort of thing for some time. However, it's the aftermath that's of concern...

That goes back to the quality of life issue. I'm physically active, mostly on a bicycle (during the warm season I'll average 80-100 mi/wk). I'd like to continue it w/o worrying about possible incontinence. Believe or not (again), ED is a secondary concern.

So, I welcome any of your thoughts. I'm told by both of my specialists that I should go on to a full and complete recovery; clouding the issue somewhat is the comment from the radiation oncologist, "with whatever way you choose". I'm scheduled to "meet" Leonardo in mid-November; guess I'll be doing more research.

-Matt

Hi Matt...welcome to our club and sorry you have to be here. This group can dump all sorts of data on you, so your request for a white paper will soon be answered. I'm not as technical and research quoting as many here, but here's my initial thoughts.

Based on your diagnosis, your prospects for a 100% cure are excellent despite whatever treatment you choose given that you appear to be a Gleason 6. (Not clear if all of your cores were GL 6.) In fact, active surveillance might be on the table for you as well, depending on how you feel about that.

Given that you have an excellent chance of a cure, I'd spend time thinking about the side effects profile of the various treatment options and comparing it with your own personal feelings--for example your statement that you want the cancer to be 100% out. In general, the SEs of brachy and IMRT seem to be less than that of surgery, but there are several folks here that have had surgery and have done quite well in that regard.

On a personal note, like you I was diagnosed this time of year (9/13/12) and also had a mid-November surgery date scheduled. In my case, I made a pretty late change to going down the brachy/IMRT path. So do count on using your time to do as much research as possible and to find the top practitioner no matter what treatment you decide on. In fact, given that your a G6...you have way more time than November to make a decision.

One last bit of advice...send out your slides to Bostwick or Epstein for a second reading. They're the best in the land and it's a simple and quick way of making sure your diagnosis is accurate. Check out the sticky at the top for how to do that.

Good luck and please keep us posted!

Matt,
Please do yourself a favor and speak to an oncologist about brachy.
Doing that was the best choice that I have ever made.

Hello, Matt and welcome to HW. As others have said, with your diagnosis it is likely that you will be cured whatever treatment choice you make. I urge you to continue to get educated on our disease. There is a good thread at the top of our forum that is designed for newly diagnosed men and you might want to read this: www.healingwell.com/community/default.aspx?f=35&m=2652250

Beyond this, there are two books that I like. Walsh's, "Guide to Surviving Prostate Cancer" and Scholz, "Invasion of the Prostate Snatchers" should give you a broad perspective between the two of them.

Also, since you have expressed an interest in brachytherapy, you should take the time to consult with an experienced brachytherapist. With all due respect to the radiologist with whom you consulted, he may or may not have extensive brachy experience and, if not, his knowledge may be limited. RE brachytherapy, there is an interesting study done by Grimm, et al that you might read. If you want a copy, email our member "Yooper" who will be happy to send it to you. Also, for a long winded first person brachytherapy journey, feel free to copy and paste the link in my signature or check out the journeys of any of the many brachytherapy members on this forum.

Finally, your prostate size is within "normal" range if the 26cc quote is correct.

Good luck and feel free to ask us anything.

Jim

Give a call to the Chicago Prostate Center. Dr. Moran will be more than happy to talk to you. He's done like 15,000+ seed implants.

Cyclist -

All excellent advice that you've gotten so far.

One thing I would like to add, and I'll bet you're already aware of this, but in case you're not, it concerns something you said in your original post:

"I'm physically active, mostly on a bicycle (during the warm season I'll average 80-100 mi/wk)."

Bicycle riding is notorious for causing an abnormal increase in one's PSA test result, especially if the riding occurred not long before blood was drawn. Of course since you've already had the biopsy and know the result, this is less of an immediate issue for you.

But if you really are into bike riding that much (even your username says you are!) then in the future it seems like it would be a good idea to abstain from the bike riding for at least a few days before a PSA test, to avoid skewing the test result, if you weren't already aware of this.

If bike riding is indeed your passion, this may be a bit of a challenge, but you also don't want anything messing up your PSA test.

Matt,

Welcome, you have come to the right place. Lots of very experienced, supportive men and women here. You will receive lots of information and advice. Take it all in and then make your own decision. At the end of the day, its your life, your body, so get comfortable with what you want to do going forward.

As for my two cents, I selected surgery and am very glad I did. I was a G6 with just one positive core. I was worried about incontinence and ED. During surgery (da vinci) my doctor discovered why I had just one positive core, most of my cancer was in my bladder. He removed my prostate successfully (nerves spared) and removed a section of my bladder. Had I selected Radiation, he simply wouldn't have seen the metastasis to my bladder.

My incontinence is under control. one pad a day at 8 months post surgery, and that is for sneezing and other pressure that will cause me to leak. I understand your concern about incontinence, but you can wear a pad (I sometimes workout in a full brief so as to be fully protected when stressing my body).

Take care Matt and keep asking away,

Pat

Matt,
There is a lot of data out there and it is pretty consistent. For a G6 the cure rate is excellent for all options. You can go on the New Prostate Cancer Infolink and search "Quality of life" and you should find more than a few studies comparing the QOL of the various options. It's pretty consistent that Brachy patients have the fewest QOL issues, and that younger patients have better QOL after surgery than older patients.
Re cure rates: The Prostate Cancer Study Group Results was a large study comparing cure rates of all the treatment options and you can Google it. Brachy also had an edge in cure rates across all Gleason grades. In your case all options are available and it is a personal choice. It seems that most all of the Brachy patients on this forum have done very well in both the cure rate and having less side effects so it is an option you should investigate given your concerns.

Thanks everyone, I’m grateful for your overwhelming responses!

Getting back at some of you:

Michael_T: all my cores were a Gleason 6. I’m not ruling out active surveillance yet. I will have the slides sent out for a second reading. Makes sense, as I had the PSA done again at another lab… just to make sure.

David and Tudpock (et al)- I will notate the option of a brachytherapy specialist consult. When I had my consult at Penn, I assumed during our discussion that the radiologist there also did seeds (personally) as well; I may have been wrong.

Tudpock- when I had the nice US probe up you know where, the urologist told me the prostate measured 26mm (length), and told me it was about 50% normal size. You’re using cc, which I think is a measure of volume. I was told by my urologist that due to my prostate size, my PSA of 7 could be considered a 14. Whether or not this is accurate, I don’t know.

81GyGuy- I had to laugh at your response (in a good way!). That’s the line I used on my internist, before she told me on no uncertain terms that I was to see a urologist. I told her how I read a couple of journal articles about how PSA can be affected by many things- sex activity, certain foods, and of course, bicycling. I could have said unicorns and rainbows too as far as that was concerned- the net/net of this is that I went and now I’m here! But yes, any subsequent PSA’s will be done after a couple of “off” days- thanks for your input!

Oldguysrule58- Sorry to hear about the extent of involvement. To be on the safe side, my urologist has me scheduled for a cystoscopy a week before the main event to check for any potential bladder problems before da Vinci is done. The radiologist concurred with this.

Reltnie and RamonV- Thanks for the seat advice. If I go for surgery, either that or a recumbent : ( )

As several of you have pointed out, I do have time. I know that, as far as the cancer is concerned. The urologist told me realistically I could go 2-3 years doing nothing. My reason for having surgery scheduled in November is primarily an issue of insurance, and my practice.

I’m a solo health care practitioner, on my wife’s family’s company health insurance. When Obamacare is initiated, for better or worse, her company’s (our) insurance rates are going to jump 22%. Normally the company’s policy renews at the end of December, however, if my wife renews before that date they can grandfather at the “old” rate for one more year (great… right?). So, my wife, as COO, elected to take the early renewal. Problem is, is that our deductible is high ($1000’s +). So, whatever I decide to do, it’s going to be done before the end of November. Otherwise, we’re into a new deductible year- not good for us.

The other reason is my practice. I’m self-employed. My surgery is scheduled about a week and a half before Thanksgiving. My urologist told me that if I had a pure desk job I could go back (technically) in a few days following the surgery. However, I’m not sitting at a desk, and I do everything. Having the surgery at that time, I figure I can return at the beginning of December barring any complications… I expect to have none if I go this way. Minimal time off during this time.

But, I’m not totally convinced this will be the way. The make/break will be comparing outcomes of all treatments for my stage. I asked the urologist about alternative treatments, but again it goes back to the “age and the stage”. He felt that other treatments would be prolonging the inevitable, and, if some treatments were done before surgery (e.g. radiation) that surgery wouldn’t be an option if the cancer returns due to the obliteration of the surgery site. From my angle, the research would be, “if brachytherapy was done would a subsequent surgery be possible if the cancer returned?” That would be far palatable to a surgery. Another interesting factor is the Ornish study of nutrition and stress reduction lowering PSA levels, which I think I found a link to off of this site. I can tell you that excess stress is my SOP du jour, and probably a lot of you out there are in the same way. Regardless of what is done I have a feeling I’m going to have a lifestyle change regardless of the outcome.

At the least I will have the cystoscopy done. Not looking forward to it, but it makes sense. By then I’ll have firmed up what will be next. And, I’m sure I’ll be asking you all more questions before then.

Thanks again everyone, I appreciate your input!

-Matt

Thanks Michael!

All the more reason for additional research before I pull the trigger...

-Matt