Surprised by the urologist

On Friday I consulted with the urologist who performed my fusion biopsy at UCLA and found a 4+3 left anterior 1.3cm. I had already obtained my ct and bone scans which both came back negative for signs of metasasis. So I was in a good mood! The second opinion on the biopsy from Dr Epstein had not been received yet.

He re-read my file and congratulated me on being a case study for his fusion biopsy finding what a mri-guided biopsy and a color doppler guided biopsy both missed. I agreed that I was glad I kept looking due to my high psa's.

He asked me what I wanted to do. I said I believe I need to attack it, and let's go through my preferred options together.

First, focal laser? He said no way, I don't qualify for his experimental program and my psa is too high anyway (last one 21.9 last month before the biopsy).

Second, HDR and SBRT? He said they are better than AS or focal, and the top guys are here at UCLA. But, since I'm young (age 58) these choices aren't too good because I should expect worsening side effects as the years go by, even with these more precise techniques. I told him I understand there's a patient tracking study of nine year results that look very attractive regarding both non-recurrence and fairly light side effects. He said doctors can spin their numbers! Not exactly a confidence building statement for his own recommendations.

Third then, surgery? He said definitely yes in my case. Get it out and then no worries about what's left behind. Also, he said with surgery you can use radiation as a salvage therapy but not the other way around. I said I believed that's a bit of a canard nowadays, plus if I'm at risk of needing salvage therapy then why would I want the side effects of both surgery and radiation. He said save the radiation for later.

Wow. It's one thing to read those points of view on websites and be able to put them in a context. But when your own high reputation urologist is saying those points in a 1:1 meeting, then it puts on a lot more weight and credibility. How is it that prostate cancer and treatments can be so peculiarly subjective.

I was planning to see another urosurgeon anyway, so maybe this changes my perspective towards treatments before having the consultations. Tomorrow I'll make appointments to see the HDR and SBRT experts at UCLA, plus see one or two urosurgeons.

Actually, you wouldn't want a surgeon who didn't think that surgery was pretty neat. That's why it's up to you to talk to doctors in a number of fields. It sounds like that's what you are doing. Just give a little less weight to what they say about the other guy's specialty and go with the one who gives you the best story.

Jim, at 3+4, chances are that surgery would be once and done. In fact, any of the common treatments for are likely to be curative. With no probable EPE or metastisis, the decision is up to you. The whole thing rolls down to side effects of the primary treatment, and which ones you're ok with.

Worrying about what your possible salvage choices are is moot at this point. If salvage is needed, it's needed. Planning based on it's probability is not the point. For me, I chose surgery for the common reasons...and some personal ones as well.

Keep looking and talking to experts in the different treatments. The light will dawn.

He is right about one thing, doctors can spin their numbers ..and he can too. It seems the surgeons are the most adamant about the shortcomings of radiation and the most likely to spin surgical results. Or so it seems to me. My own uro, when I brought up the subject of possible treatment simply said "the surgery". I said I wouldn't do surgery so what would be his second choice..he actually said SBRT, being familiar with the new Vero setup at Upstate Medical. I was fully prepared to kiss him goodbye if he was adamant, though. There are a lot of uros out there.