Northern California Kaiser Surgeons - Any recommendations?

EngineerC6

Swingshiftworker said:

I had no problems scheduling
I had no problems scheduling appts w/Drs. Martinez or Rosenbaum.

Dr. Martinez is in the SF office where my urologist Dr. Thomas is also located. Dr. Thomas just scheduled the appt to see Dr. Martinez when I was in the office and I just called the Urology Dept at Walnut Creek myself to schedule an appt to see Dr. Rosenbaum in Antioch (closer to where I live).

The only "problem" with scheduling is the lead time for the appt, which was 2-4 weeks, for a "standard" appointment. Really no need for greater urgency, unless you have a late stage cancer. But, if that's the case, I'm sure they'd try to fit you in earlier.

Two appointments scheduled
We were able to schedule two appointments today. Dr Martinez in SF and Dr Chan in Walnut Creek. Has anyone dealt with Dr Chan? We were told there are 17 robotic doctors, and only 5 had responded so far. Does anyone else have experience with a doctor that has not been mentioned in this thread?

Kongo

sallyspencer1 said:

Looking for Northern Ca Kaiser surgeons :open or robotic
Hi,
My SO was diagnosed May 2010 with Stage T2b (Gleason 3=4=7; PSA 5; three of six positive cores) and is pretty sure he wants to go the surgical route. He/we are scheduled to interview five Kaiser surgeons including Drs Hsu, Martinez, Rosenbaum and Chan who have been mentioned on this thread.

Can you let us know who you ultimately chose and how it went for you? He is also considering open RP although his urologist only recommended robotic. The latest JAMA study on the post-surgery life style differences makes him want to explore that alternative as well. Did you consider the open route?

Many thanks and hope you all are doing well.
Brien and Sally

Other Options
Sorry to see that you're having to go through this process. I see that you were diagnosed last month and that you've selected surgery as the best option for you. I was curious as to whether you considered other courses of treatment during your research or whether being with the Kaiser HMO tended to steer you toward surgery or gave you other options as well.

As many posters here who have gone through surgery will attest, those surgeons with the most experience have significantly more favorable statistics than those without a couple of hundred procedures in their rear view mirror. I would be sure to ask the surgeons you meet with how many RPs they have done.

Hoping all the best for you and that you find a surgeon you're comfortable with and that you achieve the results you expect.

Swingshiftworker

RiverRider said:

Northern CA Kaiser
Sally, I see you are newly into this search for the best choice.

I live in your area and am a Kaiser member so I've been investigating this for a few years, but, as yet, have not had a positive biopsy. Still, I have a long history of being around and very aware of NorCal Kaiser and PCa. Father and two close friends have been treated and I have read heaps over the years.

The most recent friend had one of the first robotic surgeries in Walnut Creek and came out just fine, but it was prior to my most recent biopsy and he said his doctor had left the region so I don't have his name.
You seem to have the main guys names.

The machines in Walnut Creek and elsewhere are so new, and spread between the various surgeons, such that no one has "high" numbers so far. I don't think anyone is doing more than 2 a week, if that. Most far less since the machine is used for more than just prostate surgery.
My friend was one of the first 10 or 20 with his surgeon but everything went very well. Too scary for me, but he didn't give it a second thought.

I initially saw a doctor in Walnut Creek, but didn't feel comfortable with the way they were going to handle my biopsy so I switched to Oakland with a doctor I was very satisfied with and who was going to do the biopsy personally.
Now, if I had a Gleason 6 or 7, what would I have done?

I may have chosen Drs Hsu, or Rosenbaum, but I tend to think I would have given slightly more consideration to the seed treatment that they do in Roseville.
All NorCal brachy treatments are done in Roseville. A bit far to go, but they do them over and over and over and over, at that location. I don't know the precise numbers, but it would seem the team and doctors there have more experience with that procedure than do the Bay Area doctors with robotic surgery.

You are new into this process of searching for the best treatment. I have been investigating this for years and after some time I believe I would now lean to brachy.
I don't know the specifics of your situation. Your age, percentage of each positive core, etc.
As you indicated, you aren't in a huge rush and you shouldn't be.

Don't get 100% stuck on surgery until you have given yourself some considerable time reading the more recent studies on brachy. They seem to indicate there is no advantage from surgery over brachy depending on individual circumstances.

BTW, I have had two friends who have had robotic surgery in the past 3 years. Both are doing well, but most people do have side effects. The one who had his surgery at Kaiser Walnut Creek was back in early 2008. From what I remember, they only just began robotic there in 2007. Sounds like no one is doing more than about 1 robotic surgery per week and it will just take time for the numbers to climb up there.
I don't entirely understand the numbers, because I would have assumed a urological surgeon would be doing more than one PCa per week. I think I may be wrong with that assumption. In fact, I have read in several places that the true number of annual prostate surgeries that the typical doctor, who is doing a prostatectomies, is doing is way way less than one per week. Less than one per month.

Look at this for a real world view of the numbers for typical surgeons.
NOT what you would think, if you hadn't read this article.
-------------------------------------------------------------------------
"“The research was published in the December issue of The Journal of Urology. Andrew Vickers, PhD, Associate Attending Research Methodologist in the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center, led an analysis of data on radical prostatectomy, the surgical removal of the prostate for men with prostate cancer. Of US surgeons treating prostate cancer patients in 2005, more than 25 percent performed only a single radical prostatectomy that year and approximately 80 percent of surgeons performed fewer than ten such procedures."
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Heck, I wouldn't want someone to change my oil if they did it so seldom per year.

I always think back to when I use to spend entire winters in ski resorts. Only when doing that and skiing 6 days a week did I realize out poor one's skiing is when you only come up a few times per year for a few days.
In fact, a few times where we would take off even 4 or 5 days, we'd need a couple hours just to regain our form when we got back on the slopes.. Makes irregular surgery seem scary.
Perhaps Kaiser needs a Jiffy Lube team doing the surgery, or some teens who practice with their joysticks for hours each day.

That quote is from the following article
http://prostatecancerblog.net/?p=1861

Take a look at that article.

I don't think they like to discuss numbers at WC because they know so many patients are looking for 250+ and they simply don't have anyone up there yet.
On the other hand, how else do they get up there without doing numbers 25 thru 200.

If you investigate the seed program at Roseville, ask them how many they do weekly up there. I would like to know.
In fact, please keep us informed about anything you discover in Nor Cal Kaiser since many of us are in that system and that is really our only choice.

Sounds like you are about 4 to 6 weeks into your investigation. Keep reading. I believe your views of the various choices may change. Still, you may go with the surgery.

BTW, I have to believe the majority of PCa surgery patients at Kaiser Nor Cal are getting open prostate surgery. Recent studies indicate the outcomes of that treatment are as good as robotic.
I do see why Hsu would only do robotic now, because he sees where the trends and demand is going.
I suppose you've read his bio.
http://www.permanente.net/homepage/kaiser/doctor/thomashsu/
Seems quite impressive except he doesn't yet have the robotic numbers but has lots of experience with laparoscopic.

OK...keep doing your research and let us other Kaiser member know what you find.

Remember one thing. Both my friends who have been treated in the past 3 years are now doing fine. BTW, my father who did not have surgery, lived 25 years after diagnosis and died of other causes. You should do fine.

Brachytherapy at Kaiser Roseville
I was screened for brachytherapy treatment at Kaiser Roseville early this year, but chose not to undergo that treatment and have opted for CyberKnife treatment at UCSF (which is pending) instead.

According to Kaiser Roseville's "education guide" (that I received in Feb 2010) they have done over 2800 brachytherapy treatments and do about 3-6 each week. Based on a study of their 1st 511 patients, They claim that their "success" rate is also very good: 8 year DFS (disease free survival) rate of 91% and an 8 year DSS (disease specific survival) rate of 99.8% (1 death out of 511). They also claim minimal side effects based on a survey of more than 1300 patients: 0.4% required TURP to remove scar tissue from the urethra; 0.4% needed blood transfusions and/or laser treatment for rectal bleeding; and 0.2% needed colosomy and urinary diversion. Urinary frequency is very common after brachytherapy for 1-2 years following treatment. ED is less of a problem but can still be an issue.

Ironically, my radiation oncologist at UCSF said that, if CyberKnife fails, he'd recommend brachytherapy for follow-up and, if that occurs, I may be switching back to Kaiser in order to get that treatment from them (but that won't be for awhile, if ever).

RiverRider

Swingshiftworker said:

Brachytherapy at Kaiser Roseville
I was screened for brachytherapy treatment at Kaiser Roseville early this year, but chose not to undergo that treatment and have opted for CyberKnife treatment at UCSF (which is pending) instead.

According to Kaiser Roseville's "education guide" (that I received in Feb 2010) they have done over 2800 brachytherapy treatments and do about 3-6 each week. Based on a study of their 1st 511 patients, They claim that their "success" rate is also very good: 8 year DFS (disease free survival) rate of 91% and an 8 year DSS (disease specific survival) rate of 99.8% (1 death out of 511). They also claim minimal side effects based on a survey of more than 1300 patients: 0.4% required TURP to remove scar tissue from the urethra; 0.4% needed blood transfusions and/or laser treatment for rectal bleeding; and 0.2% needed colosomy and urinary diversion. Urinary frequency is very common after brachytherapy for 1-2 years following treatment. ED is less of a problem but can still be an issue.

Ironically, my radiation oncologist at UCSF said that, if CyberKnife fails, he'd recommend brachytherapy for follow-up and, if that occurs, I may be switching back to Kaiser in order to get that treatment from them (but that won't be for awhile, if ever).

Thanks for the info about Roseville Kaiser.

I like seeing that data as you presented it.
A little uncertain about the "urinary frequency" for 1 to 2 years. Not sure how frequent that is. I normally thought it was mostly for the first couple months.
Perhaps that is true and then it slowly declines.

Briefly, what was the main feature of CyberKnife that made you choose it over brachy?

I assume the Kaiser treatment was essentially free (on plan).
How about the CyberKnife at UCSF?

Interesting to know you can do brachy after the CyberKnife.

Thinking about it, I'm guessing part of your decision was based on the smaller area radiated via the Cyberknife vs the brachytherapy.
I'm guessing Kaiser won't have a Cyberknife for several years, just like it took them 4 or 5 extra years to finally purchase a Da Vinci machine.

Also interesting "8 year DSS (disease specific survival) rate of 99.8% (1 death out of 511)"

1 person out of 511. Do you know if they take any Gleason 3+4 or 4+3 in that 511 population? Or any Gleason 8 patients?
Of course that is only 8 years out, but still impressive.

tpelle

RiverRider said:

Thanks for the info about Roseville Kaiser.

I like seeing that data as you presented it.
A little uncertain about the "urinary frequency" for 1 to 2 years. Not sure how frequent that is. I normally thought it was mostly for the first couple months.
Perhaps that is true and then it slowly declines.

Briefly, what was the main feature of CyberKnife that made you choose it over brachy?

I assume the Kaiser treatment was essentially free (on plan).
How about the CyberKnife at UCSF?

Interesting to know you can do brachy after the CyberKnife.

Thinking about it, I'm guessing part of your decision was based on the smaller area radiated via the Cyberknife vs the brachytherapy.
I'm guessing Kaiser won't have a Cyberknife for several years, just like it took them 4 or 5 extra years to finally purchase a Da Vinci machine.

Also interesting "8 year DSS (disease specific survival) rate of 99.8% (1 death out of 511)"

1 person out of 511. Do you know if they take any Gleason 3+4 or 4+3 in that 511 population? Or any Gleason 8 patients?
Of course that is only 8 years out, but still impressive.

Seeds of Hope
You might want to Google "Seeds of Hope, Michael Durso, M.D.". Dr. Durso had Brachytherapy in the late 1990's and wrote a book about his extended research into prostate cancer treatments and finally chose brachytherapy. You'll also find his positive report five years post surgery. He's still working as an emergency room physician in a hospital near Roseville. I found his book most interesting and helpful in making my choice for treatment -- radical prostatectomy. I'm seven years post surgery, last PSA was <.01 but leak about 2 pads per day. Enough to be annoying, but not enough to crimp my lifestyle, and not enough yet for AUS or sling. tpelle

Swingshiftworker

RiverRider said:

Thanks for the info about Roseville Kaiser.

I like seeing that data as you presented it.
A little uncertain about the "urinary frequency" for 1 to 2 years. Not sure how frequent that is. I normally thought it was mostly for the first couple months.
Perhaps that is true and then it slowly declines.

Briefly, what was the main feature of CyberKnife that made you choose it over brachy?

I assume the Kaiser treatment was essentially free (on plan).
How about the CyberKnife at UCSF?

Interesting to know you can do brachy after the CyberKnife.

Thinking about it, I'm guessing part of your decision was based on the smaller area radiated via the Cyberknife vs the brachytherapy.
I'm guessing Kaiser won't have a Cyberknife for several years, just like it took them 4 or 5 extra years to finally purchase a Da Vinci machine.

Also interesting "8 year DSS (disease specific survival) rate of 99.8% (1 death out of 511)"

1 person out of 511. Do you know if they take any Gleason 3+4 or 4+3 in that 511 population? Or any Gleason 8 patients?
Of course that is only 8 years out, but still impressive.

CyberKnife (CK) vs. Brachytherapy (BT)
These are my reasons for choosing CK vs. BT:

1) Blue Shield covers CyberKnife (CK) and I could switch from Kaiser to Blue Shield during open enrollment without any pre-existing condition exclusions. Brachytherpy (BT) and surgery (both open and robotic) were (are) free under Kaiser, but no other treatment options were available to me under Kaiser. CK costs $50K out of pocket w/o insurance at UCSF. I also considered Proton Beam Therapy (PBT) at Loma Linda University (LLU) but coverage under Blue Shield was uncertain, which is main reason why I did not pursue PBT; out of pocket cost for PBT at LLU is around $36k.

2) CK treatment requires the placement of 3-4 gold markers in your prostate and 4 radiation treatments. The prostate is also mapped w/MRI and CT scans prior to treatment. The radiation dosage is varied and can be applied in over 100 different angles, based on computer modeling of your prostate, which provides the highest degree of precision currently possible -- even more than PBT. The CK program also accounts for body movement and does not require you to be placed in a body mold to keep you in place as required during PBT treatment. PBT also requires 5 treatments weekly for 8-9 weeks, which requires you to live near the treatment site for 2 months. Although you didn't ask, these are the "technical" reasons why I chose CK over PBT.

3) Although the "success" of CK is apparently comparable to BT, the side effects (mainly urinary frequency and incontinence and rectal bleeding) are apparently more common w/BT than CK. Kaiser Roseville tells potential patients that urinary and ED problems can last for as long as 1-2 years. The same applies to surgery, where such problems are much more likely than w/BT or CK. The medical staff is just protecting itself from liability by warning that the problems can last 1-2 years. The problems usually resolve themselves earlier, but COULD last 1-2 years in certain cases. The same applies to CK, but I spoke w/3 prior CK patients. None of them reported any ED problems whatsoever (which was a BIG plus for me). CK is apparently able to avoid radiating the vascular bulb, which accounts for the lack of ED; not so for BT. One of the CK patients reported no urinary problems whatsoever. One reported some urinary frequency and one reported some urinary incontinence; both problems were resolved w/o treatment. And, one patient experienced rectal bleeding that required treatment. Similar rectal bleeding problems are reported for both BT and PBT for a small number of patients.

4) BT is an invasive surgical procedure during which up to 100 (usually 70-80) radioactive metal seeds are inserted in your prostate. There is only a small degree of control that the radiation oncologist can exercise in the placement of the seeds, based on their dosage and location. However, once the seeds are placed they will give off radiation in all directions and, if the dosage is too high or if the seeds move, they will affect all tissue (prostate or not) within the range of the seed(s), regardless of how well they were mapped and placed to begin with. This results in a greater possibility of damaging the bladder, urethra, vascular bulb and rectum with BT than w/CK.

5) The other problem w/BT is that the seeds continue to give off radiation for over a year and (except for the seeds that are passed out through the urethra) remain in your body for life. Some seeds may also migrate elsewhere in the body which can cause additional problems, especially if they lodge in your lung or vascular tissue. You have to exercise some care and avoid close contact w/children and pregnant women during the early stage of BT (1st 6 months or so) because of the radioactivity in your body. You also have to carry a special ID for airport (and other metal detector) screening, because of all of the metal seeds in your prostate. These are all additional reasons why I chose CK over BT.

FWIW, I do not know this for a fact but I was told that there is a CK machine in Kaiser SoCal and that is not used to treat prostate cancer (PCa) -- only brain and other cancers that they consider "inoperable." If this is true, Kaiser apparently doesn't think treatment of PCa w/CK is necessary, since PCa is treatable w/BT and surgery (open and robotic). I think that Kaiser has a vested interest in NOT treating PCa w/CK because of all of the physicians and staff that already provide BT and surgical treatment for PCa, who would be out of work if CK were used. Of course, I don't have any data to prove this, but it does make you wonder why (if Kaiser actually has a CK machine) it doesn't use CK for PCa, given that CK is a less expensive form of treatment than surgery (for sure) and is less invasive and reportedly has fewer side effects than both surgery and BT.

I do not have any access to the "raw" data that I was given at the orientation class in Roseville. The information was provided in a couple of screens of a PowerPoint presentation that we all received copies of at the orientation. You can call the BT Group at the Radiation Oncology Dept in Roseville at 916-771-2871. Ask for Joseph Hicks, who led my orientation session, to see if he can answer your questions about the person who died during the study of the 1st 511 BT patients. If you're a Kaiser member, you can also ask for Amanda who can sign you up for an upcoming orientation class, where you can ask your questions in person. They hold a class at least once a month.

Good luck!

RiverRider

Swingshiftworker said:

CyberKnife (CK) vs. Brachytherapy (BT)
These are my reasons for choosing CK vs. BT:

1) Blue Shield covers CyberKnife (CK) and I could switch from Kaiser to Blue Shield during open enrollment without any pre-existing condition exclusions. Brachytherpy (BT) and surgery (both open and robotic) were (are) free under Kaiser, but no other treatment options were available to me under Kaiser. CK costs $50K out of pocket w/o insurance at UCSF. I also considered Proton Beam Therapy (PBT) at Loma Linda University (LLU) but coverage under Blue Shield was uncertain, which is main reason why I did not pursue PBT; out of pocket cost for PBT at LLU is around $36k.

2) CK treatment requires the placement of 3-4 gold markers in your prostate and 4 radiation treatments. The prostate is also mapped w/MRI and CT scans prior to treatment. The radiation dosage is varied and can be applied in over 100 different angles, based on computer modeling of your prostate, which provides the highest degree of precision currently possible -- even more than PBT. The CK program also accounts for body movement and does not require you to be placed in a body mold to keep you in place as required during PBT treatment. PBT also requires 5 treatments weekly for 8-9 weeks, which requires you to live near the treatment site for 2 months. Although you didn't ask, these are the "technical" reasons why I chose CK over PBT.

3) Although the "success" of CK is apparently comparable to BT, the side effects (mainly urinary frequency and incontinence and rectal bleeding) are apparently more common w/BT than CK. Kaiser Roseville tells potential patients that urinary and ED problems can last for as long as 1-2 years. The same applies to surgery, where such problems are much more likely than w/BT or CK. The medical staff is just protecting itself from liability by warning that the problems can last 1-2 years. The problems usually resolve themselves earlier, but COULD last 1-2 years in certain cases. The same applies to CK, but I spoke w/3 prior CK patients. None of them reported any ED problems whatsoever (which was a BIG plus for me). CK is apparently able to avoid radiating the vascular bulb, which accounts for the lack of ED; not so for BT. One of the CK patients reported no urinary problems whatsoever. One reported some urinary frequency and one reported some urinary incontinence; both problems were resolved w/o treatment. And, one patient experienced rectal bleeding that required treatment. Similar rectal bleeding problems are reported for both BT and PBT for a small number of patients.

4) BT is an invasive surgical procedure during which up to 100 (usually 70-80) radioactive metal seeds are inserted in your prostate. There is only a small degree of control that the radiation oncologist can exercise in the placement of the seeds, based on their dosage and location. However, once the seeds are placed they will give off radiation in all directions and, if the dosage is too high or if the seeds move, they will affect all tissue (prostate or not) within the range of the seed(s), regardless of how well they were mapped and placed to begin with. This results in a greater possibility of damaging the bladder, urethra, vascular bulb and rectum with BT than w/CK.

5) The other problem w/BT is that the seeds continue to give off radiation for over a year and (except for the seeds that are passed out through the urethra) remain in your body for life. Some seeds may also migrate elsewhere in the body which can cause additional problems, especially if they lodge in your lung or vascular tissue. You have to exercise some care and avoid close contact w/children and pregnant women during the early stage of BT (1st 6 months or so) because of the radioactivity in your body. You also have to carry a special ID for airport (and other metal detector) screening, because of all of the metal seeds in your prostate. These are all additional reasons why I chose CK over BT.

FWIW, I do not know this for a fact but I was told that there is a CK machine in Kaiser SoCal and that is not used to treat prostate cancer (PCa) -- only brain and other cancers that they consider "inoperable." If this is true, Kaiser apparently doesn't think treatment of PCa w/CK is necessary, since PCa is treatable w/BT and surgery (open and robotic). I think that Kaiser has a vested interest in NOT treating PCa w/CK because of all of the physicians and staff that already provide BT and surgical treatment for PCa, who would be out of work if CK were used. Of course, I don't have any data to prove this, but it does make you wonder why (if Kaiser actually has a CK machine) it doesn't use CK for PCa, given that CK is a less expensive form of treatment than surgery (for sure) and is less invasive and reportedly has fewer side effects than both surgery and BT.

I do not have any access to the "raw" data that I was given at the orientation class in Roseville. The information was provided in a couple of screens of a PowerPoint presentation that we all received copies of at the orientation. You can call the BT Group at the Radiation Oncology Dept in Roseville at 916-771-2871. Ask for Joseph Hicks, who led my orientation session, to see if he can answer your questions about the person who died during the study of the 1st 511 BT patients. If you're a Kaiser member, you can also ask for Amanda who can sign you up for an upcoming orientation class, where you can ask your questions in person. They hold a class at least once a month.

Good luck!

Thank you for the extensive answer to your choice between the two treatments.

Currently I only am covered by Kaiser, but that situation could change and I might be able to make use of your reasoning in the future.

As I have previously mentioned, I have not as yet received a positive biopsy. Last one was zero of 10. Fingers crossed. That was about 7 months ago and I have not had a PSA since then.
However my urologist said my figure of a 70% chance of converting to positive over the next 7 to 9 years was about right.
Of course we don't know, but given my family history, rise of PSA etc. I am expecting it to be more likely than not that at some point I will have to make a treatment decision or go with active surveillance.

Because of my father's history, I've been following this subject for years, but until recently have not read much about the CK choice.

Hopefully others will find your answer and include it in their reasoning process.

Were I not in Kaiser, I'd probably be thinking of UCSF as well.
If they like it, that seems to speak well about it.

I've followed the ideas of Dr. Carroll who is also at UCSF.

Your comments about Kaiser having a unit in SoCal are interesting.
Five years tomorrow, one of my closest friends died of brain cancer.
I took him to several of his radiation treatments, but they didn't even slow down the process. Back then I doubt Kaiser or almost anyone had a CK unit.

Talk about fast compared to PCa, my friend lasted 81 days from diagnosis to demise.
That always puts any PCa concerns of mine in perspective.
BTW, on a positive note, my father who received EBRT and DES (hormone) lived for 25 years after treatment for his PCa and died of unrelated causes at 88. His was outside the capsule, thus the radiation choice. Probably best, given the status of surgery back in the early 70's.
Some continuing side effects even in the last few years, very real, but not too bad.
Back then, about 1975, I think the radiation was far less precise regarding protecting other tissues. Certainly nothing like the CyberKnife precision.
Heck, they didn't even have MRIs or CT Scans.

Thanks for your reply.

James Brown

look for Kaiser surgeon robic

Had second biopsy was worse than 1st so at this point have decided to have surgery looking for the best robotic assisted Prostatectomy surgeon in the Kaiser north bay. Have talked to a doctor Joseph Lee seemed nice very  but was all business. Doctor Lee also suggested Doctor Art Martinez if I wanted done be fore he was able to do the operation. anyone had experience with eighter of these surgeons.