Two opinions .. so far

If you talk to four different specialists, I do think you're likely to end up with four different treatment recommendations. And with your diagnosis, just about ANY treatment has an excellent chance of curing you. Once you have all of your opinions, you're going to need to weigh all the advice and see what treatment is best for you. Not an easy thing to do, but you have lots of time to make a decision. (And we're here to bounce things off of!)

Re AS, ideally it's viable forever. If it's not, a good program should be recommending treatment for you long before it ever progresses to a point where treatment success is less likely. (Although as you get older, surgery does become more difficult to recover from.) And remember, future treatments are likely to be better than current treatments.

I'd go with the beer.
Beth

Andrew,
Only six??? I thought it was eight. :)

rainwest said...
The meeting was much more upbeat and I left less worried, but wondering how long AS really is viable, doe sit just make surgery eventually more difficult? She said only 30% of similar cases end up progressing under AS.

Hi rainwest,

Glad to hear that your educational journey is progressing. Have you encountered any of the works/words of Dr Ian Thompson? He's a well-known PC specialist who is in a lot of the literature. One of his recent quotes speaks directly to your question above. Dr Thompson wrote:

“...if you have a choice of a dollar today or a dollar 10 years from now, take the dollar today. But if you have a choice of a curative treatment for prostate cancer today or a curative treatment for prostate cancer 10 years from now, choose it 10 years from now.”

Had the third consult today, with the local RO. Again he was very helpful, and we already know him since he treated my wife. Again it was encouraging. And so far none of the physicians have seems to be pushing their own solution. The radiation they do is IMRT with Calypso radio transducers using a Trubeam STX. Total would be 79.2 gy fully fractionated over 44 sessions.

He was quite up front that in his opinion BT gave a bit better results. They used to offer it but Dr. Swift who did all the Brachy moved to Stanford.

All in all a good an informative session. He fully agreed with the UCSF approach to get the 2nd path report, the genotype testing, and then the MRI fusion biopsy in Feb/March. "Right now you are just information gathering," he said. "You can afford to take your time."

Next up will be getting an appointment with a UCSF radiologist and finding someone who is a BT specialist.

It seems that for me, now, the AS is really delayed treatment, at least until I get more info, enough to make a decision.

It does seem, though, that I'm 66 now and in good shape, very active, and ten years down the road I'll be 76 and who knows what kind of shape I'll be in, so the surgery and radiation options may not be the same.

Even so it is not a choice between now and 10 years, just a month by month choice.

As Halbert said and I want to reiterate, AS is a treatment plan if properly pursued....it is not watchful waiting or delayed treatment.

Regarding prostate surgery, it just isn't performed at age 76. Patrick Walsh, who started the nerve sparing process, would not operate on men over 70 unless they brought both parents to the consultation. So surgery is either a now or never option in my opinion . As for radiation it is not age limited. My brother-in-law used IMRT three years ago at age 75 and is doing great. He had a low involvement G7. So radiation is a very viable option for men as we age.

For effectiveness, low side effects, and your convenience; HDR Brachytherapy and SBRT appear to me to be the best choices. One week of treatment, no cutting, no catheters, no hospital stay and very effective cancer control. A lot of positives. I would next seek out the very best practitioners of these methods and consult them. On the west coast you have several well known choices for each method, but you need to speak to the people who actually perform the specific method. A permanent seed LDR brachytherapy practitioner should not be relied upon regarding HDR and vice versa. Same with SBRT. The rad-onc that uses IMRT is not the SBRT specialist.

rainwest said...
ten years down the road I'll be 76 and who knows what kind of shape I'll be in, so the surgery and radiation options may not be the same.

Even so it is not a choice between now and 10 years, just a month by month choice.

Hopefully, that may be more a quarter by quarter by quarter or year by year choice.

Look how many changes have occurred in the last ten years. Five years from now things will likely look different treatment wise. New genetic testing continually coming on line, ION beam radiation may well be a choice for treatment, more tracking data, clinical trials finishing, etc. The field is dynamic, not static.

I would venture to say that things may well look different to/for you if you can viably remain on AS for three years.

All sorts of things can happen. Who knows? The horse may talk.

Active surveillance is a proactive, prospective therapy (not a treatment) to measure the pace of disease progression (or lack thereof) by regular monitoring AND instituting treatment based on pre-defined changes in the monitoring tests.

You are not, by the way, “on AS” while you are exploring options. Quite the contrary, you certainly are a candidate for AS but you need to be further vetted and ultimately carefully selected.

There have been tweaks to the protocol over time has usage of AS has grown and a larger base of experience has been established. This has resulted in a loosening of the criteria because of the high levels of success. For example, many 3+4 favorable-risk patients are also included in AS (based, of course, on the unique individual case characteristics besides Gleason score to be the deciding factors). For those who do ultimately go on to treatment, delayed treatment for patients with small, lower-grade prostate cancers does not compromise curability…the success rates for those men are the same as those who seek immediate treatment; of course the benefits are that a significant percentage of men never need treatment, and for those that do the future treatments are superior to current technology.

The best AS programs also include dietary and lifestyle changes to influence the natural biological behavior of what’s been found. If you’ve got lousy diet and are unwilling to change, or you have no intent on ever exercising even if you’ve been told it will improve your odds of success (and longevity), then you might not be a good candidate for AS.

Look at AS as a means to effectively preserve curative options. You can look at the changes in the last 10-years as a guide to the next 10-years. First of all, look at the emergence of the less aggressive approaches. Today, if you were 76, had been on AS for 10-years (which verified slow growth PC), but a pre-defined threshold was passed and you wanted treatment, you would probably go in for a SBRT blast and be done with it for the rest of your days. 10-years ago, that wasn’t an option. HIFU is not really ready for prime-time today, but in 10-years it would be ideal (my crystal ball says) for such cases.

Secondly, if you have low-risk PC that you monitor closely on AS for 10-years until you are 76, then you can be confident that it will not suddenly and dramatically change…PC biology doesn’t work that way. After 10-years you might not do anything aggressive if you did surpass the pre-defined change limits because it would likely take years and years, decades and decades more for that already verified slow growing PC to advent itself in any initial symptoms.

Thirdly, as mentioned above, success rates for treatments improves over time.

These are the three key reasons Dr Thompson says to avoid unnecessary aggressive treatments today if you are in the low-risk category.

-Norm

Post Edited (NKinney) : 11/12/2015 10:24:45 AM (GMT-7)

FWIW Rain: I've formed the following rough plan (pre-biopsy results) for my beloved prostate which aligns with some of this thinking, I offer it here purely as an illustration of my own thinking (I have yet to vet it through the guys here and will await my results before I do that officially rather then tempt fate). If I come in at a higher Gleason next week then I have to start further down the list; such is life.

0. Pray I wake up and this is all a bad dream
1. Pray for benign
2. Pray for G6
3. Do AS as long as it is medically prudent to avoid SE's with little/no increased risk according to established experts like Ballentine Carter
4. Consider focal therapy to buy (more contingent upon 3.) time with low risk of SE's
5. Proton Beam or SBRT or HDR to seek cure with low'ish risk of SE's
6. Some funky Immunotherapy that is currently in a test tube.
7. Drop dead at 86 running away from a young lady's shotgun wielding husband

All the time the clock is ticking, I'm pushing my missus around the carpet and medical science is advancing.

NKinney said...
You are not, by the way, “on AS” while you are exploring options. Quite the contrary, you certainly are a candidate for AS but you need to be further vetted and ultimately carefully selected...

Thanks, I guess I wasn't clear but that's exactly where I am right now. Until I get the 2nd path report, genotype testing and 2nd biopsy it's still research.