Urologist vs Oncologist - who's right????

Perineum

Hello all, I've been diagnosed with prostate cancer last month.
I've consulted with multiple urologists and oncologists which gave me different treatments.

Urologists recommends radical surgery to remove all prostate and lymph nodes.
They say there is a chance of curing the disease. They said that after surgery, according to the prostate examination, I might need radiation (but they think that I won't need).

Oncologists deny surgery saying it won't cure me (GS8), and recommends radiation+hormons. They say that the tumor is probably spread because the Gleason 8 high grade.

My medical info:
- Gleason 8(4+4) - 1 out of 12 cores has cancer (0.5 cm) (replaces 10% of this core and less than 5% of entire cores)
- PSA rising for the last 5 years, now it is 9 (started with 5 at 2005)
- Prostate volume is very large - 90 (measured in US)
- Had CT, Bone mapping, ultrasound - nothing found
- clinical stage T1C (stated by my urologist (not an expert))
- 63 years old.

I really don't know what to do. Scheduled a surgery 2 months after the biopsy, and now I need to decide what to do: Surgery or Radiation+Hormons.

I really don't know how to consider these two options. I don't know the chances...
Read a lot in the net, forums, etc but I really don't know...

Is there anyone here that had the same medical info like me and can share the treatment and results he had?

Thanks a lot ! Please advise

Old-timer

Treatment for prostate cancer
I offer you encouragement but I am far from qualified to offer advice for treatment. I am 84 years old and have personally coped with prostate cancer since I was 64. I have had ups and downs; but happily, many more ups than downs. Options for treatment were few in 1991: surgery, radiation, or "watchful" waiting. My Gleason score was 7(3+4). My PSA reading was 4.0. I chose surgery over the other options. I have always been comfortable with my choice. Shortly after surgery, my PSA dropped to .0 (told to me by the urologist). Checked annually by my internist, it remained at that level for 13 years. But then it began a slow rise: .02, .39, .64 (at three month intervals). It reached 1.16 after about a year. On my uroligist's recommendation, I consulted an oncologist. After 35 sessions of external beam radiation, my PSA readings continued to climb. Obviously, the cancer had eluded the radiation. I had radiation six years ago. Three years ago,after my PSA reached 20.0, I went on hormone therapy. The PSA dropped to "undetectable."

Overall, I have suffered a degree of anxiety from time to time. But life is great. I feel good both physically and mentally. I remain active in many activities and I am, far from being ready to give up and quit. Strangely enough, I think this "old cancer" has caused me to live a fuller life. I won't go into other details. But I will say that I am a happy camper. I have an unfortunate side effect from the radiation treatments. Elsewhere on this discussion board I have mentioned a problem with incontinence. Soon I will be evaluated by my urologist to determine whether an artificial urinary sphincter might be right for me.

Best of luck to you. Hope this is helpful.

VascodaGama

Old-timer said:

Treatment for prostate cancer
I offer you encouragement but I am far from qualified to offer advice for treatment. I am 84 years old and have personally coped with prostate cancer since I was 64. I have had ups and downs; but happily, many more ups than downs. Options for treatment were few in 1991: surgery, radiation, or "watchful" waiting. My Gleason score was 7(3+4). My PSA reading was 4.0. I chose surgery over the other options. I have always been comfortable with my choice. Shortly after surgery, my PSA dropped to .0 (told to me by the urologist). Checked annually by my internist, it remained at that level for 13 years. But then it began a slow rise: .02, .39, .64 (at three month intervals). It reached 1.16 after about a year. On my uroligist's recommendation, I consulted an oncologist. After 35 sessions of external beam radiation, my PSA readings continued to climb. Obviously, the cancer had eluded the radiation. I had radiation six years ago. Three years ago,after my PSA reached 20.0, I went on hormone therapy. The PSA dropped to "undetectable."

Overall, I have suffered a degree of anxiety from time to time. But life is great. I feel good both physically and mentally. I remain active in many activities and I am, far from being ready to give up and quit. Strangely enough, I think this "old cancer" has caused me to live a fuller life. I won't go into other details. But I will say that I am a happy camper. I have an unfortunate side effect from the radiation treatments. Elsewhere on this discussion board I have mentioned a problem with incontinence. Soon I will be evaluated by my urologist to determine whether an artificial urinary sphincter might be right for me.

Best of luck to you. Hope this is helpful.

Perineum; Treatments aim to cure but on a “guessing” modality
Hi Perineum

You are not alone in the matters of prostate cancer. Confusion is common because there is no “silver bullet” to kill the cancer. Treatments aim to cure but on a “guessing” modality. If successful we all accept consequences in good mood otherwise, the side effects must be endured for ever, and that becomes part of the decision process we do when deciding on a treatment.

The idea of having surgery and then radiation means a double contingency of side effects. I would suggest you stick with only one and hope for the best.
Both treatments are advisable to cases where the cancer is KNOWN to be confined. If any chance exists indicating a probable extra capsular extension but still LOCALIZED, then surgery would not be proper, and a combination of hormones plus radiation is recommended. In this case the radiation planning is for a wider spectrum, therefore different from that of an initial directional treatment (ex; CK).

Your diagnosis may be correct but you should try to get more detailed information from your pathologist report to pinpoint those pieces of info giving an idea of any possibility to metastasis. Gleason 8 with PSA 10 and only one core positive out of 12; with a voluminous prostate could be considered on both sides of the “coin”; Contained against extra-capsular extension.

My opinion as a layman is that, the high PSA could be causes from any infection of the prostate which is double of the normal (30 to 45) size. One core indicates a non-voluminous cancer which may rule-out any micro-metastasis. However the Gleason pattern of 4 is of an aggressive type of cancer cell, which, if the core comes from the apex, would require an excellent surgeon hand “sharp” enough to cut the prostate at the base, without leaving any piece of it behind.

Your case in accordance with the info you provide, is localized but of the type standing in the border line between a contained and non-contained diagnosis.

In this site you can get many examples of cases similar to yours that may give you some insight about what you are looking for. You can narrow the search by Gleason, age, PSA, etc, and read corresponding diagnose, initial treatment and outcome;
http://www.yananow.org/Experiences.html

Wishing you peace of mind.
Welcome to the board.

VGama

2ndBase

Treatment
Perineum, I was psa 24 Gleason 9 at age 52 in 2003. My cancer had already spread beyond the prostate and I took one shot of Lupron to shrink the tumor and then the 40 radiation treatments. In about 2008 I had a second biopsy to see if there was any cancer left in the prostate to kill and the test found zero. So even if the cancer had not spread the radiation would have saved my life and surgery could be avoided. The radiation treatments are much better than they were 20 years ago and I had very little to zero side effects from the radiation. My cancer is now in my bones and I have to take morphine in very large amounts to keep the pain level below 8.
I was told I had a 50% chance to survive 2 years in 2003 and a 2% chance to make it for 10. I give most of the credit for my survival to my wife who keeps all the stress out of my life. It is not easy but I still work a couple part time jobs, work a large garden and play golf as much as possible.
You will be able to kill the cancer in the prostate either with surgery or radiation. The radiation has much less side effects. Hormone shots have bad side effects as I am sure you know. I had to have one to shrink the prostate or otherwise I would have refused it.
I wish you all the best as you begin to fight.

Swingshiftworker

Get A 2nd Opinion On The Biopsy
I had an accident today and can't type well because I almost cut the tips of 2 fingers off of my left hand. I'm sure others will chime in w/more detai; soon.

Here's the short version of my view:

1) Get a 2nd opinion on the biopsy ASAP. Dr. Jonathan Epstein at Johns Hopkins is very highly regarded and did mine.

2) Because of the serious side effects (best case ED & incontinence for about a year and worst case possibly permanent) and prolonged recovery time and all of the normal risks associated w/surgery, I suggest avoiding surgery if at all possible.

Surgery is not warranted if the cancer has spread or suspected to have spread beyond the prostate. Not sure what lymph nodes your urologist wants to remove, but if the cancer has spread to your seminal vesicles and require removal too, you should really try to find out w/additional testing, if available, whether the cancer has spread significantly beyond the prostate capsule. If it has, then surgery really is NOT an option.

BTW, if the surgery fails you'll just have to get radiation w/hormone or chemo anyway. So, if radiation will work why bother w/the risks and complications of surgery on top of the problems associated w/radiation and hormone and/or chemo?

3) IMRT (intensity modulated radiation therapy) w/hormone therapy has been used successfully in treating high risk PCa. There are some recent threads here that discuss this concerning another member diagnosed as Stage T1c w/Gleason 8. High Dose Rate Brachytherapy (HDR BT) may also be an option.

The threads you should read were posted by AussiePup and are titled: "Recently Diagnosed and am a Bit Confused" and "Update on my "confusion." They are both relevant to your own confusion over the conflicting treatment plans that have be proposed.

Good luck!!!

Randall72

uroloigist vs oncolgist
I am having Divinci surgery in about 2 weeks.I am 57,my surgeon is both of the above. The 1st question both the uroligist and radiogist both asked was " how more yrs you think your going to live." I said aleast 30-40 yrs. I am in pretty good health over all. Both Drs agreed that surgery would be best at this time.And if needed later,radiation.You cant do radiation 1st then surgery,because of scar tissue. Good luck on your decicion.My date is June 21st.Hopefully this helped somewhat. Randall72

Swingshiftworker

Randall72 said:

uroloigist vs oncolgist
I am having Divinci surgery in about 2 weeks.I am 57,my surgeon is both of the above. The 1st question both the uroligist and radiogist both asked was " how more yrs you think your going to live." I said aleast 30-40 yrs. I am in pretty good health over all. Both Drs agreed that surgery would be best at this time.And if needed later,radiation.You cant do radiation 1st then surgery,because of scar tissue. Good luck on your decicion.My date is June 21st.Hopefully this helped somewhat. Randall72

Not Necessarily True
Sorry, but it's not necessarily true that you can't have surgery after radiation.

Surgery is difficult but NOT impossible after radiation treatment. Most urologist/surgeons would prefer not to undertake such surgery because it is difficult due to the scarring that you mention, but again it's not impossible.

However, the more important question is whether surgery following radiation is necessary. In most cases, it would not be necessary especially if the cancer has migrated beyond the prostate.

In that case, further radiation treatment and/or chemo and/or hormone treatment would be recommended regardless if the the initial treatment was surgical or radiological.

bdhilton

My Urologist is also my
My Urologist is also my Oncologist. He has a large and successful practice with national recognition for their Robotics…He went over all treatments and did not press surgery over radiation/Hormones but he also offered to send me outside of his practice to Northwestern to have William Catalona do my surgery.

So from my experience I was better “served” by an Urologist Oncologist….I never felt he gave any bias to any treatments but when he offered to send me outside of his practice I knew he was watching out for my best interest… I believe he would have had his robotic surgeon (national recognized) do the surgery if it was a good fit (I even argued it)…..

So I would be looking for a well regarded Urologist Oncologist in your area…Best to you in your journey

Oneoldman

Randall72 said:

uroloigist vs oncolgist
I am having Divinci surgery in about 2 weeks.I am 57,my surgeon is both of the above. The 1st question both the uroligist and radiogist both asked was " how more yrs you think your going to live." I said aleast 30-40 yrs. I am in pretty good health over all. Both Drs agreed that surgery would be best at this time.And if needed later,radiation.You cant do radiation 1st then surgery,because of scar tissue. Good luck on your decicion.My date is June 21st.Hopefully this helped somewhat. Randall72

Who's right... good question
I'm an 85 year old..feel like a kid most of the time.. Had T1C rating last summer..urologist, after negative bone scan and MRIs gave the usual choices, or options.....I waited till Jan of 2011 and saw an oncologist who talked about Cyberknife in a rather positive way while not specifically stating that he recommneded it.. My internist said, do nothing..at my age something else will get me...added that PSA tests are no longer done on octogeneraians....

I opted for the 5 day cyberknife.. had the fiducials implanted in prostate and the 5 days of Cyberknife in Mid FEb 2011..PSA from5.6 before.. was 1.4 60 days later. Nothing to it... Very pleasant experience.

Currently,have the burning in the urethra canal that was supposed to occur during the first week or so after CK radiation.. also the moderately loose bowels .. both of which started in Mid May...The urologist thinks it's a side affect of the radiation...it may or may not be permanent..

I can live with these side effects if I have to... at my age, I'll settle for just about anything to stay ambulatory... Good luck to you

virginian08

My history
You should take my history with a grain of salt: my situation sounds different from yours, especially in that I had a smaller prostate. I was 56 at the time of my surgery.

From the biopsy, I was told that I had a Gleason score of 7. I was given a high chance of cure from the surgery. Fortunately, my urologist recommended a full frontal incision with the maximum number of lymph nodes removed.

The surgery showed a Gleason score of 9 tumor that had metastasized. They found cancer in one lymph node. I had to have Lupron and radiation, but I still have no detectable psa.

I am glad that I had the most aggressive surgery, because I doubt that I would be alive otherwise. I do have severe incontinence, but that situation seems to have been aggravated by the radiation. (The incontinence was improving in the time between the surgery and the radiation.)