Apr 30, 2010 - 6:24 pm
As many of you know from previous posts, I was diagnosed with PCa about five weeks ago. Age: 59. PSA at Dx=4.3. 1 of 12 biopsy cores showed adenocarcinoma with 15% involvement. No evidence of perineural invasion. Gleason score was 3+3=6. My prostate volume is 47 ml giving a PSA density of 0.092 ng/ml/cm3. My PSA velocity from PSAs ranging back to 2002 is 0.23 ng/ml/yr and PSA doubling time has been calculated at 9.28 years. I am waiting on a second opinion on the biopsy. DRE is completely normal, the prostate is not enlarged and there are no other urinary or erectile symptoms. Staging is T1c.
During the past month I have read nine books on prostate cancer and reviewed over 40 clinical studies. I’ve consulted with my urologist, my GP, an oncologist, and three radiation specialists who have extensive experience treating prostate cancer. I have also consulted with a urologist who specializes in active surveillance.
I believe I have gathered enough information to make a treatment decision and would appreciate feedback from those who have gone down this path before.
One of my guiding conclusions is that for an early stage prostate cancer such as mine, surgery and radiation are equally effective in eliminating cancer at the 15 year point. Watchful waiting is another very viable option with extremely high survival rates but at my age I believe that eventually I will have to seek a treatment and would prefer to do it while I am still (relatively) young and in good health. For me then, the decision was about minimizing the side effects of the treatment options rather than deciding which treatment was more effective in addressing the cancer.
My urologist, GP, and oncologist recommended surgery. I carefully considered this option and weighed the advantages and disadvantages as well as the potential side effects. I also looked and the pros and cons of open surgery compared to robotic procedure and found that while about 70% of surgeries performed today use a robotic procedure, this treatment has a higher incidence of incontinence and erectile dysfunction. I believe that is due to the wide disparity of experienced surgeons using this technique and that over time this trend should reverse. The biggest drawback to me on surgery is that the relatively high incidences of the side effects of incontinence and erectile dysfunction, even with nerve sparing techniques, was unacceptable. Another aspect seldom addressed is that the effective size of the penis is reduced by about an inch during the surgery procedure as the urethra removed with the prostate is repaired by drawing the base of the penis into the cavity to connect the urethra in the penis with the remains coming out of the bladder. Also with surgery, 23% of patients who undergo RP have to have follow-on radiation treatment because the cancer remains in the prostate base. The additional procedure increases the likelihood of long term incontinence and ED issues. I know many who post here have had great success with surgery and I am happy for them. While it may not be representative of the entire population, the number of posts on this site pertaining to vacuum pumps, artificial sphincters, penile implants, injections, debates on which diaper or pad is best and so forth is very scary for one considering options. There’s also the recovery time, blood loss, and the general risks associated with any surgical procedure whether it is one six inch incision or six one-inch incisions. For me, the accumulation of potential side effects posed by surgery was simply a bridge too far.
I investigated and consulted with radiologists regarding brachytherapy, HDR brachy, XBRT, proton treatment, and two stereoscopic procedures. The proton therapy consult was with Loma Linda Medical Center in Southern California. The two stereoscopic procedures were the Novalis Tx process and Cyberknife. While radiation has drawbacks and side effects too, they are significantly lower than those involved in surgery. Urinary complications generally involve a sense of urgency or frequent urination that resolve within two months of treatment and are greatly mitigated by drugs such as Flomax. About 15% of men who undergo radiation will have ED problems three or four years after the procedure but the good news here is that the nerves remain intact and the condition is well treated with Viagra like drugs. In Brachy therapies and XBRT there is some incidents of rectal bleeding where radiation doses have damaged the colon. There is a surgical procedure that essentially cauterizes the damaged veins that corrects this if it occurs. The Novalis and Cyberknife system delivers a high dose of radiation in five sessions, each of which last about an hour. A variation is that there is a day of rest between sessions to allow normal cells time to recover. These procedures deliver radiation at sub-millimeter accuracy so that damage to surrounding organs is minimized. The dosage is comparable to HDR brachy which has a very high success rate but does require two or more hospital stays for a couple of days each. The 4-year data on Cyberknife is extremely positive…virtually no side effects, minimal urinary discomfort which if it occurs resolves itself in a few weeks, and continued strong sexual function. The Loma Linda proton therapy is very promising as well with a high success rate and you just can’t say enough about the quality of their staff, physicians, and their overall approach to treating the “whole man” not just the cancer. The downside of proton therapy is that it requires 8-9 weeks on site at one of the proton centers as you are treated 47 times, each session lasting about 15 minutes. Even though I live in San Diego, I would have to move to Loma Linda for 2.5 months to avoid five hours a day commuting. Protons are delivered with a high degree of accuracy and the threat to organs near the prostate margins is minimal. Recent studies have shown that protons do not offer any significant advantages over other forms of radiation.
I am fortunate enough to have insurance that would cover any option I choose and have the financial means to self-pay if necessary. I have enormous sympathy for men whose treatment decisions are based on insurance coverage instead of what is best for them. In my case, money or insurance was not a factor in making my decision.
I also looked at HIFU but as it is not yet approved in the US, I passed. I want a medical team that will be with me for the long haul, not just over a long weekend in Jamaica or Cancun.
All of the specialists I met with had impeccable credentials. For the most part they operated from state of the art facilities with attentive and empathetic staffs.
At this point, I am about 90% decided on going forward with the Cyberknife procedure.
Some may say "take your time"...and I believe I have done that. I put together a matirx with 20 individual Quality of Life and other factors and rated the procedures against each other from my perspective.
While my mind is still open, I don't want to be in a state of paralysis through analysis. My continued research is at the point where I am reading the same statistics over and over.
I didn't seriously consider acupuncture but I did look at some homeopathic and alternative treatment protocols. While I don't think they are appropriate for a primary course of action, I believe they can complement the course I have chosen through diet and lifestyle changes.
Sorry for the long post but would appreciate any feedback from those who have tried to decide amongst similar choices.