Advice on PC surgery

Gemlin said...
Hi,
a scandinavian study reported e.g. in www.livescience.com/43898-prostate-cancer-surgery-survival.html. Full study in March 6, 2014 issue of the New England Journal of Medicine.

I don't believe this outcome is fully valid for AS vs. RALP now a days. These patients where diagnosed an treated 24 years ago! But my personal belief is still that if you are *young and healthy*, "get rid of it", there is a good chance for small SE when treated with surgery early.

This text copied from the article above:
"Young men with early-stage prostate cancer who undergo surgery right away, instead of waiting to see if their cancer progresses, may lower their chances of dying from the disease over the long term, a new study from Scandinavia suggests.

In the study, men with localized prostate cancer (cancer located only inside the prostate gland), who underwent surgery called a radical prostatectomy were 44 percent less likely to die from the disease over the next two decades, compared with men whose cancer was observed through "watchful waiting" to see how it progressed."

You are right, 24 years ago is a long time! Still,

Somebody said...
However, the reduced risk of dying from prostate cancer was seen only in men who were younger than 65 at diagnosis, or whose tumors had a medium risk of spreading (as opposed to a low or high risk)

So the reduced risk did not apply to low risk men who had surgery, the typical AS candidates. (Nor sadly, to the high risk like me).

Somebody said...
The study involved 695 men with early-stage prostate cancer who were randomly assigned to receive radical prostatectomy or watchful waiting between 1989 and 1999, and followed for up to 24 years. (BillyBob's question: what were the Gleason scores? Were some men with higher G scores randomly assigned to just be watched, or were all 695 of these guys G6 men? It appears to me they were randomly assigned regardless of risk category, is that right? If some higher Gs were assigned watchful waiting, no wonder that the men who had surgery did better! And amazingly, treated or untreated, the solid majority did not die of PC. Which is not to say that they did not suffer from PC )

During the study, 200 men in the surgery group and 247 men in the watchful-waiting group died. Of these, 63 deaths in the surgery group and 99 in the watchful-waiting group were due to prostate cancer.

An earlier version of the study found benefits to surgery, but in the new study, which had a longer follow-up time, the benefits were even more pronounced, Rider said. Eight men in the study needed to be treated with surgery to prevent one death from prostate cancer, the study found.

Wait and see

Although older men and those with low-risk prostate cancer who underwent surgery did not have a reduced risk of dying from the disease, they did have a lower risk of their cancer spreading, and were less likely to need hormone treatments compared to those in the watchful-waiting groups. Both cancer spread and hormone treatments are factors that can affect a person's overall quality of life, the researchers said.

Older men, and those with low-risk prostate cancer, primarily died of causes besides their cancer, Rider said.

The study also found that 40 percent of those in the watchful-waiting group who were still alive two decades later had not needed any surgery or other treatment for their cancer.

This finding "really shows that there is this large percentage of men with localized prostate cancer who can live for a very long time without any sort of major health consequences of their diagnosis," Ridertold Live Science.

"That points to the potential for over-treatment in these men," she said. In other words, if all men underwent surgery, some would receive a treatment they didn't need. Moul noted that the "watchful-waiting" approach used in the study is different from the concept of active surveillance that doctors use today to observe prostate cancer, which involves more frequent assessment of the tumor progression. So it's not clear how well the study findings translate to today's patients, Moul said.

Post Edited (BillyBob@388) : 8/16/2015 12:35:48 PM (GMT-6)

NKinney,

I don’t agree that the study is "worthless poppycock”. It seems very serious to me.
(Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. The New England journal of medicine. 2014 Mar 6;370(10):932-42.)

But I do agree with you that AS of course is the best choice for some men. It is individual decisions and we all have different preferences.

The European Association of Urology also writes in the European guideline for prostate cancer
uroweb.org/wp-content/uploads/07-Prostate-Cancer_LR.pdf page 56, 57

"Active surveillance is an option in patients with the lowest risk of cancer progression:
> 10 yrs life expectancy, cT1/2, PSA ≤ 10 ng/mL, biopsy Gleason score ≤ 6, ≤ 2 positive biopsies, minimal biopsy core
involvement (≤ 50% cancer per biopsy). Follow-up should be based on DRE, PSA and repeat biopsies. The optimal follow-up interval
is still unclear."

But also RP is an option for low risk: "In patients with a life expectancy > 10 yrs, RP should be offered."

I was not at low risk at detection time so AS was sadly never an option for me. But if I had detected my PCa earlier at low risk and then was a candidate for AS, would it had been better to go on AS for some years and delayed the treatment? One of my SE now is related to the lymph node removal. If treated immediately I would not have needed to remove them and would then have less SE now. So in my case (hypothetically) immediate early treatment would probably have been the best option, I believe. But for others that never will need treatment then AS is obvious best. But how to know if your PCa will eventually turn out to be aggressive like mine?

AS and Gemlin, you're truly hitting the nail on the head. I absolutely believe the day will come, and it's coming soon, where it will be possible to differentiate between the case that needs treatment by surgery or radiation and the case that will be indolent for years. At which point, the whole over-treatment argument will end.

halbert, as far as choosing AS, that day is here.

Using modern medicine imaging tools available now, low risk men who pursue AS with the expectation of moving on to treatment if more aggressive indicators appear and low risk men who pursue aggressive treatment have the same long term outcomes.

Men with more aggressive (NOT low risk) PC do experience some benefit from immediate treatment, but for low risk men they experience the harms without any statistically significant benefit.

Think about that...

That's good. From what I read here, you had great post-surgery pathology results...very typical of low risk cases. With your 3+4 you STILL would have been a potential to start afresh on AS.

Alex, we'll be here for you on the other side. Now is the time to make your shopping list for the supplies you'll need for the first week or two. Here's my list, and some comments:

Waterproof mattress cover
Absorbent pads for your chair (the ones for dog training are cheaper)
Donut cushion (I bought one but never used it)
Alcohol wipes for wiping around the catheter (I got a handful from the nurse at work)
Shower Bench (borrowed)
Depends pads (the thick ones to use after the catheter comes out)
Depends shields (the thin ones for later)
"basketball pants"-these are sweat pants that snap all the way up the legs, makes managing the catheter bag easy. I found them at eastbay.com-

I set up a small folding table next to the recliner for my water mug, laptop, remote, etc.

Alex, good luck to you. Once you declined AS, I assume you spoke with specialists in SBRT, HDR Brachy and LDR Brachy so your decision was truly informed? That was the wise approach chose by Pratoman so, even though surgery was his final choice, he had the benefit of speaking with multiple doctors about his options. That was due diligence.

Jim

Alex said...
Hi all thanks for the support. Yes I consulted with a number of people and while they all have an opinion, it really comes down to just simply making an informed choice that you can live with. Mentally, it is also a choice that I felt in my case I needed to make.

Thanks Halbert for the "shopping list" . What really was the deciding factor was speaking first hand to close friends similar to me who had the operation and them taking me through the "experience". They now all cycle, rock climb and gym still and have little or no SE.

Alex

Well best of luck to you, and may you be in the lucky group as far as long lasting sexual and urinary SEs go! Since you are in such a low risk group, there should be no need to "cut wide" as they say, and they most likely will attempt full nerve sparing, so your odds are pretty good. I suggest you push them about an aggressive post op penile rehab approach to maximize your odds. That didn't do much for me, but it might make a world of difference for the lower risk and nerve spared guys.

Good luck!

Alex, welcome back! The next great day is when the catheter comes out. I promise, you won't miss it a bit. Keep moving, keep hydrated. In a week or so, get your doc to prescribe cialis to take daily to start the rehap process.

I'm in roughly the same age group and was diagnosed at 52. I followed AS for 4 years until my cancer progressed slightly and then decided the risk reward ratio had tipped in favor of surgery. I'm very happy with the surgery results. I would echo Teacher Lady's advice to find the best doctor available.

Hi All

Some more feedback to this wonderful forum.

If you recall, I had the radical on the 16th September. 5 days hospital. Then home for 2 weeks with catheter. Catheter was a hassle but not really a big deal. The up side is you do not need to think about having pee. It is on auto mode!
Post operation biopsy came back and it seems I dodged a bullet as the cancer was larger than expected than the initial biopsy. Good news is the the margins are clear! So I assume that I am done with the pc. Glad I now had the radical.
At home walked a lot. Took it easy. Drank lots of fluid. All helped. Very few pain killers. Sometimes one in the evening just to calm things down. Stool softeners were heaven as it just made any constipation history. Highly recommend Movicol.
Two weeks after discharge from hospital I had the catheter out. Was expecting a bit of a pain but just some tugging and weird feeling and out it came..... with a bit of a fountain. Pretty nurse said all standard procedure.
Then on with a pad and off home. What a relief...freedom!
First day of catheter removal, i leaked a bit into pad. By next day very little. 3rd day can control urine very well. No issues at night at all. I can stop and start urine stream at will. Urinating while standing seemed to be easier. Hopefully this means that incontinence will not be an issue. Today, 4 days later, took pad off.
Only issue I have and here I am asking for advice.... is it normal after catheter removal to have a sensitive urethra? I assume so. When I pee, the length of the urethra is quite sensitive and sometimes you need to stop urinating. After few seconds I just urinate again and then have reasonable steady flow with little or no sensitivity. I also seem to be urinating more often but volume not as much as pre-operation. I gather your bladder shrinks a bit? Also stream pressure is not what it use to be. Does this improve?

Walking around helps a lot. I just increased distances every day. I do find that the cut becomes sensitive with too much walking and acts as a signal to slow down. Almost like your clothing irritates the cut a bit.

Drove a car 2 days after catheter removal. No problem at all but I will wait a bit more.

Whether little "Johnny" is working again or not, I am not sure yet. However there are already positive signs that he is waking up! Urologist has give me cialis 2,5mg per day to increase blood flow and healing.


Will keep you updated.

Kind regards
Alex

Hi Halbert

Pathology post operation showed the following:

No malignancy in bladder neck
Left lymph node - no disease evident
right lymph node - no disease evident
Gleason 3 +3 = 6
Proportion of prostrate involved with tumour = 40%
Dominant nodule 15mm
Margins clear
pT2c

Pratoman said...
....19 seconds (up from 12 seconds at most, right after surgery (yes, i took my iphone to the bathromm with me and used the stopwatch to time it.
For no apparent logical reason, i decided to time it again today, 9 months post op and my pee lasted a total of 26 seconds from start to finish,....

Got to love Pratoman's postings, if he doesn't know he says so and if he does know he is specific!

ETA to be clear, I grinned when I read his post because timing my pee by my phone is exactly the sort of thing I would do, and have been thinking about timing.

Post Edited (Ken) : 10/8/2015 9:07:19 AM (GMT-6)