Timing for surgery after diagnosis

CharlieG

Everybody is so helpful here! I read Dr. Walsh's book and it was so facinating, I read it in like 2 days (and it's a big book).

I know that for me, surgery is my best and only option. I am 51 and have a long way to go in this world...

I am now contemplating the other choices over which I have control - my Dr., the Open vs, Robotic and then timing.

Dr. Walsh talks about not rushing because one has to give the prostate time to heal from the biopsy. He (and my doc) recommends 6-8 weeks minmally. I had a "saturation" biopsy - one where they took 41 samples because the first biopsy came back clear after 12 samples. So, I am sure my little prostate gland is pretty pissed off and needs time to heal.

My brother had a similar experience after the multiple biopsies it took to find his cancer. By the time they removed his prostate, it was "a bloody pulp" according to his doc.

So, since my 41 samples came back with only 2 positives (both in the same area) and a Gleason score of 3+3=6 and my PSA is around 4-5, I am thinking that I might have a little more breathing room. Who knows, right?

Has anyone out there any opinions on timing? I have to believe that most of us feel the "get it the hell out of me" feeling if surgery is our choice.

Three weeks and counting,

Charlie

randy_in_indy

Charlie
I waited 10 weeks to the day prior to my surgery and my both the surgeons I was contemplating doing the deed said minimum 6-8weeks following the biopsy. With your saturated biopsy I might consider waiting longer however that would be totally up to you to decide.

I felt completely recovered from the biopsy at 10 weeks but only had 8 samples taken because they thought the prostate was on the small side. Here is my stats and path.

52 years old
PSA 9/09 7.25
PSA 10/09 6.125
Diagnosis confirmed Oct 27, 2009
8 Needle Biopsy = 5 clear , 3 postive
<20%, 10%, 10%
Gleason Score (3+3) 6 in all positive cores
11/09 Second Opinion on Biopsy slides from Dr. Koch
(4+3) = 7 5%
(3+4) = 7 10%
(3+4) = 7 10%
Endorectol MRI with Coil - Indicated the Palpal tumor was Organ confined
da Vinci 12/29/09 - Dr. Hollensbee & Scott
Post Surgery Pathology:
Prostate size 5 x 4 x 3.5 cm Weight: 27 g
Gleason: Changed to (3+4) = 7
Primary Pattern 3, 80%
Secondary Pattern 4, 18%
Tertiary Pattern 5, 2%
Tumor Quantitation:
Greatest Dimension, Largest tumor focus: 19 mm
Additional Dimension 18 x 15 mm
Location, largest tumor focus: Right posterior quadrant
Multifocality: Yes
Greatest dimension second largest focus 10 mm
Location: second largest focus: Left Posterior quadrant
Extraprostatic extension: Yes
If yes, focal or non-focal: Nonfocal
If yes: location(s) right and left antero-lateral
Seminal vesicle invasion: No
Cancer at surgical margin: No
If no, closest distance with location: less than 1 mm, right posterior quadrant
Apex involvement: No
Bladder involvement: NO
Lymph-vascular invasion: No
Perineural invasion: Yes


Randy in Indy

Trew

Options
I met a number of men who had that attitude of just getting the thing out of there. I can't said I held that option. Looking back I wish I had considered just the hormone and radiation route myself. And I wish I had worked with an onoclogist team instead of an individual doctor. I like the team approach used at some cancer centers.

As far as getting the Thing out of there, that doesn't mean you are home free. Even after surgery the cancer can come back. What I should have considered more carefully is the quality of life after treatment. Looking back is always easier than looking forward, but 1 year out from surgery I wish I had considered other options more carefully.
Something else to consider while you are waiting. I learned from poster Erisian who quite involved in PCa that frequent PSA tests have some value. I wish I had the doctors take three PSA tests from the 1st one I have in NOv 08 that got everything started. I should have had a PSA taken in Jan,Feb, early March to see if the PSA was moving upward or holding. That would have given my an idea if the cancer was aggressive or not. That may impact the type of treatment chosen, too. If I were in your shoes, my first choice whould be proton therapy, but I didn't have that option. Too bad. I did not like surgery, and I still leak. I was very active, now the leaking is an anchor on tht part of my life, too.

Just another prospective on this nasty thing you now have to deal with in your life.

CharlieG

Trew said:

Options
I met a number of men who had that attitude of just getting the thing out of there. I can't said I held that option. Looking back I wish I had considered just the hormone and radiation route myself. And I wish I had worked with an onoclogist team instead of an individual doctor. I like the team approach used at some cancer centers.

As far as getting the Thing out of there, that doesn't mean you are home free. Even after surgery the cancer can come back. What I should have considered more carefully is the quality of life after treatment. Looking back is always easier than looking forward, but 1 year out from surgery I wish I had considered other options more carefully.
Something else to consider while you are waiting. I learned from poster Erisian who quite involved in PCa that frequent PSA tests have some value. I wish I had the doctors take three PSA tests from the 1st one I have in NOv 08 that got everything started. I should have had a PSA taken in Jan,Feb, early March to see if the PSA was moving upward or holding. That would have given my an idea if the cancer was aggressive or not. That may impact the type of treatment chosen, too. If I were in your shoes, my first choice whould be proton therapy, but I didn't have that option. Too bad. I did not like surgery, and I still leak. I was very active, now the leaking is an anchor on tht part of my life, too.

Just another prospective on this nasty thing you now have to deal with in your life.

Thanks, Trew... I have had
Thanks, Trew... I have had so many PSA test over the last 2 years. Actually, annual for the last 10 then every 3-6 months since 2008.

Mine has gone from 3.5 to 6.2 back down to 3.9 (fairly slow but consitently after taking Prostate 2.3 by Theralogix)then creeping back up to almost 5 again.

First biopsy was clear but the Dr. insisted on another, the saturation one, and I put it off and put it off (probably about 12 months or so). I am glad that we did the saturation cuz I wouldn't want to go through another cleansing prep and then the actual procedure again.

Not finding anything in the first biopsy and the finding only 2 positive cores in 41 samples (and both being from the same quadrant) gives me some feeling of hope that this is very early stage. One never knows until and unless it is removed and then analyzed, I guess.

I am certainly waiting the minimum for healing and considering waiting through the summer.

CharlieG

randy_in_indy said:

Charlie
I waited 10 weeks to the day prior to my surgery and my both the surgeons I was contemplating doing the deed said minimum 6-8weeks following the biopsy. With your saturated biopsy I might consider waiting longer however that would be totally up to you to decide.

I felt completely recovered from the biopsy at 10 weeks but only had 8 samples taken because they thought the prostate was on the small side. Here is my stats and path.

52 years old
PSA 9/09 7.25
PSA 10/09 6.125
Diagnosis confirmed Oct 27, 2009
8 Needle Biopsy = 5 clear , 3 postive
<20%, 10%, 10%
Gleason Score (3+3) 6 in all positive cores
11/09 Second Opinion on Biopsy slides from Dr. Koch
(4+3) = 7 5%
(3+4) = 7 10%
(3+4) = 7 10%
Endorectol MRI with Coil - Indicated the Palpal tumor was Organ confined
da Vinci 12/29/09 - Dr. Hollensbee & Scott
Post Surgery Pathology:
Prostate size 5 x 4 x 3.5 cm Weight: 27 g
Gleason: Changed to (3+4) = 7
Primary Pattern 3, 80%
Secondary Pattern 4, 18%
Tertiary Pattern 5, 2%
Tumor Quantitation:
Greatest Dimension, Largest tumor focus: 19 mm
Additional Dimension 18 x 15 mm
Location, largest tumor focus: Right posterior quadrant
Multifocality: Yes
Greatest dimension second largest focus 10 mm
Location: second largest focus: Left Posterior quadrant
Extraprostatic extension: Yes
If yes, focal or non-focal: Nonfocal
If yes: location(s) right and left antero-lateral
Seminal vesicle invasion: No
Cancer at surgical margin: No
If no, closest distance with location: less than 1 mm, right posterior quadrant
Apex involvement: No
Bladder involvement: NO
Lymph-vascular invasion: No
Perineural invasion: Yes


Randy in Indy</p>

Thanks, Randy. You are a
Thanks, Randy. You are a champion and a poster adult for the positives in this world of PC. Some of your stats are greek to me as I presume that you got much of this from the lab after removal?

jmchugh

i did what you are doing
i was your age and had an almost similar path report and had it removed. what i would add to the discussion is that you fully vet your surgeon... make sure, whether open or rob otic, that he or she is good at it.
in the walsh book read the chapter on incontinence.. you'll know you are at the right part when you see this quote "the well wear a crown only the sick can see" good luck jm

CharlieG

jmchugh said:

i did what you are doing
i was your age and had an almost similar path report and had it removed. what i would add to the discussion is that you fully vet your surgeon... make sure, whether open or rob otic, that he or she is good at it.
in the walsh book read the chapter on incontinence.. you'll know you are at the right part when you see this quote "the well wear a crown only the sick can see" good luck jm

I loved that quote... "The
I loved that quote... "The well wear a crown only the sick can see"

luckyman2

CharlieG said:

I loved that quote... "The
I loved that quote... "The well wear a crown only the sick can see"

Take the time you need.
Sorry to see that you have joined this club, but now that you're here, take the time you need to make the choice that's right for you.

You can read my PC journey and stats on my profile, but they appear to be similar to yours. However, only 1 out of just 8 biopsy samples showed 20% cancer cells with a Gleason Score of 6 (3+3). I was just one month short of my 55th birthday when I was diagnosed with prostate cancer. I decided to do my research (everything from HIFU to radiation) and to wait until I was comfortable with my final decision to have surgery.

My doctor, who is the head of Urology and Oncology at the Montreal General Hospital, suggested surgery because of my age and that I had a lot to lose by waiting too long... saying that a year should be the maximum in my situation. I waited 8 months from the biopsy session in March 2006 until my surgery in November 2006. I'm glad I did.

Kongo

Options
Charlie, like you my urologist recommends surgery at an early opportunity arguing that an early stage, indolent cancer has a good chance for a "cure" (defined as post-operative PSAs being < 0.1 ng/ml). Like most surgeons, he recommends surgery. Am only a week out from diagnosis myself and have not yet talked to an oncologiest or radiologist and am in the process of scheduling those now. Interestingly, my urologist did not reccommend the robotic surgery that many in this forum favor as he felt that in our area (San Diego) there simply weren't enough surgeons who has significant experience in the procedure although he felt that in the future most protatectomies would be robotic. One point he made which I thought was valid is that surgeons are surgeons primarily based on their abilty to use their hands and he felt the advantage of tactile involvement with the organs was a significant factor for an experienced surgeon over one who was performing the operation from a keyboard without tactile sensation. He also indicated that open surgery essentially had a single, 6-inch incision vice about six, 1-inch incisions. He also expressed that the rapid rise in in robotic surgery was the result of a very aggressive marketing campaign. Prostate cancer is big business in the United States.

When I queried my urologist about side effects he candidly indicated that there is a small, but significant percentage of post-treatment incontinence in varying degrees. Many posts in this forum allude to these complications (see the interest in artificial sphincters) Regarding potency and erectile function, he pointed out that after surgery sex was not going to be like it was before but that if nerves could be spared, more than 50% of men reported the ability to achieve erections "sufficient for penetration," often with the help of viagra-like drugs, penile vacuum pumps and associated paraphenalia. In addition to being sterile, orgasms change significantly without a prostate as there is no ejaculation (the seminal fluid being produced when the prostate spasms during climax), the erection is not as hard as before and the frequency of being able to achieve an erection is much less. Although different, he indicated some patients reported that when they occurred, their post-surgery orgams were more intense than before.

Besides the standard Gleason score, biopsy results, and PSA readings, you may also find it useful to assess your condition with a couple of other parameters that are easily calculated. PSA density is a measure of PSA to prostate volume and is easily calcualted by dividing your PSA at diagnosis by prostate volume which should have been calculated when they did the transrectal ultrasound during the biopsy. Another factor useful for determining long term risk factors is the PSA doubling time, which is a logarythmic function. The more PSA data points you have over time the more accurate the prediction. I found several readings from previous annual physicals going back to 2002. There are several PSA nomograms available on the web that can calculate this number for you. I used the one from the Sloan-Kettering site although Johns Hopkins has similar online tools.

Generally the literature I've read indicates that a low PSA denisty and a long PSA doubling time is indicative of having plenty of time to make an informed decision. One thing about PSA to keep in mind, however, is that the more aggressive forms of PCa tend to produce much less PSA than less aggressive strains so in the case of a large volume of cancer in a biopsy, evidence of capsular extension to seminal vessels or lymph nodes may mean that PSA denisty and doubling times aren't appropriate for your form of cancer.

The literature that I have read indicates that if you are T1c, PSA <10, Gleason <7, and low biopsy volume, low PSA density, and long PSA doubling time, the long term survival statistics for surgery, radiation, and active surveillance are the same.

I am also investigating some radiation techniques other than the rather standart brachy and XBRT that include a procedure known as Cyberknife (see cyberknife.com), proton therapy at Loma Linda Medical Center, and a very new procedure called Altaris Tx where there are ongoing clinical trials in San Diego. These procedures aim to achieve the same levels of radiation treatment to the affected areas in much less time and much more accurately administered (sub millimeter accuracy) that is supposed to minimize side effects and potential damage to surrounding tissue.

Good luck with your decison process.

jminnj

Charlie
I am 47, was diagnosed in November (13th) and had my robotic procedure on January 21st. I had one positive core (10%) out of 10 samples and 3+3 on the Gleason scale. Upon biopsy of the full prostate, 35% of the gland was impacted but it was all contained. I was definitely in the mindset of "get it the hell out of me". It is of course a personal choice as to the timing, but I did not want to go through the mental side of going back for tests every couple of months to see if my PSA level had gone up/down.

I wish you all the best on whichever path you take.

Joe