Need help deciding on treatment.

Sorry about your diagnosis and that you have to be here. Making a decision treatment is one of the most difficult parts of this. You mentioned Johns Hopkins--by any chance did you ask their lab to give you a second opinion on your biopsy slides? (Or better yet, did they do the original reading?) If not, I would do that to get a definitive read on your diagnosis, as JHU is the best at reading prostate biopsy slides. Right now you're straddling two different risk levels: G7 (4+3) is unfavorable intermediate risk...if you were G7 (3+4) or a G8 that might make a difference in your thinking so I'd urge you to confirm. (Unless, as mentioned, they did the initial reading.)

But assuming you stay some type of G7, you have a very good chance of being cured no matter what treatment you choose. You are correct in that most would agree that seeds (low dose brachytherapy) have fewer side effects than surgery. There is also high dose (HDR) brachy and an external radiation treatment called SBRT that could be excellent choices for you. As I understand it, Johns Hopkins is mainly geared toward surgery, so you'll likely need to find other experts to talk about these treatments.

You are also correct in that surgery gives you more information in the form of a full pathology of your prostate. You also know sooner if it worked since you have an almost immediate PSA of 0, as opposed to a slow decrease following radiation. However, I would not put a ton of emphasis on the fact that surgery has radiation as a salvage procedure. Radiation has its own salvage procedures, so it's not like you get two chances with surgery and only one with radiation.

Good luck to you...hope we can help you sort things out.

VA Beta-

It is not any doctor's job to tell you what to do. It's your life, your body, your decision. There is no such thing as an unbiased opinion. Only you know what is most important to you. In my case, I was low risk and every treatment had equal odds of curing me (95+%). After that, preserving sexual function was most important to me, I didn't care if I ever knew what had been there before treatment, I didn't need 20 or more years of data, and I valued convenience - so I chose SBRT. At the end of the sticky for the newly diagnosed are questions you might want to ask various kinds of doctors, and also questions to ask yourself.

VA Beta,

Prior to my surgery I was getting up 4x per night to pee. While my selection of surgery was in no way related to that issue, I assumed a side benefit would be sleeping all night without having to pee. In my case it didn't work that way. Although my flow is better now, my frequency for needing to pee did not change. My doctor never gave me a good explanation for that.

VA Beta, I am 57 and had open surgery Dec 20, i used to go every 2 hrs at night and now i wake up maybe 1x at night. so far the only side effect i have had is the ED issue and that should go away and if not i am comfortable with it. i was a 3+4 and just wanted the cancer to be gone and that is why i went with surgery, but you have to find out what is best for you or i dont think you will ever be comfortable with the decisions that you made and thats important mentally. No Dr can tell you what is best because truthfully i dont think they know, they only have information of their specialty. I was also lucky as my primary walked me thru the different options and told me one important thing and that is Only you can make the right choice as its your body and your emotions. We are not able to do like other surgeries and say for 100% that this is the right choice for you.

Good morning and sorry you are here. Our DX are very similar I also am a 4+3. The URO that made my DX told me that either surgery or radiation could be curative. After we talked and he explained the surgery and possible side effects so on and so fourth he asked if I wanted to talk to a RO. (This is at a teaching hospital UAB in Birmingham Al) if so he will call and have one come over. I did and within about 30 min the RO came and he explained about SBRT. From the beginning I did not want surgery so I chose SBRT. I am about 5 months out from my treatment and things are good except for the HT. My RO told me that because of the 4+3 DX that 6mo of HT was the standard of care but I think there might be some disagreement on that. I am in the second month of my last 3mo shot. My bathroom habits have been a little different but are getting settled down now. I still get up 2-3 times a night to go depending on how much I drink before bed. I have had my PSA checked twice since treatment and it was <.1 and 0 I am sure it will change when the Lupron wears off. I feel this was the right decision for me and so far so good. Just weigh all the options, learn as much as you can, pick what you are comfortable with and don't look back.
Best of luck
Perry

LAPilot,

My number #1 concern is getting rid of the cancer and I guess as everyone says there are a number of choices that all have about the same success rate. I'm leaning towards the surgery. I've got the surgery scheduled for May 4th with the director of robotic surgery for Johns Hopkins. He has done over 3000 daVinci RP's and is currently doing 9 a week, so I guess he knows his stuff.

After getting rid of the cancer my concern is staying dry and getting it up. The surgeon trained under Dr. Walsh at JH and is supposed to be really good at the nerve bundle sparing procedure. He did say that if he thinks the cancer is in the nerves on the left side, he would have to take those, but the right side is completely clear.

I guess what I'd like to hear from all of you guys that had the surgery is if you have any regrets. It seems like the radiation route has fewer incontinence and ED side effects. I'm hoping that the surgery will help me with reducing the number of trips to the bathroom at night and I understand the radiation will not help that. I also like the idea of getting the cancer out and understanding more with the pathology on the removed prostate.

I just can't tell you how much I appreciate you guys telling me your stories. I feel like I'm not alone.

Tall Allen,

Can you direct me to anything that says radiation does a better job of getting the cancer out. Everything I've read says there is no significant difference between radiation and surgery. I also read that there was a 50% higher probability of rectal cancer and other complications with constriction of the urethra.

I didn't say that radiation does a better job - that will depend on the risk level and which radiation therapy is chosen. You said about surgery "I also like the idea of getting the cancer out..." implying that surgery does a better job of that than radiation. I responded that that is not true - surgery does not necessarily "get the cancer out."

How good a job they do depends on the risk level of the cancer. Within each treatment, the higher the risk, the lower the expected outcomes. The only clinical trial that randomized patients to surgery or radiation (and not very good radiation by today's standards) was the ProtecT trial. It found that outcomes were equal. But, for a number of reasons, it won't be all that useful to you with your diagnosis:

/pcnrv.blogspot.com/2016/09/the-first-randomized-clinical-trial.html

If you look retrospectively at recent data at the experience of individual/multiple institutions the 5-year progression-free survival was as follows based based on Gleason 4+3:

RP: 63% at 5 yrs /www.ncbi.nlm.nih.gov/pmc/articles/PMC5002992/
IMRT: 71% at 8 years at MSK www.europeanurology.com/article/S0302-2838(13)00257-1/fulltext/
SBRT: 68% at 7yrs (Katz) /www.ncbi.nlm.nih.gov/pmc/articles/PMC4937020/

For low risk, oncological outcomes are pretty much identical no matter which radical therapy is chosen. As risk increases (and the probability of cancer outside the confinement of the capsule increases) radiation reports increasingly superior outcomes compared to surgery.

VA Beta said...
I'm leaning towards the surgery. I've got the surgery scheduled for May 4th with the director of robotic surgery for Johns Hopkins. .

VA, if that ends up being your choice then I wish you the best. However, I still strongly suggest that you meet with several RO experts in their different fields so that you clearly understand the range of options open to cure you. Treatment regret can be real, especially for men who don't get themselves fully educated.

Jim

A lot depends on your personality. I chose surgery because I wanted to know. Those darn PSA tests are stressful, but they do give you a pretty definite answer after surgery and that was the best choice for me. Check out all your options and choose what's best for you.

Good luck,
Tom

Tall Allen said...
The risk of secondary malignancy is about the same, whether the patient has surgery or radiation. Most studies failed to find any increased risk due to radiation therapy.

/pcnrv.blogspot.com/2016/08/the-real-risk-of-secondary-malignancies.html

Allen - Also the Wallis et al. study that you provided a reference to in your article had almost the same wording as the European guideline. Quote: "In particular, for patients with a long life expectancy of 20 years or more, the possibility of secondary malignancy related to radiation needs to be included in management discussion."

The Jin T et al. study referenced from the European guideline stated Quote: "When the follow-up extended to >10 years, a significantly increased secondary malignancy risk was observed"

Maybe the reason "Most studies failed to find any increased risk due to radiation therapy." is that they used a lag period of only 5 or 10 years when in takes 20+ years for the secondary malignancy to develop.

I don't believe the risk is significant at all but on the the other hand we shouldn't neglect for younger patients.

Based on the experience of survivors of Hiroshima and Nagasaki, they found that there is a lag time of 5 years and most malignancies show up within 15 years. Many of the studies use 10 years - if they were going to show up, we would have seen them. But this is difficult to ascertain - how do we know that a second malignancy had any relationship to the radiation? This is where the mathematical models come in. They look at large databases like the SEER-Medicare database and filter out any second malignancy that occurred sooner that 5 years after therapy. Based on the best of those models, the maximum risk is on the order of 1.5-5 per 1000 patients treated with f/u by 15 years. As I like to point out, it is on the order of magnitude of the seeding of the cancer by prostatectomy - not anything anyone ought to be seriously concerned about.

/pcnrv.blogspot.com/2016/08/radiotherapy-induced-second-primary.html

Anyone can have opinions, but I prefer to rely on evidence.