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Is surgery ever the right choice even for aggressive PC?

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Posted 6/8/2016 5:38 PM (GMT 0)

alephnull said...
Wow, took a post about surgery for high risk PCa G8 - G10, and turned it into another AS for all G6 (low risk) discussion.
Well, G6s don't get it. You likely won't die and so maybe AS is best for you. I don't care. Honestly, for your sakes I wish they would reclassify G6 as pre-cancerous or not cancerous.
So it really has nothing to do with this thread.

If I hadn't had surgery we wouldn't have known I am really a G9 not a G8. Wouldn't know it had escaped the capsule. Wouldn't have known of the seminal vesicle invasion. Wouldn't have known of + margins. And wouldn't have known about my positive lymph nodes.

So, I had surgery, found all this useful information and am being properly treated for it.
In my case surgery was very much helpful.

And the things you mention are really the point I was trying to get discussed in this thread. I can not be accused of having been a fan of PC surgery or a cheerleader for the treatment I had(surgery), not at all. In fact, if anything, my (strictly personal) opinion has been more like no one should have surgery.

However, having reviewed Bobby Mac's signature, the light bulb went off: at least for the probably not small group of people in Bobby Mac's situation ( and apparently also yours), in retrospect at least, is there any other treatment that would have been as appropriate ( leaving out personal preferences for now) as surgery? For both of you, with any other treatment choice, you would have had no knowledge of those nodes. And evidence of that might not have shown up for quite a while, giving plenty of time for more spread. How was it not useful for you to have this info? Then, maybe, maybe not, add any possible benefits of removing the main tumor, I guess that is still debatable. I can only think of a couple of studies where when, rather than following the standard of care and closing people back up prostate intact when they found a positive node, instead they did the RP, those patients did a good bit better as far as survival than the one's who did not get RP. But I don't know if those studies have been confirmed or proven wrong.

Of course the question is: how does one know if they are in your shoes if they don't have the surgery with nodes checked? Some other form of testing?
Posted 6/8/2016 6:20 PM (GMT 0)

BillyBob@388 said...
...no benefit ... useless info


a false security is not the same as "no benefit"/"useless info"

It is absolutely a false security for someone to choose surgery over any other mode just because they think their pathology report will tell them everything they need to know...as demonstrated in this case. Yet, we've seen instances here at HW/PC where men have given that as a primary reason.

I'm sorry if my comment got misunderstood...I get tired of people putting words in my mouth. I'll try to be more clear...
Posted 6/8/2016 6:21 PM (GMT 0)
I will admit to having a bias for radiation for high-risk guys as that was the path I chose and--knock on wood--it seems to have worked out. My thinking was that 1) it treats a wider area (and BTW, my lymph nodes were included) and 2) if you have a good chance of needing SRT (often the case in high risk guys) those SEs can be more difficult than if you had radiation as your primary treatment.

But...(and this is a big "but." I wish I could make the text on that word larger)...those were the things that were important to me and they're clearly not as important to other guys. This thread shows that for many it was more important to specifically know their pathology and have a really good look under the hood. Similar to some of JNF's comments, those things didn't matter to me, but clearly they do to some other people.

So based on my own thought process and personal preferences, I do think radiation is a better protocol for high-risk guys. But like everything else here, some guys might come to other conclusions and I think it's perfectly valid that they do so. I think the key is being thoughtful and sifting through the evidence, data and medical opinions and lining them up against your own preferences.
Posted 6/8/2016 6:36 PM (GMT 0)
I had a larger reply written, but decided against posting.

Everyone is different and since we are, treatments should be individualized no matter the opinions of others.

G6s AS or RP or RT or HT or whatever, your cancer your choice of treatment

G7-G10 RP or RT or HT or whatever, your cancer your choice of treatment
Posted 6/8/2016 6:58 PM (GMT 0)

JackH said...

BillyBob@388 said...
...no benefit ... useless info


a false security is not the same as "no benefit"/"useless info"

It is absolutely a false security for someone to choose surgery over any other mode just because they think their pathology report will tell them everything they need to know...as demonstrated in this case. Yet, we've seen instances here at HW/PC where men have given that as a primary reason.

I'm sorry if my comment got misunderstood...I get tired of people putting words in my mouth. I'll try to be more clear...

I agree a path report will NOT tell you everything you need or would like to know about your PC and it's possible spread. But it will, of course, tell you about several negative possibilities that most will want to know about. And, if there is no indication in the path report of spread, it certainly does put the odds more in your favor. For example, even a G9 who is SV-, LN-, and has no positive margins, has clearly better odds than the guy who is the opposite. Definitely useful info, even if it could be better, and maybe tell us "you are cured" or at least "definitely no mets so far", though SV-/LN-/clear margins comes pretty close to that latter.

But of course, as in all matters re: life and death, no guarantees.
Posted 6/8/2016 6:59 PM (GMT 0)
I sorta agree with this...

alephnull said...
I had a larger reply written, but decided against posting.

Everyone is different and since we are, treatments should be individualized no matter the opinions of others.

G6s AS or RP or RT or HT or whatever, your cancer your choice of treatment

G7-G10 RP or RT or HT or whatever, your cancer your choice of treatment


...except for these points:

(1) "...your cancer your choice of treatment" sounds whimsical. For unfavorable risk cases especially, it really depends on much MORE than just Gleason scores.

(2) AS is one of the appropriate choices for 3+3 and 3+4 cases where all other factors are also in the favorable risk category...you mistakenly grouped "G7"...this is why doctors generally use the individual Gleason grades, not the overall score; because they are so different in many ways. (But even this oversimplifies it...in some 3+3 cases, AS is the ONLY treatment mode recommended by the NCCN.)

(3) "...no matter the opinions of others." What the heck is that!? I think many different medical opinions from different PC specialties are appropriate.


Other than that, I agree.
Posted 6/8/2016 7:03 PM (GMT 0)

BillyBob@388 said...

JackH said...

BillyBob@388 said...
...no benefit ... useless info


a false security is not the same as "no benefit"/"useless info"

It is absolutely a false security for someone to choose surgery over any other mode just because they think their pathology report will tell them everything they need to know...as demonstrated in this case. Yet, we've seen instances here at HW/PC where men have given that as a primary reason.

I'm sorry if my comment got misunderstood...I get tired of people putting words in my mouth. I'll try to be more clear...

I agree a path report will NOT tell you everything you need or would like to know about your PC and it's possible spread. But it will, of course, tell you about several negative possibilities that most will want to know about. And, if there is no indication in the path report of spread, it certainly does put the odds more in your favor. For example, even a G9 who is SV-, LN-, and has no positive margins, has clearly better odds than the guy who is the opposite. Definitely useful info, even if it could be better, and maybe tell us "you are cured" or at least "definitely no mets so far", though SV-/LN-/clear margins comes pretty close to that latter.

But of course, as in all matters re: life and death, no guarantees.

I think we're on the same page, BillyBob. Someone else (halbert) in this thread wrote: "And it is the most understated advantage of surgery over RT/HT treatments. That it is ONLY with surgery that you know beyond doubt what you're dealing with. That's a high degree of false security.
Posted 6/8/2016 7:04 PM (GMT 0)

Michael_T said...
I will admit to having a bias for radiation for high-risk guys as that was the path I chose and--knock on wood--it seems to have worked out. My thinking was that 1) it treats a wider area (and BTW, my lymph nodes were included) and 2) if you have a good chance of needing SRT (often the case in high risk guys) those SEs can be more difficult than if you had radiation as your primary treatment.

But...(and this is a big "but." I wish I could make the text on that word larger)...those were the things that were important to me and they're clearly not as important to other guys. This thread shows that for many it was more important to specifically know their pathology and have a really good look under the hood. Similar to some of JNF's comments, those things didn't matter to me, but clearly they do to some other people.

So based on my own thought process and personal preferences, I do think radiation is a better protocol for high-risk guys. But like everything else here, some guys might come to other conclusions and I think it's perfectly valid that they do so. I think the key is being thoughtful and sifting through the evidence, data and medical opinions and lining them up against your own preferences.

Well, if you can have your nodes radiated at primary treatment, then maybe that again knocks out some of the advantage of the surgical path report.

Is that normal, to have the nodes radiated? I suppose that could not be done with BT? How did you know to radiate your nodes, if it is not routine?
Posted 6/8/2016 7:22 PM (GMT 0)
#1 You do know my using Gleason scores is simply a way of categorizing severity, don't you? Come on Jack, you caught that, right?
As for G7s, no, no I didn't group it wrong. Even if the patient is a 3+4 they are considered intermediate risk. If they have a 4, then they have fairly aggressive cancer in their body.
But the point is, it's the patients body, it should be the patient's choice of treatment. And as you stated in #2, AS is just ONE of the appropriate choices of treatment. And as such, the patient has the right to choose their treatment.

#2 "AS is ONE of the appropriate choices". I would classify having a 4 in your Gleason scores as being unfavorable. After all, it is an opinion. And as you said "where ALL other factors are also in the favorable risk category", since all is a logical construct that does not allow escape from the subset, then all other treatments are on the table.

#3 was a reference to persons on forums who THINK they know best for the rest of us. But I will include clinicians also, as the clinician is to examine, inform, advise and treat (this is not an exhaustive list). Notice I didn't say the clinician has the right to make the choice of treatment.
Posted 6/8/2016 7:26 PM (GMT 0)
One thing I have taken away from this thread and many others:

We have a few with a particular ax to grind. Hence, all kinds of threads will be transformed into one that fits the obsessed agenda.

Some others chose tx. XXX rather than YYY and consequently they do not hesitate to advise XXX as the best tx.

That's unfortunate, but it takes all types to constitute a village!

Mel

Post Edited (compiler) : 6/8/2016 3:48:48 PM (GMT-6)

Posted 6/8/2016 7:34 PM (GMT 0)
I believe having your lymph nodes radiated depends on the particular plan that your RO puts in place. That said, with high risk guys I do think it's common. (Can others confirm that?)

Does anyone know if SRT typically targets the lymph nodes?

For me it was through the IMRT part of my combo treatment. (And I wonder if that has a role in the fact that combo treatment has better stats with high risk patients.)
Posted 6/8/2016 7:36 PM (GMT 0)
Interesting topic Billy Bob.

My surgery roommate who was diagnosed as a 4+5 ended up with a very poor pathology. Svi+ Margins+ I think 3 lymph nodes +. I thought after we got his pathology that MAYBE radiation would have been a better choice. Especially the HDR. We have become friends since we met and I would never had made that comment to him because I strongly believe there is no point to second guessing your decision once treatment is done. If it crossed his mind and he brought it up for discussion I would comment otherwise no chance in hell. But I had not thought of it in the way you brought it up with this topic.

With this knowledge from the pathology he is left to decide whether to attempt radiation. They have stated he probably would have only a 20 to 30% chance of being successful. He also knows that HT will play a big part of his life to battle this and that the odds are he will probably die from prostate cancer. With this knowledge he may be able to have a treatment plan with the HT that is more suited to his poor prognosis. I also think it has allowed him to sort through many things he wants to do with his life and come to terms with the consequences of the continuing treatment that he may need. Now I have to assume if being SVI+Margin+LymphNode+ puts him in a category of only 20-30% chance at best of radiation working now then that would lead me to believe if radiation was his initial choice he still would have had the same percent chance but he would not have known that and it may have taken some time before it metastasized for him to know. Similar outcome but without the knowledge he would likely not have been as prepared. Also knowing ahead may help him to look into some trials or investigate treatments that may prolong his life and slow down the progression.

Now I don't claim to have all the knowledge on this subject at all. Nor have I really thought this out thoroughly as I just read your topic. But your thread has me thinking in a different way as to the choice he made. Very interesting indeed....Jim
Posted 6/8/2016 7:43 PM (GMT 0)
See? It aint just me. Think about that. Its not always what one says, but how one says it.
Posted 6/8/2016 8:24 PM (GMT 0)
Since you asked...my responses in bold

alephnull said...
#1 You do know my using Gleason scores is simply a way of categorizing severity, don't you? Come on Jack, you caught that, right? Yes, of course. I believe that patients should, and I would encourage them to, use the same nomenclature that the medical community uses...it's really part of a good "patient education." The medical community which cares for cancer categorizes PC by "risk category," and they do not use a category called "severity." You are, however, welcomed to make up anything you'd like for your own individual purposes.

As for G7s, no, no I didn't group it wrong. Even if the patient is a 3+4 they are considered intermediate risk. If they have a 4, then they have fairly aggressive cancer in their body. I thought this was more widely known, but since you raised this...Intermediate risk PC is split into two categories: favorable intermediate and unfavorable intermediate risk. AS is often recommended for favorable intermediate risk cases, but is not recommended for unfavorable intermediate risk cases.

But the point is, it's the patients body, it should be the patient's choice of treatment. It is. Always. That is why we encourage favorable risk men to take their time, learn about the true biology of favorable risk cases, and understand that there is generally no benefit to aggressive treatment. It often takes TIME to understand these things.

And as you stated in #2, AS is just ONE of the appropriate choices of treatment. And as such, the patient has the right to choose their treatment. Yes. Always


#2 "AS is ONE of the appropriate choices". I would classify having a 4 in your Gleason scores as being unfavorable. Maybe in your system of catagorization. See discussion above.

After all, it is an opinion. As I just said...

And as you said "where ALL other factors are also in the favorable risk category", since all is a logical construct that does not allow escape from the subset, then all other treatments are on the table. Sorry, cannot follow your attempt at logic.


#3 was a reference to persons on forums who THINK they know best for the rest of us. But I will include clinicians also, as the clinician is to examine, inform, advise and treat (this is not an exhaustive list). Notice I didn't say the clinician has the right to make the choice of treatment.For the 3rd time, it is always the patient's choice. It is not the clinician's choice.

Posted 6/8/2016 9:40 PM (GMT 0)
Jack, I don't like being taken out of context any more than you do. My statement about surgical pathology being 'better' is one of those things. Two choices: No surgery, no complete pathology. Or, Surgery which gives a complete pathology. Without surgery, no matter what other tools are being used, there is a LOT less information available to determine future courses of action. Is pathology perfect? Of course not. But, knowing "what is in the sealed box" is preferable, in certain situations to not knowing what is in that box.

Sigh.

The premise of the thread, as I understood it, was to pose the question: Are there times, for intermediate-to-high risk patients, where surgery is a preferred primary treatment? And the example of our friend Bobby Mack's pathology report was used as the beginning of the thought experiment.

Without that pathology report, that shows LN+, the patient could have gone through RT as primary and not dealt with the LN's, and been potentially listed as a 'failure' patient, because nobody looked at the LN. In this case, knowing is IMO better than not knowing...or assuming either way.

In general, I really don't get the animosity against surgical treatment by some here. It's a choice, a preference. It's not a character flaw to choose surgery.
Posted 6/8/2016 9:51 PM (GMT 0)
Best line in a long time:

>>>>>>>>>>>>>>
It's a choice, a preference. It's not a character flaw to choose surgery.
>>>>>>>>>>>>>>>>>>

Mel
Posted 6/8/2016 10:17 PM (GMT 0)
Hey, thanks halbert for your clarification. I think you'll agree now (at least that's how I'm reading your recent post) that the pathology report does NOT provide the information to "...know beyond doubt what you're dealing with." Maybe you didn't mean that the first time, but it's what you said. (BTW, directly quoting you is really different than the situations I've whined about when somebody has used different words than what I used then attributed it to me. When I challenge them to quote me, they clam up and go away.)


And just in case there is any uncertainty about where I stand on this question (not that anyone should really care), but I am completely NOT AGAINST any particular form of treatment (well, maybe proton beam therapy, for other reasons; ok, maybe HIFU, too, but also for other reasons) for cases that need treatment. I've said many times here at HW/PC that we should aggressively treat cases that need aggressive treatment, and not aggressively treat cases that do not need aggressive treatment! Period. Simple. The fact is, that some high-risk cases are under-treated in my opinion. So, I don't know if your comment about "some here" was directed at me or not, but now you can better know and understand where I stand...just in case you're interested, LOL!

Post Edited (JackH) : 6/8/2016 5:18:18 PM (GMT-6)

Posted 6/8/2016 10:27 PM (GMT 0)
Michael T and Billybob... Since I also had BT and IMRT (to extend the RT into the lymph node areas), which according to my MedOnc (Dr Lam), that it is normal for the high risk group. Like Michael T, I also chose this path since my Gleason was already a 9 so I really didn't need to worry about a post op upgrade and I wanted the extra zapping to grab any possible micro mets. I am still in treatment but I am happy with my path. -JR
Posted 6/9/2016 12:11 AM (GMT 0)
Wow, I'm amazed at the detailed opinions here on this thread. It reminds me of when I was trying to figure out what to do myself. The conclusion I came to was due to scar tissue adhering to the prostate from a previous colectomy. Stage one having about a foot of my lower colon removed. The next issue was my core volume from the biopsy. At a military treatment facility that was reviewed by another clinician. On the high side to say the least. And yes I heard all the advice to go to a center of excellence and also to have the biopsy reviewed by Epstien etc etc etc. I agreed to 25 rt to the general area and 20 to the prostate bed. 30 days of Casodex and 2 years of Lupron. Believe me guys I did not disregard anyone. I only made my mind up this was best for me. And then I went out and bought a pontoon boat that would take my mind off the unending research that gave me more questions than answers. My signature tells much of the story, but not the daily rollercoaster of ADT, or hoping my family will continue to stay close to me. Especially my wife of 36 years. I really don't think I'm at the forefront of anything here, just a guy who works, provides, and is dog determined to keep going. I got some things to do. This G9 dx will not keep me from it.
Posted 6/9/2016 12:40 AM (GMT 0)

RioMedinaBill said...
And then I went out and bought a pontoon boat...


Cool, Bill, from one pontoon boat (plus sailboat) owner to another. Being on the water is a great way to take one's mind off things. We are also about the same age...HS Class of '77...I'm still 56, but young for my graduating class.
Posted 6/9/2016 12:41 AM (GMT 0)
After reading these post i feel i am one of the lucky ones.I was originaly diagnosed as a 4+3 and i decided on open surgery.When i got my patholigy report i was a 5+4, negative sv, ln - margins.the cancer was outside the prostate and in the neck of the bladder and the left nerve bundle, PT3a. My docs told me if i had not had surgery i would not have lasted 2 yrs. I have had no RT, or HT, no treatment at all.I feel that surgery was the right choice for me and i don,t regret it . It is coming up to 4 yrs post op and my psa is still 0.00. I still have very little stress incontinece and ed but you learn to deal with that
Posted 6/9/2016 12:49 AM (GMT 0)

compiler said...
Best line in a long time:

>>>>>>>>>>>>>>
It's a choice, a preference. It's not a character flaw to choose surgery.
>>>>>>>>>>>>>>>>>>

Mel

yeah
Posted 6/9/2016 1:05 AM (GMT 0)

wingman63 said...
After reading these post i feel i am one of the lucky ones.I was originaly diagnosed as a 4+3 and i decided on open surgery.When i got my patholigy report i was a 5+4, negative sv, ln - margins.the cancer was outside the prostate and in the neck of the bladder and the left nerve bundle, PT3a. My docs told me if i had not had surgery i would not have lasted 2 yrs. I have had no RT, or HT, no treatment at all.I feel that surgery was the right choice for me and i don,t regret it . It is coming up to 4 yrs post op and my psa is still 0.00. I still have very little stress incontinece and ed but you learn to deal with that

Wow! Lucky you! What a great result for a G9 ( which you thought was G7 going in) spread to bladder neck/nerve bundle with surgery only! Fantastic! May my luck/blessing( and all the others here) chart a similar path!

So, you were non-nerve sparing apparently?

Hey, I just noticed you had surgery at Vanderbilt. same here! Joseph Smith? He would not spare nerves for me. Probably wise, though I have sure missed my nerves.
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