VA Radiation vs Surgery

I am new to the forum. I am 62 years old. Diagnosed in June with Gleason 3+4=7 and 4+3=7. 12 cores taken 2 came back positive. I was told that because of the 4+3 that I am not a candidate for AS. My healthcare is though the VA hospital in Indianapolis. It is a teaching hospital and I have had very good treatment for other issues. They offer the De Vinci Surgery or external beam radiation. . Met with my Urologist and he told me that because of my age and the later side effects of Radiation, he would recommend the surgery. He also told me that because I am overweight and have diabetes, that I am" not an ideal candidate for the surgery". I met with the radiation Oncologist yesterday and heard a much different story. We discussed the side effects, of this facilities radiation, and how they are much less sever that those of surgery. In his 8 years of working at this hospital he has had one patient who needed a catheter. The machine they use divides the beam into 7 parts that rejoin in the Prostate, so there is minimal dosage to the surrounding tissue. We also discussed hormone therapy with the radiation. One shot that lasts for 6 months. Radiation would start 8 weeks after the shot, so the prostate can shrink before markers are put in it for aiming. Side effects of the HT seem to be mostly hot flashes and mood swings.
My concern is if I go radiation first, and then need more treatment later, surgery after radiation is not usually, or easily done. I guess it all comes down to the question of Radiation vs Surgery, and HT or not.
I should mention , my brother also had PC at age 59. He was treated at Loma Linda with Proton Radiation and HT. He has no side effects 7 years post treatment.
Seeking any help.

The machines that deliver the radiation are called LINACS, linear accelerators. The newest equipment (Varian Rapid Arc or newer) are considerably more advanced than the older units still in service. They can be aimed more accurately and cause less healthy tissue damage..I would find out exactly what equipment your VA hospital is using and if it's more than 5 or 10 years old I would ask if perhaps a nearby hospital has newer equipment..The newer LINACS usually don't require the gold markers..I would also ask about Brachytherapy, seed implants. If your local VA hospital does not offer it, perhaps a nearby one does....The combination of seeds and beam radiation is the most effective radiation treatment...

welcome to HW, sorry you need to be here.

One thing to remember - when your only tool is a hammer, everything looks like a nail.

UROs are surgeons and recommend surgery, ROs do radiation. It's up to you to choose. The good/bad news is the likely either surgery or RT would be curable. Given your diabetes, going with RT might be a better plan. The long term effects aren't as scary as you think. Six months of HT won't be fun, but you can get through it.

Given your other health concerns, I think RT/HT combo is a great path to explore.

and if (a big if) radiation fails, there are plenty of follow on treatments - including surgery. Normally surgeons don't like to operate on parts that have been radiated, but it be done.

Hang in there and keep us updated on your progress,
Andrew

Actually, your doctors are correct:
Radiation after a failed surgery is certainly do-able whereas the reverse is not that easy at all (much more difficult surgery). That is an extremely VALID point and should be considered.

We have had this argument many times, and I've given up responding to it (I get tired). But I'll try again:

It is true that if SRT (Salvage radiation treatment) succeeds, you can then say that the surgery was unnecessary as most likely the radiation itself would have been successful. But that is specious reasoning as you DO NOT KNOW THAT going in. Hey, there are plenty of possible treatments. If you knew in advance that treatment X would have worked, then of course you would choose treatment X. But, GOING IN, you have no idea. I understand that you should try and pick the best first shot tx. But, again, the idea of having radiation as a back-up plan/hedge is quite valid. Your doctor is correct. I get villified when I point this out!

So, you need to look at your age and general health and choose your poison. The surgery SE will be more immediate and the SE should improve over time, but one never knows. In fact, I think surgeons tend to minimize ED. For me (a sample size of ONE): I had incontinence for 2 weeks and it resolved 100%. I had ED and still do to a degree. As a steady HW participant, it seems that my experience is VERY typical. You have to be honest with yourself and decide how important the SE is. I have to say that we have accepted the ED. I don't like it one bit, but I have accepted it. The incontinence would be miserable. Now, with radiation, many minimize the SE. My understanding is that they come on slowly over a period of a few years. Bowel problems and urinary problems can occur. I guess you can do the research. There are cases on HW where surgery went horribly wrong and cases where radiation was a disaster. But these are outliers. People have died during routine small surgical procedures.

This is not a cut and dried decision. It is not clear-cut. Be careful of those who always advocate one solution over the other.

It depends so much on your situation and you are unique in how you view things.

As an example of uniqueness, I've mentioned my situation where I had BPH for probably 15 years. Flomax was great for about 12 years. But, then, it kind of stopped working. I had great difficulty urinating at times. Twice, I had my jacket on about to go to the hospital for the dreaded cathaterization. Fortunately, things improved at the last minute. Had I not suddenly had the PC dx., I was looking into getting a green light laser tx. So, the BPH was one of the many reasons I chose surgery. In MY UNIQUE SITUATION (the BPH), it was a good choice. I have not had a repeat of that misery (being unable to pee).

Mel

compiler said...
br />Radiation after a failed surgery is certainly do-able whereas the reverse is not that easy at all (much more difficult surgery). That is an extremely VALID point and should be considered.

We have had this argument many times, and I've given up responding to it (I get tired). But I'll try again:

Mel

Mel, as you know I tend to disagree with your statement as written because i think it is incomplete. As I believe you also know, there are good salvage treatments available after a failed radiation as there are salvage treatments after a failed surgery. As long as that caveat is mentioned then I have no issue with a patient considering "what happens if the initial treatment fails". Where I have an issue is when a doctor (usually a urologist) omits (either purposely or out of ignorance) the salvage possibilities after either surgery or radiation.

Beyond that, I do agree that doctors tend to minimize the SE's of both surgery and radiation. However, if we are talking about statistics today then it's clear that the primary onerous SE's of incontinence and ED are, on average, more prevalent with surgery than with modern radiation treatments. Now there may be factors other than SE's (like your BPH) to consider but when considering SE's the facts are pretty clear.

Jim

Mel,
I get your argument, but what you and many doctors fail to mention is that there are also many backups for failed radiation that work just as well as the backups to a failed surgery.
The most common is either low or high dose Brachy added to the prostate, the second is cryosurgery. The last and worst option is salvage surgery, but that option is the only one that is always brought up. If all the salvage treatments were mentioned in giving the patient information I would not have an issue. Not to mention them and only mention the last and worse option is disingenuous.

John:

I agree and should have mentioned that while surgery is not a great backup for failed radiation, there are backup choices, as you mentioned.

My main quibble...was already stated in my post!

Mel

I suggest you take a look at the website of Dr. Mark Scholz. He recommends radiation:
The End of “Surgery is the Gold Standard”

I had an MRI done and they found a small extracapsular extension. In this case I would not do surgery followed by radiation but just have radiation done instead.

George

Both options can be curative. I had daVinci surgery and after 2 years I had to undergo salvage radiation due to positive margins. Both nerves were spared and I was one of the few that never suffered ED or incontinence after surgery. As for radiotherapy, I had 39 treatments at 1.8 grays per session for a total of 70.8 grays. For me radiotherapy was a non-event. I had very minor fatigue during the last half of the treatment. I never changed my diet or habits and never suffered from any diarrhea, other GI problems or urinary urgency. It has been over 8 months since the completion of radiotherapy and still zero issues.

Looking back do I regret surgery? That is a hard question, surgery failed but knowing the post surgery pathology and cancer contained within the prostate was nice to know. I could have gone back to work after the second week, but took three weeks off since I had plenty of time. My oncology urologist trained at MD Anderson is one of the few in the gulf state area that does salvage surgery after radiation and he told me that the surgery is a mess, usually with poor quality of health issues afterwards such as full urinary incontinence, to requiring a colostomy bag due to colon removal. There are other salvage alternative for failed radiotherapy, but I know very little about.

There are no guarantees on surgery, outcomes vary widely. My biggest fear was incontinence, but my highly trained oncology urologist told me since I was fit and in excellent health and I have zero urinary problems that it would be rare. He did mention that post prostatectomy incontinence is more of the problem in older men, obese men, diabetic men and men with other health related issues.

Dan,
You are 62 years old and are being treated by the VA. Are you a Vietnam veteran -- boots on the ground for even a day? If so have you applied for Agent Orange disability benefits for PCa?. I and others here can tell you how if this applies.
Jim

Thanks to all of you for the replies. After meeting with the RO for a second time and being stood up by the surgeon for my second appointment (he never showed), I have decided to go with the Radiation. Had a lengthy discussion about HT and as I had only one risk factor to put me in the intermediate level, my RO believed that there would be not real benefit from doing the HT and a real for less than favorable side effects. I am having the fiducials put in on the 20th, and a week later go for an MRI and CT Sim. Should start treatment a week after that. 43 sessions with the Varian True Beam Rapid Arc machine. Nice new equipment, great RO, in Dr Shapiro. I have all the confidence in the world that we can cure this. bluesharp, thanks for your insight into the VA. I have been going to them for about 5 years now, and don't really have any serious concerns. Nice to know that you have gone through this and all came out well.
Bohemond, I am a Vietnam ERA Vet. I spent 11 months 23 days in Ubon Thailand 73-74, but never "in country". So close, yet so far away.

Dan, I'm late to this thread, just wanted to say congratulations on making what seems to be a well considered decision. The fact that you are confident going in will help you tremendously. I hope that (and am sure that) everything will work out well for you. Please keep us posted and we'l me to healingwell

compiler said...
Actually, your doctors are correct:
Radiation after a failed surgery is certainly do-able whereas the reverse is not that easy at all (much more difficult surgery). That is an extremely VALID point and should be considered.

We have had this argument many times, and I've given up responding to it (I get tired). But I'll try again:

It is true that if SRT (Salvage radiation treatment) succeeds, you can then say that the surgery was unnecessary as most likely the radiation itself would have been successful. But that is specious reasoning as you DO NOT KNOW THAT going in. Hey, there are plenty of possible treatments. If you knew in advance that treatment X would have worked, then of course you would choose treatment X. But, GOING IN, you have no idea. I understand that you should try and pick the best first shot tx. But, again, the idea of having radiation as a back-up plan/hedge is quite valid. Your doctor is correct. I get villified when I point this out!

So, you need to look at your age and general health and choose your poison. The surgery SE will be more immediate and the SE should improve over time, but one never knows. In fact, I think surgeons tend to minimize ED. For me (a sample size of ONE): I had incontinence for 2 weeks and it resolved 100%. I had ED and still do to a degree. As a steady HW participant, it seems that my experience is VERY typical. You have to be honest with yourself and decide how important the SE is. I have to say that we have accepted the ED. I don't like it one bit, but I have accepted it. The incontinence would be miserable. Now, with radiation, many minimize the SE. My understanding is that they come on slowly over a period of a few years. Bowel problems and urinary problems can occur. I guess you can do the research. There are cases on HW where surgery went horribly wrong and cases where radiation was a disaster. But these are outliers. People have died during routine small surgical procedures.

This is not a cut and dried decision. It is not clear-cut. Be careful of those who always advocate one solution over the other.

It depends so much on your situation and you are unique in how you view things.

As an example of uniqueness, I've mentioned my situation where I had BPH for probably 15 years. Flomax was great for about 12 years. But, then, it kind of stopped working. I had great difficulty urinating at times. Twice, I had my jacket on about to go to the hospital for the dreaded cathaterization. Fortunately, things improved at the last minute. Had I not suddenly had the PC dx., I was looking into getting a green light laser tx. So, the BPH was one of the many reasons I chose surgery. In MY UNIQUE SITUATION (the BPH), it was a good choice. I have not had a repeat of that misery (being unable to pee).

Mel

Though I am not usually, or overall, an advocate of surgery(at least for myself if I had another shot at choosing), I must hands down admit one thing: when it comes to doing away with problems of my giant prostate ( 106 gms ) combined with 30 years of on and off miserable prostatitis, the surgery has been wonderful. I pee like a racehorse. In public restrooms I now notice lots of guys taking all day, but no one is faster than me, the fastest pee in the west or east! I often sleep all night long, 7-8 hrs, without ever having to get up. I can drive for hours without needing to stop to pee. As long as my one remaining problem- a mysterious spasm of something(bladder?) that tries to force a squirt of urine out involuntarily several times a day- does not strike faster than I can Kegel/clamp down- I can be up and walking for well over 2 or more hours with no problems. I often notice that I might leave for church a few minutes before 0900, not bother to get to the reat room while gone, and get home about 1300, realizing I am not in any particular hurry to pee. That part is like being 16 again. In fact, I happily challenge any of you to a pissing contest! ;) Other parts were more like waking up aged 35 years, but that one part is undeniably a good deal. Or at least it was once I quit peeing myself, although it was good at night from the day the cath came out.

That part has been wonderful. People with severe BPH might want to take that into consideration. Of course, for all I know, RT and/or HT might also have a beneficial result on BPH. I wouldn't know. And, with surgery, you might have to take on other onerous and even permanent SEs in order to enjoy peeing like age 16 and sleeping all night.