Very important 2-4 week stretch for me....selecting treatment.

The journey begins.....

I have some general questions/comments for the membership.

I am a stat guy, so the numbers state that about 200,000 men in the US get a Pca diagnosis every year and that about 30,000 men die from it every year. So, as years go by, many, many men are LIVING with Pca. I believe there are over 2 million survivors and with the numbers above, survivorship will only continue to grow.

You see my stats below my posts. Am I one that can be 'cured', or am I mostly one that will live and fight this disease for years and years until one day there is no fight left in me? I can only assume that it is unknown at this time. That is the frustrating aspect of Pca and selecting a treatment option.

My initial thought about surgery is, if the Pca is contained, then cut it out, that's it, 'cured'! If not, then it's onto radiation and drugs the rest of my life. OR is it? If surgery fails, can radiation after surgery still 'cure' you (me)? My biggest fear about surgery first, is them going in, finding that the Pca is not confined, and therefore, in my opinion, doing it (surgery) for nothing.

How about radiation alone, without surgery? Can that 'cure' you (me), or more specifically, in my case, can a 4+3 and minimum T2a be cured by non-surgical methods, or am I dreaming? If I assume I cannot be cured, then why would I go thru surgery with which could potentially lead to some pretty significant side effects? Maybe I would select quality of life over quantity of life.

As all of you out here, I am starting this journey with the hope of a cure and living another 20-30 years and hoping that something other than Pca gets me in the end. Is there reason to hope for such an outcome based on my stats and the current treatment options available to me? It's funny (not really), but my urologist told me when we were discussing my biopsy results, that he intends to 'get me to' 68 (I am currently 54). I think what he meant, was that 14-15 years could be an acceptable target and if we get that, consider yourself fortunate. Or, he could have just been referring to basic Pca survival stats that say upwards of 90% of Pca patients survive 15 years now. I can't help but wonder if those numbers are heavily loaded with those patients with numbers less than 4+3.

In my short time out here, I have found so much valuable information. I will continue to seek you out and ask for guidance. I know the decision is mine, I just wish the science was more exact. I'm sure one day, it will be, and hopefully, my two sons (ages 21 and 18) will benefit from it.

Enjoy your week and I'll be in touch.

J

Yes, you can be cured. The most problematic part of your diagnosis is the G7 (4+3), which bumps your risk profile a bit. (Assuming it is a 4+3 and not a 3+7...have you had a second opinion from Bostwick or Epstein?) But even with a 4+3, you have a very good chance of doing well and there are (many) guys that are Gleason 8s and 9s that can be cured. (I'd like to think I'm one of them...)

As to whether "radiation alone" can you cure you versus another treatment, there's nothing definitive in this game. That said, I think it has an equal to better chance than surgery since it treats a wider area than surgery. The problem with more aggressive diagnoses is that if it has eased out from the prostate, surgery needs radiation as a back-up anyway. As a result, some guys with more aggressive cases simply choose to cut to the chase and start with radiation.

As to your life expectancy question...I'm 55 and in good, but not great shape. I eat well and work out regularly, but should push myself harder. I'm 5' 10" and weigh 180 and probably should lose 10 pounds. I'm on statins, but it does control my cholesterol. Compared to my peer group, I'd give myself a solid "B" grade. When I put all of that info into a calculator, I have a 10-15% chance of dying of a heart attack within 15 years. Even as a G9, that's higher than my chance of dying of PC.

I think the period in which you choose a treatment is the toughest part of this game. But since the odds are in your favor being cured, I think you should assume that you will be cured. That means picking a treatment based on its potential SEs. All treatments have them and most guys can tolerate certain ones better than others.

I feel for you...I was a basket case when I was in your shoes. But when you pick a treatment, it's just a matter of moving one foot in front of the other until you're done. And you will be done and while there's no guarantees, the odds are you'll have done well--even as a 4+3. Good luck to you!

With your diagnosis both surgery and various forms of radiation offer the same cancer control statistically. Surgery is also statistically shown to have more significant side effects. But you are not a statistic and no one can say for sure what your exact situation will be

At your risk level I believe the choice should be for the treatment that. Statistically provides the least significant side effects. That points to radiation particularly the HDR brachytherapy and SBRT. These use the most modern radiation technology to achieve the highest level of cancer control and the lowest level of side effect significance. Both have a long enough track record to provide statistical validity and reliability.

However you have to have a long time with undetectable PSA to say you are cured. This cancer can come back after 15 years or more and present problems. That is not common but it happens. My wife gave me great advise. Look at this as managing a chronic disease like diabetes. Do it right and something else will get you hopefully at an old age. My two cents worth and successful five years worth from a high risk situation says to use leading edge radiotherapy for cancer control and the least significant side effects. By its very nature surgery must do significant damage to do good. That is true of any surgery. The best forms of radiation simply do less damage but get equal cancer control.

Good luck and let me know how I may be of assistance

Jack

Hi JayMot,

Your nervousness is certainly understandable and has been felt by all of us. I'm a stat guy myself, and I find that knowledge relieves my anxiety, as does my practice of Mindfulness.

I'll try to address your questions.

The gross incidence/mortality numbers - I'm afraid that doesn't tell you much. Prostate cancer is never fatal for a lot of men, which may be because they did not have a virulent strain, or because treatments cured them, or because treatments allowed them to survive long enough that something else killed them first. It has a very long natural history, so detection of PC now, may result in a death 20 or more years later.

Can you be cured? - Probably so. You have what NCCN calls "unfavorable intermediate risk" prostate cancer. So your chances of a recurrence after treatment is better than the high risk guys but worse than "favorable intermediate risk" or low risk guys. The probability of remaining free of a biochemical recurrence within 5 years of treatment ranges from 60% to more than 90% (depending on the therapy and the institution), so odds are in your favor. The success depends on how well contained the cancer is. Your doctor may want you to have a bone scan and CT to assure that there are no distant metastases.

The reason that most studies report "biochemical" recurrence (meaning PSA rises significantly) rather than prostate cancer survival is because it takes way too long to determine the length of survival. At your risk level, the odds of surviving more than 20 years with treatment is probably over 99%. You can check your predicted stats on this nomogram.

Surgery. Johns Hopkins reports 5-year recurrence-free progression probability of 63% after surgery for men with Gleason 4+3. (and about 50% after 10 years.) This is because Gleason pattern 4 (unlike pattern 3) can escape the prostate and seed into surrounding tissues or metastasize distantly. If you're lucky, it is still completely contained and surgery is curative without further treatment. Sometimes they do adjuvant or salvage radiation, but that significantly raises the complication rate.

Radiation. A recent study (see this link) observed unfavorable intermediate risk men who were mostly treated with a combination of external beam radiation with a brachytherapy boost (some had ADT as well). After 15 years, 93% remained free of biochemical progression. This is because radiation treats areas outside of the prostate as well. This kind of combination therapy has been found to be the most effective. Similar results have been reported for both kinds of brachytherapy (high dose rate and low dose rate) given as a boost therapy and for SBRT. The key is a high dose to the prostate and wide margins, with excellent image guidance to limit toxicity.

It falls to you to get out there and talk to doctors who are specialists in each kind of therapy. If you care to say where you are, we can probably make some recommendations.

Tall Allen,

I am located in Metro Philadelphia.

I did have a bone scan last week. Clear.

CT Scan was denied by my insurance, but I will appeal. Dr. did not supply all the info they were looking for. Not sure what CT Scan will find.

Already set up surgical consult with Dr. David Lee, Chief of UPENN Urology on March 31, 2016. He did surgery on my buddy and his Bio mentions over 2,220 RALP surgeries. Does he actually do them all, or just the 'major' part of each surgery? That is a question I will ask him.

I am also setting up Radiation Oncology consult with Fox Chase outside of Philly. They do all, including HDR Brachy and Cyberknife, IMRT, SBRT, etc.

I looked into Proton Therapy, but my insurance lists it as 'investigational' and will not pay for it. UPENN Roberts Proton Center has a blind trial, and my insurance will pay, but I would get either regular radiation OR proton therapy on a 50/50 coin flip. I am looking into self pay with financial assistance.....that is, if I really want this option.

I guess every consult may be a 'sales' pitch also. Right now, leaning on RALP with Dr. Lee.....unless someone blows me outta the water and convinces me otherwise.

Thanks, Tall Allen, you have been most helpful.....and have been helpful. I read you on many other posts too!

J

HI Jay, Welcome to HW and sorry you have to be here. You already got some great advice on your questions so I just want to wish you luck in your decisions. Looks like you read/investigate a lot so I'm sure you will make a decision you will feel good about. Good luck and let us know what you decide and how it all goes with your journey. Take care. -JR

Jay - So sorry to read that your insurance denied the CT scan! Those kind of things get my blood boiling...

My husband had a similar DX to yours, although a little lower on the Gleason scales (G7 favorable). After almost 4 months of research and consults, he went with SBRT at the Cleveland Clinic. Treatment concluded 12/2015, so he's only a few months out, but he was happy with both his decision and treatment plan.

Two things I wanted to say:
1) Be sure to allow yourself enough time to make a really informed decision. While I can understand your desire to get the ball rolling, this is not something you want to rush.
2) We must have read on this forum 100 times that once we made the decision on what treatment to have, we'd have a peace about it all and relax. Well, let me confess that no matter how many times we read it, I just did not believe it. But guess what -- it's true!

The journey you're on is not an easy one. We wish you the best.

Suz

Tall Allen,

Are all, or most, cyberknife doctors and centers the same? You mention Brady in Philly, but Fox Chase also has cyberknife. Would going there be significantly different (worse) than Brady in Philly? I say that because I have a consult with Fox Chase on non surgical options. My surgical options will be discussed at UPENN, simply because I researched the surgeon and personally know 2 of his patients.

Thank Again!

J

Hey guys,

All these Dr.'s and hospitals want all my records....no big deal, but you know what, my last PSA test was last Aug 31, when it came back 2.5. These places want my current PSA, so I am going to ask my Uro for a script to get my latest PSA. I have been reading some things about what not to do do prior to the test. Not that is matters now, but everyone wants my PSA # and I guess I gotta get it.

So, what can I not do prior to the PSA blood test? Remember also that my 13 needle biopsy was 2/22/16. Is there a waiting period from that point, too?

Thanks again.

J

Tall Allen,

I read sometimes where PSA jumps considerably in 6 months.....I was just wondering if I was one of those guys....2.5 6 months ago and "who knows what" now.

Tx.

J