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Why I Chose Radiation Seed Implants over Prostate Surgery

David_B
Posts: 10
Joined: Oct 2011

In late 2010, based upon higher than normal PSA numbers, my family physician suggested I meet with a Urologist. Further testing by my Urologist led to a biopsy in early March... a none-too pleasant experience with a great deal of pain, swelling, a visit to the emergency room, catheter placement for two days and blood in my urine for several weeks.

On April 1st, 2011, I was diagnosed with Prostate Cancer. As a relatively young man in my early 50's, you can imagine that I was quite devastated. With a Gleason score of 6, and being in relatively good health, I was given quite a few options for my treatment. The "watchful waiting" approach was not for me... my family physician lost a young patient who waited to long. I was going to be aggressive in my approach.

My first conversation was obviously with my Urologist. To be completely honest, I was rather put off when he went quickly went through the various treatment options and immediately suggested radical prostatectomy (he would be happy to perform the operation). No thank you.

After reading tons of online documentation, and at the suggestion of my family physician, I next visited Penn Medicine in Philadelphia, which is using an ultra-modern new method of external beam radiation using proton beams. This method is apparently more targeted and leads to less tissue damage (outside of the prostate) than traditional external beam radiation. But, unfortunately, like traditional external beam, it takes 40 sessions... 5 days a week for 8 weeks. As an advertising sales executive who makes a commission-based living on the road, this seemed like a very difficult choice to make.

I next consulted with Thomas Jefferson Hospital in Philly. I was immediately put at ease by Dr. Edourado Trebulsi, one of the foremost Urologists in the Delaware Valley, with vast experience in robotic prostatectomies. Rather than pushing me towards surgery, which several other Urologists have done, he actually said to me that his profession has been rightly criticized by the rest of the medical community for being "too quick to cut" (I'm paraphrasing). My thoughts were immediately, "if I am to choose surgery, this is the gentleman I want to do it." Surgery sounds simple easy... cut out the cancer! The problem with surgery, as anyone who has studied the issue can attest to, is that it is not only a very serious and sometimes risky operation, 20% of men experience nerve damage and permanent impotence. Add to that wearing a catheter for up to two weeks and incontinence for many months after. It is a very serious decision. Radiation has its own issues. Surgery afterwards radiation is not an option. Permanent scar tissue, etc. Dr. Trebulsi arranged a multi-discipline consult for me, for which I am very grateful. I met with several doctors, including radiation oncologists. One concern in my case for radiation was my very difficult experience with the biopsy. It was thought that seed implants (LDR Bracytherapy) could cause a similar and perhaps worse, swelling.

Two weeks later, after a lot of mediation and thought, I had just about made up my mind to choose surgery. But something was nagging at me. For one thing, surgery has an almost identical rate of cure as radiation, with far greater side effects. I was just about to call Dr. Trebulsi to schedule surgery when I thought, "You know what? I will always regret it if I don't look one more time into radiation." I realized that I still hadn't contacted the world-famous Fox Chase Cancer Center, right here in the Philadelphia area. I read that Dr. Eric Horowitz and his team of radiation oncologists were some of the best in this field.

I arranged a consult and was pleased to meet with Dr. Horowitz personally. I asked him about my experience with the swelling, and he asked me I was given Flomax before and directly after the biopsy. When I told him, "no", he said that Flomax may have very likely prevented the swelling. A urologist at Fox Chase also suggested that is also possible that problems occurred with the actual biopsy. Dr. Horowitz said that not only was he not worried about the swelling; in fact, I was an almost ideal candidate for radiation seed implants, based on the size of my prostate, my low Gleason score, my PSA numbers and other factors. I breathed a sigh of relief. After all, radiation seed implantation is one the least invasive of all treatment options, with some of the fewest side effects. I mentioned that the radiation oncologists I spoke with at Penn Medicine told me that seed implantation is not as targeted as external beam. Dr. Horowitz smiled and said, "It depends who is doing the procedure." (Dr. Horowitz does both seed implants and external beam.) Radiation Seed implantation (LDR Brachytheraphy) is one of the oldest treatment methods for prostate cancer and the technology improves with each passing year. It is, in fact, very targeted, if performed properly. The prostate is very carefully mapped out before and during the procedure.

On October 12, 2011 (Columbus Day), I was treated with Iodine-125 seed implants at Fox Chase Cancer Center by Dr. Horowitz and a great staff. Everything went very smoothly (aside from the after effects of the general anesthesia and some pain). Very little blood in the urine. I took Flomax for several days prior to the procedure and will continue for some time after. So far, no swelling. I was released the same day. I am very hopeful for a full recovery.

Many of you reading this post are no doubt aware of the recent recommendations by the United States Preventive Services Task Force against PSA testing for healthy men. I am not a doctor; but I believe that these recommendations were not only very poorly explained, but even possibly irresponsible. While it is true that PSA testing is imperfect, it is a very good indicator of possible cancer. Until someone comes up with a better test, it is all we have. More importantly, the data from which they drew their conclusions is possibly flawed... focusing on older men. European studies with younger men have drawn different conclusions. While it is also true that men diagnosed in their mid to late 70's are more likely to die with prostate cancer than from the cancer, since it is generally (but NOT always) a slow-growing cancer, what about younger men? While for only a minority of cases does the cancer becomes metastatic, for those men, this is often a death sentence. Frank Zappa died at age 52. Cancer cells can leave the prostate and find new homes in soft tissue, especially lymph nodes and bones, resulting in a very painful death. Without the PSA testing, diagnosis and treatment, how would those men's lives be saved? Prostate cancer is the second-leading cause of cancer deaths among men.

In closing, I DO completely agree with the criticism regarding urological physicians who too easily push for surgery. It is currently the most common form of treatment among younger men. I personally believe that it is way overly-recommended. I believe that due to the serious side effects of the surgery it should be perhaps the last option chosen. Consider this... if radical prostatectomy has a similar success rate as the latest radiation procedures (90+%), what conclusion can you make? Further advancements are being made each year to improve success rates. Again, while I am not a doctor, it seems fairly obvious that in the 10% of cases where neither treatment is successful, the cancer very likely already become metastatic and left the prostate, and it may not have mattered which treatment method you chose. Therefore, I highly recommend that you speak with several radiation oncologists to learn if you are a good candidate.

Men of ALL ages over the age of 49, until a better method is found, GET YOUR PSA TEST ANNUALLY. And if you are diagnosed, do your research. Meet with multiple urologists and radiation oncologists to determine the best course of treatment for YOU.

jct9841
Posts: 19
Joined: May 2011

David,

Your path of discovery and decision making is very similar to mine. I have just about concluded that Brachytherapy is the way to go for me but am researching Cyberknife in comparison before I make my final decision.

Did you consider Cyberknife?

Quality of life post treatment is very important to me.

John,
Diagnosed 5/11
PSA 4.18
Gleason 3+4
Age 60

David_B
Posts: 10
Joined: Oct 2011

I looked into Cyberknife briefly. However, it was not a specialty of the three cancer centers I visited. I think its important, that whatever form of radiation treatment you choose, that the doctors/ staff have a lot of experience with the procedure.

mrspjd
Posts: 688
Joined: Apr 2010

David,

Glad to read of your successful tx for PCa and best wishes for continued success.

You apparently feel strongly as many of us do re the USPSTF's recent recommendation against PSA based screening/early detection/PSA history tracking for asymptomatic men. If you haven't already done so, I encourage you to please read the Call to Action thread:

http://csn.cancer.org/node/228042

and learn how you can make a difference by submitting your comments directly to the Task Force. The USPSTF is currently accepting all public comment at their website now through Nov. 8, 2011.

If men want to make PCa as much of an issue as women have done with Breast Cancer, then, IMHO, this is a good place to start.

I hope we can count on you to submit your comments. Thanks.

David_B
Posts: 10
Joined: Oct 2011

I already submitted my comments. I encourage all Prostrate Cancer patients and their loved ones who believe that PSA testing saves lives to do the same.

mrspjd
Posts: 688
Joined: Apr 2010

Thank you for doing that. My husband and I have submitted our comments to the USPS Task Force as well.

Everyone, men and women alike, concerned about the USPSTF's controversial recommendation is urged to do the same--submit your comments to the USPSTF at their website before Nov 8, 2011: http://www.uspreventiveservicestaskforce.org/tfcomment.htm

Best to all.

kddh
Posts: 14
Joined: Nov 2010

Thanks for your very well-written summary of your experience. Having ended up with brachytherapy myself (after not being able to get CyberKnife paid for by insurance) I am quite happy with the results (4 monthst after implantation), the minimal side-effects, etc.

Like you I also had trouble from the biopsy and, like you, talked to a urologist who was "too quick to cut" and another who virtually warned me away from prostatectomy. I second your recommendation to talk to lots of doctors of different stripes.

And from my limited knowledge I share your skepticism about the recent Task Force recommendations. Although I must admit: if cancer had not been found, the illness which resulted from the biopsy would have seemed a pointless suffering.

David_B
Posts: 10
Joined: Oct 2011

You're quite welcome. Thank you. Urologists should give more warning about the side effects and complications with prostate biopsies. But, as you wrote, without the PSA testing and ultimate biopsy, how else would we have been diagnosed? Wait until the cancer becomes metastatic, and we have to start putting our affairs in order? No thank you, US Preventive Services Task Force.

I hope your recovery goes well. It's 12 days for me, and counting. Some pain, irritated bowels, etc. But overall, no complaints. I was in the hands of a very good radiation oncologist.

kddh
Posts: 14
Joined: Nov 2010

I just read your note of Oct 24 replying to mine. I hope your recovery continues smoothly. You may experience, as I have, that the urinary and/or bowel symptoms seem to happen in waves,though overall mild in my case. I think I recall being told that 4 weeks out, as you are now, is one period to expect some symptoms, as the radiation has built up for a significant period of time and the seeds haven't yet decayed significantly. Again, pretty mild at least for me.

Good luck!

David-2
Posts: 2
Joined: Nov 2011

Hi David,
I am new to this site and am a 65 year old Englishman. I read your post with great interest, as I seem to have been on the same path of discovery, as you are on now. In Gt Britan we seem to have a take it or leave it approach, that is if you are worthy of treatment you get it if not you dont. We have our own "National Health Service into which we pay all our working life.

Following a "Blue Light procedure to my Bladder and a Template Biopsy to my prostate, I was diagnosed with both Prostate and Bladder cancer in May of this year. The bladder being contained at multi t2. As far as the prostate was concerned, I had rapid advancing PSA over 6 weeks from 4.5 to 26 with a gleason score of 13. Scans indicated a rapid aggressive form of cancer. The process here is; that all the info is passed onto a Multi Disciplinary team, who assess weather you are a candidate for treatment or not. Luckily I was, and was put onto Hormone therapy whilst a decission was made by the MD team with regards to treatmment and funding. I was lucky to a point, as my prostate cancer had many micro tendrils that had left the capsule, so radical prostate surgery was out of the ball park. However as my Urologist felt the problem with my bladder was so unusual, and he felt it was beyond his scope he refered me to a Professor Langley. A prof in Urology at another nearby Specialist Cancer Hospital ( St Lukes in Guildford Surrey (Good web site) well!! under him, treatment then took off. He told me that he wanted to do a partial TURP and resection of the bladder neck prior to radiation (External Beam) as I had an obstructed urethra that needed rebuilding, then He felt that the best course was External beam therapy and Brachytherapy implants.

I asked about cyberknife ? as you have said your research was as mine. Cyberknife indicated that, less other vital organs were affected. His reply was that cyberknife is great, however it is such a fine and directed beam that history has shown it may be too directed, whereas many cancers need a flood beam, rather than a very fine beam, and if any tenderils have left the capsule, cyberknife cannot get them all. External beam therapy can !!. So now I am having six weeks of BCG treatment to my bladder, followed after a two week break, with Five weeks of external beam therapy, followed by Brachytherapy implants. Both the prof and his partner Oncologist at this hospital just ouze confidence, they are both very well respected throughout the medical fraternity and travel all over the world tutoring sugeons in this procedure. They are enjoying a 93% sucess rate with the combined treatment based on 10 years procedures. Incidentaly the prof and the Oncologist started this procedure in UK and this hospital is the leading cancer hospital in the UK.

I wish you well with your treatment and hope this has answers to your points. I also would hope you keep me informed how things go, as I would like to compare notes as it were.

All the best David P

David_B
Posts: 10
Joined: Oct 2011

Dear David:

It sounds like you are in excellent hands. I'm glad that you were considered a good candidate for treatment. It's unfortunate that you had to be "approved" for treatment. Such things are coming to the US, as well, should the current health law care remain intact. One of the provisions in the controversial Stimulous Bill and the subsequent "Affordable" Health Care Act includes a new rationing board, the Federal Coordinating Council for Comparative Effectiveness Research, which will essentially dictate treatment procedures in the US to doctors in the future (based on the age, health, etc of the patient), beginning in 2013 in the US. No longer will doctors be able to work one on one with patients to plan a course of treatment, particularly for those aged 65 and older. The Medicare Advisory Board is creating similar rules for our older citizens.

I feel so blessed that my insurance plan allowed me to visit 3 different world-class cancer clinics and make my own choice for treatment.

David, I wish you every success in your treatment. You seem to have a very positive attitude which, I believe, is critical to the healing process.

David_B
Posts: 10
Joined: Oct 2011

It's been 9-1/2 months since my Radiation Seed Implant procedure at Fox Chase Cancer Center in Philadelphia with Dr. Eric Horowitz. My PSA numbers are way down, the side effects few. I was able to get back to work within 4 days of my procedure. A friend of mine who underwent radical robotic prostectomy essentially lost a year of his life, including depression, etc. (not everyone does, of course). And we have all heard the horror stories surrounding the very high probability of permanent impotence with surgery. Again, I think each person has to make his own choice (and do a lot of research, as I did). But it does seem that, unless the cancer is quite advanced, that radiation is a far less extreme treatment approach for a cancer that is, for the most part, very slow growing. For my complete story, feel free to read and comment at http://csn.cancer.org/node/228380

CaringB
Posts: 1
Joined: May 2013

Thanks for your insight.  We are faced with the same decision and was leaning toward seed implant.  However we just met with an MD (who is biased toward surgury) that said that 3 - 5 years after implants the patients have the same nerve damage as surgury that can lead to impotence.  I have tried to find evidence on the web but haven't come up with anything.  How are you doing and have did you hear anything like this?

Thanks so much!

 

Bloodman33
Posts: 1
Joined: Jun 2013

Hi CaringB. Since David didn't reply, I thought I would. My experience and research was identical to his in many aspects, although I had more acute side effects (swelling of both the urethra and rectal sphincter, which caused some near accidents) for a few weeks post seed implants.

My urologist, who is also the head of urology at a highly rated DC-area hospital, had strongly recommended seeds. He was critical of his colleagues who went "too soon to the knife." He especially condemned robotics, which he said was an expensive gimmick that had no better outcomes than open surgery and more complications, based on the experience (or lack of same) of the operator.

To your question on ED, my urologist did warn me that some men had ED a few years post implants. In my case, I had mild ED before the implants and my wife was so pleased with the results of Viagara, I still take it (a small dose of 25 mg about an hour before intercourse). I notice that don't have problems achieving an erection without Viagara, but when it comes to intercourse my job is to please my wife! So if there has been a decline in potency within the last five years, neither I nor my wife have noticed, and sex is better with Viagara than it was before my diagnosis. A friend who also had seeds and routinely takes Viagara put it this way: "I didn't not realize how much potency I lost due to age until I started taking Viagara right after the implants." I hope this response is helpful.

BTW, my neighbor just died from infection complications post prostate surgery. He was in his late 50s. I don't know the specifics of his cancer, but had I known he was contemplating surgery, I would have tried to talk him into seeds. Very sad. I've known too many men with short and long-term post surgical complications. 

Good luck with whatever route you take!

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