Prostatectomy vs. Radiation

After receiving a 2nd opinion from Bostwick Labs (Right Mid, Gleason 3+4 involving 10% of the sample, and Gleason 4 representing 10% of the sample; and the nodule, Gleason 3+3 involving less than 5% of the sample) and a GPS score of 14 from Oncotype DX testing, suggesting I'm in the low risk category, it's time to make a decision on treatment.

RO suggests a 6-8 week course of treatment with IGRT using the Calypso 4D Localization System. He also noted that given the Gleason 4, he would not advise LDR. Urologist (with over 1000 operations) suggests prostatectomy.

I'm about 90% sure I'll go with the IGRT using the Calypso, however it appears that most on this forum elected a prostatectomy.

I'm curious, given the equal success rate of both modalities, what was the ultimate factor in deciding your treatment?
_________________________

age 63, 3/1/2015 PSA 1.9, nodule noted on prostate, 5/20/2015 biopsy (15 cores), ultra sound was described as normal, however 3 cores were positive. Prostate nodule: Gleason 3+3 in 1 of 3 cores, occupying 2% of the core, and 1mm; and right mid: Gleason 3+4 in 2 of 2 cores, occupying 13% of the cores and 4mm.

I had my prostate removed over six years ago. The reasons for my choice were much the same as BigMac's. Radiation is better accepted today.

If I were looking at IGRT I think I would also give a close look at SBRT/Cyberkinife .... many guys swear it was the best with no side effects.

I would be interested in why LDR was ruled out. Is HDR a viable candidate?

I am guessing that Avtive Surveillence (AS) is off the table?

Anyhow, sorry you have to be here, but welcome. Best wishes as you move forward.

Post Edited (RCS) : 8/4/2015 12:27:36 PM (GMT-6)

I did the radiation thing and glad I did. You'll do fine with it.

The side effects weren't bad and now 3 years later the only lasting effect is a bit of ED and some bowel issues.

I went with RT because I wanted to avoid the trauma and risks of surgery. I have some heart/lung issues that my surgery a higher risk and I just hate the pain caused by surgery. The other reason was that there was some suspicious stuff near the margins and a probability that PC might be close to the edge of the prostate capsule. In surgery that might they might have to cut wider, but with IGRT, they just widened the beam slight and dealt with it.

The only thing I wish I would have done was to have been more aggressive in treating my internal hemorrhoids prior to RT. The radiation made them worse and I suspect if I had got them treated before RT, I wouldn't have had the issues I did.

As to the other points people like to make: Secondary cancer? Sure but you could also die on the table during surgery or get hit by a bus. No back up plan? Ask your RO, there are secondary treatments if RT fails. and that is a big if.

In the end, it's your choice. and IGRT is a good one for your numbers.

Andrew

Browntrout - you bring up a good point. Even among ROs, they tend to specialize in the certain methods.

My brother was sent to a RO who mostly does IGRT. When we asked about LDR, the RO flatly stated he didn't do LDR (although he thought my brother was a good candidate for LDR), but could give us a referral to a doc he thought was the best in the area. My brother ended up doing the LDR and it worked very well for him.

Andrew

I went the surgery route as well. My reasons were probably 75% about wanting an immediate outcome, rather than waiting months for PSA nadir along with just wanting it over and done, and 25% "creep out" factor about not wanting radiation for any reason. I also had this statement rattling around in my head from my mother: "Don't do anything weird or experimental, which is what your Dad did, and you know how that came out."

There are so many studies that say pretty much what the researchers doing the studies want them to say. I like the idea that the radiation therapies are great, with fewer SE's early, but there are some scary indications of what can show up 15-20 years down the road. This suggests that an important part of the mix is the age and general health of the patient. I was 56 1/2 at the time of surgery, with no ED or continence issues pre-surgery. My surgeon told me that given my age and general health and lack of issues that I had a 90% chance of making tri-fecta within 3 months. This proved to be true.

In the end, as others have said, it's a gut question. What feels right for you? When you relax and let it all soak in, you'll know what is best....and who is the best team leader for you.

Hi Gary-

If I understand you correctly,you had nothing higher grade than Gleason 3+4. If that's true, it is certainly NOT the case that LDR brachytherapy is ruled out. In fact, it would be a very good choice. However, you have to talk to a doctor who specializes in LDR brachytherapy and not a generic radiation oncologist.

In my opinion, IGRT/IMRT for initial therapy is a relic of the past. There is no reason to undergo 40+ treatments when you can get it done equally as well in 5 using SBRT. Once again, you would have to meet with an SBRT specialist. Same holds true for HDR brachytherapy.

The big advantage for surgery is that if it is totally successful, you will get a pathology report and undetectable PSAs that will inspire confidence. The big advantage of radiation is its side effect profile.

I chose RALP for the following reasons:
1. Age = 56
2. Biospsy results detect cancer but more times than not, the Gleason score is downgraded in the pathology report.. didnt trust the biopsy results.
3. I felt i had extremely good chance of getting it all (as good as it can be done) with surgery
4. Biopsy doesnt show if the cancer escaped the prostate....at least to the extend the pathologly report does.
5. Trying to get surgery after radiation is possible.but way more.difficult. would rather get the salvage radiation later if needed
6. One of the top surgeons with a great track record is 1 hr away from me.
7. Radiation and chemo creeps me out. Get this shat out of my body and use the alternates as a back up.

If you read my thread "my experience with Dr. Vip Patel" you can read about my experience and results

Gary,
You might consider Proton radiation. I have been very pleased and have not suffered any quality of life issues. Side effects were a driving force in my decision and it sounds like any treatment you decide will give you a good chance of a positive outcome. Good luck with whatever you choose.
Regards,
Kris

With 11 of 14 cores positive, DaVinci was best for me. Doc also said that if I have surgery first, radiation can still be an option later if by chance needed. If I went radiation first, my surgical options later would be limited. Mayo also agreed with surgery.

Gemlin said...
I had my prostate removed 11 month ago. I think operation is preferred at our low age. Operation removes just the prostate and leaves the tissue around it intact. Radiation will destroy the tissue (some centimeter) around the prostate as well. If you are unlucky and have reoccurrence of the cancer, you can have a second treatment with radiation. If you go for radiation first you can not have it a second time.
Good lock whatever treatment you choose.

Gemlin,

Your statement at the end isn't true. You said, "If you go for radiation first you can not have it a second time".

Of course you could.

I chose HDR because of its record of cure equal to surgery. Plus, I worried a surgeon would cut into nerves, vessels, etc. and leave me impotent. When the get in there, their main goal is to get all of the cancer, which should be the goal. However, it's bad if they go too far and bad if they leave any behind.

I'm almost nine months out and doing great.

I decided on Proton Therapy at UFPTI as my primary treatment. My 8 weeks of treatment ended on January 15, 2015. So far no SE's.

I didn't rely on the data entirely to make my decision. I talked to about 30 men who had been treated there and all were pleased with their results and most had no SE's. I made sure I talked to some who had been treated several years ago.

I find it interesting that so many men decide on surgery because they want to get their PSA results within a few weeks, yet when they do and it's zero, they still worry before each subsequent test. I think it's because they know they're not out of the woods just because their first few tests were low. We've all seen posts from men who were zero for months and then see rising PSA.

I had consistently rising PSA which I know wasn't over a 7 when I agreed to the biopsy. The biopsy resulted in 7 out of 12 positive cores with a Gleason 0f 7. Never really spoke with a RO which in retrospect was probably ignorant. After biopsy report decided to get opinion from a urologist at Cleveland Clinic. Just felt better in their hands. I knew of some of the RT side effects and in my mind surgery was more cut and dried (no pun intended) and seemed to have less side effects. Unfortunately, in my case, the pathology from the surgery revealed an aggressive cancer raising the Gleason to a 9. There was SVI, etc. at the post op visit we received the bad news. So now, approx 3.5 months later I have just begun on 8/3/15 radiation therapy which will go on for 39 treatments and I will have to deal with the side effects I had hoped to avoid by choosing surgery. I also had a 6 month Lupron shot in July. I had a PSA of 0.07 on 6/23/15. I had the Lupron injection 6/24/2015. The day radiation started, a PSA was drawn prior to the first treatment. It came back non detectable. Radiation Oncologist was really pleased but said I still had to go through with the treatments which I guess I knew. Was it the Lupron that brought the PSA down? Would ADT have been enough? Should I have never had surgery and done radiation in the first place? If I had chosen that route, how would the extent of the cancer be known? I just have to be resigned that the course chosen will ultimately lead to positive outcomes. Has this course of events happened to anyone else? Has anyone else had a higher Gleason post-op?

Digger,
My Gleason went from 3+3=6 to Gleason 3+4=7. Upgrades are very common. Another plus for surgery, getting a final pathology report.

Bill from Florida