Flummoxed or I'm number one!

SBRT is great for you, as would be brachytherapy both seeds and High Dose Rate or conventional IMRT. However, most of us hold that you should be treated by a high volume practitioner regardless of the method. They they have done a lot of other cancers is great...when you get one of those other cancers. But you have to find the specialist for your cancer.

There should be other practitioners within a reasonable distance of you. Do a little more research and let us help. Where are you located and what is the center you have already consulted with?

If you tell us generally where you live (nearest big city is usually enough info) we may be able to suggest alternatives. Do you know how much experience the center has -- and the RO has -- with treating prostate cancer regardless of the type of machine? If they/he have done lots of SBRT for other cancers and treated lots of prostate cancer with other machines but they have not yet treated prostate cancer with SBRT that might make me more comfortable than if they were brand new to the whole thing.

If they have experience with SBRT on other cancers, they're probably fine. That said, I'd admit to some apprehension at being the first PCa guy to have it at that facility. I would probably end up looking for another place for SBRT, unless I had a compelling reason to stick close to home.

Good luck to you!

Lol halbert: online map of Michigan

Blackjack, That was my exact thought about being first. The RO mentioned having to be patient with them if I chose it. They appealed to me because I could prep at home, drink some water on the way down, and get treatment. My wife tends to think more along the lines of JNF, high volume practitioner, which is hard to argue against. But my thought has been as you mentioned. Programming. How much human input is really involved in the actual delivery once a plan has been mapped out? Not knowing the answer to that question is really why I posted. Since the facility is very experienced with SBRT for other areas, is my prostate that much different? Are there standards for margins, pending tumor location, to protect other tissues? I can see both sides of being first, I appreciate your input.

Peter, Yes, they use other IGRT's(?) for PCa, and seem to do many LDRBT treatments. That does become an influence in a decision, maybe adds a plus for them.

Michael, Those are the exact thoughts buzzing around my brain for the last 22 hours! It would be convenient, and maybe I'm letting that factor in too much.

Thank you all!

"I did not due largely to the issues of RT late-term side effects. Already in your 60's, RT could be a good choice for you."

there you go again. I think you do the board a disservice when you say SBRT isn't a good choice for younger men. those SEs you keeping talking about that we really don't see many talking about on this board

i'm nine years out. none of your SEs. with surgery the life-altering SEs -- incontinence and ED -- are usually immediate and in many cases permanent. those are the SE tales of woes we do see here in abundance.

you chose surgery and it worked. good for you. but you really should tone it down on the SEs of radiation, which I believe are largely mythical and a scare tactic straight out of the prostate snatcher handbook.

Paxton said...
Well, as long as we're "book bashing," when I was first diagnosed, I read Dr. Walsh's book from cover to cover. I was startlingly disappointed to see how biased that work is against most forms of radiation therapy. That book, IMHO, should come with a "black box" warning that states that it was written by a surgeon and that any discussion of any treatment other than surgery should be used at the reader's risk.

I think it kinda does...isn't it clear that the non-surgery chapters were written by other specialty practitioners, and not by the innovative surgeon Walsh who first developed nerve-sparing prostatectomy? (I read that book, but gave it away years ago so I can't look myself now.) I agree, by the way, of the surgeon's bias of that book. In fact, it is NOT a book I typically recommend. However, it is outstanding in it's very thorough description of the anatomy and purpose/functions of the various organs, etc. in that area...wouldn't you agree?

RT may not require as much experience as RP, but I would not want to be in the first group of patients for a program that's just getting up running. True, someone has to do it, but it wouldn't be me unless there were no alternatives.

Wow! First, thanks to all for the responses! It kind of gives me a lump in my throat. In a good way.

Halbert, thank you, I'll watch for anything from RW.

Paxton, thank you also! I've read many of your posts as I've stalked this forum for weeks. ALGH and Dr. Hirsch's team had caught my attention very early on. I will consider that a very strong option. Reasonable distance and super reputation. I have considered RARP, and have consulted with the top surgeon here in west MI. One of the early DaVinci guys. Full confidence in him. Choosing a RT for for various reasons, mostly recovery based and an urgency to get out and live the life my wife and I have worked so hard to have within our grasp. I'm within 18 months of the age Pops died, heart related, and that's always in the back of my selfish mind. And mostly, thanks to my PAC for monitoring my PSA yearly, and catching this at a point where I have options for treatment. I am blessed, grateful, lucky, and any other term one could apply to my situation. I am so aware of others here that are fighting a bigger, but winnable battle.

Sr Sailor, you make a solid point. I appreciate that. Thank you.


F8, thank you, I am really trying to study up on SE's of RT, short and long term. My newbie impressions are leading me to believe that newer RT techniques are leading to less SE's, but I am really trying to learn. Thanks.

Blackjack, "Invasion" is still sitting in my Amazon cart! I have read through the books from Scholz, Walsh, and Ripoll w/ Saunders, as well as "100 questions", that my uro gave me. I'd better order Invasion too. Thank you.

Paxton, I did feel that way about the Walsh book. Found the Sholz book informative.

JNF, Dr. M is on my radar as well. Family on that side of the state. HDR is, of course, on my list too. Thanks.

Thanks to all of you so much for your comments. This is such a valuable resource for me. I will make sure I respond to all of you, time to step outside for some fresh air. Do some chores. Thanks again!

Regardless of whether (a) the nerves were spared during surgery or whether (b) the most precise dose planning was used during radiation therapy, erectile dysfunction remains the most common side effect after treatment. This is because the nerves and blood vessels that control the physical aspect of an erection are incredibly delicate, and any trauma to the area can result in changes. However, even if you do experience some side effects of treatment, there is also room for optimism: many excellent options for managing erectile function exist on the market today.

However, within one year after treatment, most men with intact nerves will see a substantial improvement. The skill of your surgeon can have a significant impact on this outcome (the surgery learning-curve previously discussed), so it’s important to select your team carefully. Likewise, men with baseline erectile dysfunction and/or other diseases or disorders that impair their ability to maintain an erection, such as diabetes or vascular problems, will have a more difficult time returning to pre-treatment function. It’s important to remember that your functionality after treatment can only be as good as it was before treatment. The best predictor of how you will be after treatment is how healthy you were going into treatment.

Prostatectomy: Since the 1980s, most men are treated with what is termed a “nerve-sparing” prostatectomy...but as this seems to be outside of your indicated choices, no more discussion on this.

Radiation therapy: Similar to surgery, damage to blood vessels and nerves after radiation therapy can result in decreased erectile function over time. In general, radiation therapy has less of an impact on erectile function in the first 5 to 10 years after treatment compared with surgery, and approximately 70% of men who have baseline erectile function before treatment will keep erectile function after treatment. However, radiation therapy has a slower delay in erectile function decline than surgery; 15 years after treatment, the rates are similar to those who underwent surgery. This is what's known as "late-term" side effects (or long-term effect); one of them. Many of the quality-of-life studies tend to focus on the results in the first 2 years (typical), so they don't generally take late-term effects into account. The late-term effects of RT are, of course, the key reason that many doctors recommend radiation therapy more frequently for "older" PC patients. 15-years later, it might not matter so much if you've got a drippy butt, or ED, etc. As I mentioned, this was my concern when I was diagnosed...but I was treated at age 50 (that was a key difference-maker). I didn't want a yet-to-be-born grandchild sitting on my lap saying, "What's that smell, grandpa?" As I said, though, if I was 10- or 15-years or more older at the time, radiation would have probably been my choice, too.

BTW, for this reply I've referenced material published by the Prostate Cancer Foundation (PCF) here. Many of us here are donors to PCF, and have used/reused much of their material. They also publish some excellent info on PC and lifestyle/nutrition, largely from the UCSF medical research center, one of the top PC institutions.


added later as an edit: I'm sorry that I forgot to also say this earlier, but I would 100% agree with Tudpock's recommendation to have a 2nd opinion reading of your biopsy slides by Dr Epstein...especially with only one core positive at 4+3. The common issue is that hospital pathology departments read a lung cancer slide, then a prostate cancer slide, then a breast cancer slide. Cancer looks different in all of them. Epstein specializes in prostate cancer pathology...and he literally wrote the book(s), and his readings are generally considered "golden." He re-grades about 50% of cases...half up, and half down. Read the "Newly diagnosed..." sticky thread at the top of this page...it's Step #1. If you were to be re-graded at 3+3 (or possibly 3+4), for example, your best choice by far would be to do nothing. https://pathology.jhu.edu/department/services/secondopinion.cfm#

Post Edited (Blackjack) : 8/6/2019 12:27:05 PM (GMT-6)

mumbo, thanks for link to Lacks. I have several in-laws that have been treated there, and my wife gets her mammograms there too. I just didn't think to check there. The RO associated with my URO worked through LHCC, and I didn't think to look down the street.

blackjack, thanks again, I'm going to pursue a 2nd reading, I'd have to agree on the prostate specialization. As far as SE's go, I've dealt with ED for about 7-8 years. Cialis helps, but 14 years of type 2 diabetes meds have probably not helped straighten things out, per my family doctor! ED is low on my concern list. Continence, on the other hand is at the top of my concern list, assuming that the therapy I choose will be curative. No grand kids, so no worries there, it's what can the wife tolerate!

It's time for a long overdue update. This may be rambling! My treatment search led me to Dr. Doug Brown, a RO, at Munson Health in Traverse City for HDRBT. He interned and did his residency at Beaumont in the 90's, so he worked with some of the best. Had a great consultation with him, all the time in the world to answer questions and explain everything. A review of my slides confirmed 4+3, and, following NCCN guidelines, I had a 4 month dose of Lupron in mid October. An MRI confirmed nothing outside the capsule. I had my first HDRBT last Friday, and then another at 2 weeks. No surprises, bouncing back quickly. I can't say enough great things about Dr. Brown, Dr. Gillett, my URO, and Dr. Kohler, the medical oncologist. The time they spent with us really put us at ease.
With the second brachy, I'll get SpaceOAR hydrogel and gold markers, followed by 25 targeted EBRT treatments. The EBRT will be done in Muskegon, at the Mercy Health Johnson Cancer Center, guided by Dr. Nina Johnson. It's a 25 minute drive on the highway to Muskegon vs 2+ hours to TC on winter roads, so I'm thrilled to finish up close to home. For those PCa patients in northwest Michigan, I have to say Dr. Brown would be a great addition to your consult list. Thanks again to everyone that responded to my original post. Your help has led me to where I am now, and I'm very confident in my treatment.