Laparoscopic or open surgery? - G8 (5+3)

Pathfinder

I apologise for opening a new thread, and if it's against the rules feel free to merge with the old; but I feel the concerns in the other have been kindly and thoroughly addressed and the most recent dilemma now requires a more direct discussion.

Previous thread: http://csn.cancer.org/node/303384#comment-1545753

Summary in-brief: 

Father in-law with PC, 62 years old, into 2nd month of HT, based in China. Gleason 8 (5+3), prostate size fairly normal (slight enlargement), PSA 24 prior to HT (currently unknown). MRI suggests cancer contained within the gland, but by no means a guarantee. Doctor's stage appraisal: T2c - T3a.

The current dilemma:

China doesn't have advanced enough radiotherapy to trust it as a primary option. Therefore we have decided to use it as a backup to surgery. The surgery has been decided on based on the staging ambiguity (T2c - T3a). In the event the PC is contained within the gland then the surgery will hopefully excise all of it. If not, then surgery still offers the ability to cut away anything outside the perimeter, with radiotherapy as a backup. We are aware of and have taken into account all the side effects of surgery.

At the moment we have two options on the table:

1: A highly experienced expert surgeon in Shanghai who favours open surgery to deal with PC.

2: A highly experienced Beijing surgeon and professor who is an expert in Laparoscopic surgery (and teaches other hospitals and doctors around the country about how to perform this method).

Note: Robot surgery is not an option here.

The problem is, on Chinese PC support groups similar to this one, 90% of people suggest open surgery as the better option for G8 patients. This is partly due to a Chinese belief that open surgery is cleaner and easier for the doctor to "catch all", whereas the obstacle of working through holes via Laparoscopic is less efficient.

These are people who have dealt with PC themselves or within their families before, so their recommendations aren't given lightly - but they have a very strong lean toward open surgery. That said, not all people here do open surgery, and many on the group have had Laparoscopic and are doing well.

Money is an issue for anyone facing disease in China. Going to Shanghai for open surgery is hugely expensive, whereas the Beijing surgeon will actually come to us to perform Laparoscopic surgery. It's a saving of approx 60%.

We're not factoring in money as a method of deciding, but if it's true that the difference between Laparoscopic and open surgery methods is genuinely negligible, then it would become an important factor. From everything we've read from western studies, Laparoscopic is actually favoured over open surgery these days, and there is no evidence to suggest it's less efficient. This is conflicting with the Chinese consensus and giving us a headache!

We're aware recovery time with Laparoscopic is much better than with open too, and in the event we opt for this, we would have money left over to consider things like radiation salvage treatment etc. There's also been some suggestion that open is potentially dangerous to people over 60 due to trauma. Potentially life shortening?

So I'm really (really!) interested in your thoughts and advice on this! Literally the only thing swaying us on open surgery is the mass belief and recommendation of Chinese people with PC experience that open is more efficient, and more necessary for a Gleason 8 patient.

Based on your understanding and experiences with G8 or above, open and laparoscopic surgeries, do you feel there are any advantages or disadvantages of note here?

Thank you again for your support and advice.

Max Former Hodgkins Stage 3

??

Pathfinder,

I am unaware of any "rules" regarding beginning new threads.

Your post here today appears IDENTICAL to one you submitted on July 22 ("Need Your Advice on Surgery Types").  The issues you share regarding oncological services in China, and the types of surgical delivery available are identical also.  And the financial issues: Identical.

Of course it is also OK to resubmit an identical set of questions, I just found it odd.  Do recall that you got numerous replies to your July 22 enquirey ?

max

Swingshiftworker

Interesting.

I've watched with interest all of the varying conditions and limitations that the OP presents in trying to assess what path the patient should take in this case.  This is just another wrinkle in the discussion.  Nothing "bad" about this but I'm wondering when the OP will have enough info to make the choice.

In any event, given all of the constraints and being limited now to only a choice between open or laproscopic surgery in China, I would recommend open. 

Why?  It seems that open is the more common surgical approach in China, which means that surgeons and hopsital teams are better prepared to do it.  It removes the need to find an "experience" laproscopic surgeon of which there are relatively few in China.  It allows the surgeon an unobstructed view of the prostate and surrounding area so that if the cancer has spread it can be more additional diseased tissue can be identified and removed (which might be missed doing it laproscopically). 

Open surgery increases the risk of infection and other problems associated with surgery generally and increases the recovery time BUT, as Will Doran said in the other thread, what you should be most concerned about is the RESULT (not just the process) and, given the limitations presented, open surgery for advanced (GS-8) prostate cancer would probably be the better choice.

 

Timon

RALP vs. ORP

Here's a link to a recently posted article that refers to an Australian study:

https://prostatecancerinfolink.net/2016/07/27/ralp-vs-orp-data-from-a-randomized-phase-iii-clinical-trial/

Good luck!!

Timon

Pathfinder

Hi!

Hi!

@Max

"Your post here today appears IDENTICAL to one you submitted on July 22 ("Need Your Advice on Surgery Types").  The issues you share regarding oncological services in China, and the types of surgical delivery available are identical also.  And the financial issues: Identical."

My apologies Max, they do indeed seem very similar. I should have been more explicit.

The fundamental change that's occurred since that post is that a hospital has located an expert in laparoscopic surgery who would travel from Beijing to perform the operation.

Prior to being given this unexpected second option, we were indeed mind-made-up on open surgery in Shanghai, because the doctors located in the city who offered Laparoscopic didn't have the experience.

Once we were notified of this option, it was a case of going back into research of the pros and cons of open surgery versus laparoscopic. We now have two experts available to us, and a cost differential of 60% depending on which we choose.

Rather than continue the previous thread, which got us to this point of decision making, I wanted to open this one as a final question. It's crunch time basically, and contrary to the Chinese forum group recommendation, western reports don't seem to favour open surgery as being definitively superior, which is why I wanted to get your take on it.

@Swingshiftworker

" It seems that open is the more common surgical approach in China"

Actually it isn't! Laparoscopic is definitely the preferred method of surgery by the vast majority of hospitals. It's actually difficult to find a surgeon who does open surgery, and who does it well - hence the Shanghai doctor being very busy. It's primarily the online PC commentators who are making the decision difficult because they favour open surgery. The hospitals don't really see any reason to favour it though.

 

@Swingshiftworker

"I've watched with interest all of the varying conditions and limitations that the OP presents in trying to assess what path the patient should take in this case.  This is just another wrinkle in the discussion.  Nothing "bad" about this but I'm wondering when the OP will have enough info to make the choice."

Us too, and I do apologise for asking so many questions. I'd be lying if I said we weren't finding the process of deciding incredibly tough, and a lot of that is because we don't have the kind of care and attention, or one-to-one professional advice we're used to in the West. The system here is very different, and 90% of the research and decision making is down to you.

In many cases a PC patient in China will stay with whatever hospital they were in when the PC was discovered, never question anything at all, and end up having whatever surgery is offered in the exact same hospital without being aware of the risks or severity of their condition. 

It's only the proactive children who tend to get online and start making discoveries and reaching out to others for guidance in decision making.

So really this is the last hurdle: Expert Laparoscopic with 60% saving to spend on future treatments, or expert open surgery that's costlier but preferred by Chinese forumites (but not hospitals!)

@Timon

Thank you for that report. Although we don't have robot assisted Laparoscopic as an option, that is indeed in-line with all the western case studies we've read - there doesn't seem to be any definitive difference (bar blood loss) between this and open surgery.

But I'm still really confused about what to do.

Max Former Hodgkins Stage 3

None

Pathfinder,

In medicine, and especially cancer treatment, there are no "definitive differences."  There are studies, statistical analyses, the opinions of experts.  If you are waiting on "definitive" or irrefuatble reasons to choose one form of surgery over the other, it will never happen.

Both are sound, established ways of doing RPt. Both have high curative rates.  Several responders have recommended using the more established surgeon.  I agree with them.

Beyond that, there is not much to say.   Cancer treatments have no guarantees. They do not come with a warranty.  If treatment fails, no one gets their money back.  But this is true of life in all areas.

In the history of philosophy there is a story from around 1350 AD, entitled Buridan's ****  (it also goes by the name of The Philosophical Donkey).

There are slightly differning versions of this, but the one I was taught relates that a wise donkey was tied equal distances between two piles of hay. They are identical, both are fresh, healthful. The donkey always chooses carefully, and looks back and forth, back and forth. He cannot decide which is best; he agonizes over the decision.

Eventually, he starves to death, unable to decide.  Either pile would have kept him alive and well.

max

 

.

Swingshiftworker

I would still favor "open" surgery in your case

Pathfinder said:

 "Laparoscopic is definitely the preferred method of surgery by the vast majority of hospitals. It's actually difficult to find a surgeon who does open surgery, and who does it well - hence the Shanghai doctor being very busy. It's primarily the online PC commentators who are making the decision difficult because they favour open surgery. The hospitals don't really see any reason to favour it though."

Given what you said about the lack of experience among laparoscopic surgerons in doing PCa surgery in China, I would still favor open surgery for your father-in-law, ASSUMING that the surgeon in Shanghai is as experienced as you say he is AND if there is any doubt (as there should be with a GS-8 diagnosis) about whether the cancer has spread beyond the prostate capsule AND assuming that your father-in-law is physically strong enough to endure the procedure AND the hospital where the surgery is performed is properly equipped to handle the procedure and any complications.  Cost and other considerations obviously come into play.

The risk of surgery laparoscopically is a bit less but the risk of "missing" some latent cancer is greater especially w/a GS-8 case.   It is quite common on this forum to read the stories of men who had laparascopic surgery for their PCa but then had to undergo follow up radiation to treat the cancer that was missed during the operation.   There have not been many men who have logged on here who have had open surgery but, among those who have, I do not recall any who have said they had to have follow up radiation done.  On the contrary, what I recall is that those men said that their surgeons found cancer during the operation that had not been revealed previously and were able to remove it.

Of course, with any surgery for PCa, there is also the risk of ED, incontinence and damage to collateral organs but you have already ruled out radiation and chosen to go with surgery.  So, as between open and laparascopic, you'll just have to weigh the risks/rewards for yourself and decide which is the better course for your father-in-law. 

Good luck!

 

Swingshiftworker

Actually, much the same in the US

Pathfinder said:

"In many cases a PC patient in China will stay with whatever hospital they were in when the PC was discovered, never question anything at all, and end up having whatever surgery is offered in the exact same hospital without being aware of the risks or severity of their condition. 

It's only the proactive children who tend to get online and start making discoveries and reaching out to others for guidance in decision making."

Actually, the situation is much the same in the US.  The burden of finding out about the available therapies for PCa is entirely up to the patient (or his family).  Not very much help is given by the treating urologists and only the most proactive patients (or families) will discover much of what you have learned from us here.   And, often men simply decide to choose whatever therapies that are recommended to them by their doctors without doing any further research on their own.

Here's my story which is an example of the kinds of struggles PCa patients in the US also have to endure to get the treatment they want:

I was with Kaiser in Northern CA and was given only 2 choices for treatment -- surgery (open or laproscopic) or brachytherapy -- when my PCa was discovered by biopsy in Jan 2010.  I immediately got online to do research on PCa and the 2 treatments offered to me and I did NOT like what I read.  Further research over the following 3 months revealed other alternatives that I considered better -- particularly CyberKnife, which I eventually chose.  However, I then had to find a site that offered CK treatment for PCA.  Fortunately, it was offered at UCSF in San Francisco where I lived. 

Then, I had to figure out how to pay for it.  I was enrolled in a group health plan that offered only a few providers other than Kaiser.  Fortunately, Blue Shield was one of the other providers  and just recently in the fall of 2015 changed their policy on CyberKnife -- deciding that it was then no longer an "experimental" treatment and from then on eligible for medical reimbursement.  Having discovered this, I then had to make the change in my medical group coverage during what's called "open enrollment" (which only occurs once a year) to change from Kaiser to Blue Shield so that I could switch from Kaiser to Blue Shield to get CK treatment at UCSF.  Fortunately, the open enrollment period was in April and became effective in July.  So, I was then able to get CK treatment at UCSF in September 2010. 

It was a struggle but it was the best decision I could have made.  The treatment was a complete success and I have experienced no side effects what so ever - no ED or incontinence or any other complications.  I recently passed the 5 year "cure" threshold and my PSA level continues to drop after a worrisome delay and bounce.  So, I am a very healthy and happy cancer survivor.

I wish your father-in-law the same good fortune,

Pathfinder

Max and Swingshiftworker,

Max and Swingshiftworker, thanks to you both. 

Swingshiftworker, thank you for your insights and information. I think our gut is also going with open surgery. Just to be clear the only reason we were given reason to be swayed is the Laparoscopic surgeon from Beijing is equally an expert - no need to worry about lack of experience. He teaches people around the country on performing the procedure.

As you say though, open will probably provide the best picture. We also have a Cyberknife clinic on our doorstep, but have heard mixed things about it. Would you mind me asking what your gleason/PSA was when you had CK surgery?

Related and slightly unrelated, one doctor has told us surgery immediately, another has recommended we finish the HT treatment for three months. Searching out info is conflicting on this. Some people say they experiences metastases while on initial HT treatment, others say that's unlikely and there are advantages for surgery if HT is carried out for three months.

Any input on this? Is it true HT can make surgery more successful/easier to perform, or should we get on and do it ASAP. My father in law has been on HT for 1 month so far, and has just started month 2.

Thanks guys.

Swingshiftworker

CK for PCa

Pathfinder said: "We also have a Cyberknife clinic on our doorstep, but have heard mixed things about it. Would you mind me asking what your gleason/PSA was when you had CK surgery?"

I was rated Gleason 6 with a PSA of less than 10 when I was diagnoses w/PCa, which is "ideal" (if there is such a thing) for CK treatment, because the cancer caught early and was still confined to the prostate. 

CK has been used for patients w/Gleason 6 because there is confidence that the cancer is confined to the prostate.   CK and any other method of radiation can be used for men rated at Gleason 7 or 8 but there has to be a high degree of confidence that the prostate is confined to the prostate capsule and/or to a specifically identified location.

When my PSA was erratic and bounced about 3 years after treatment, I received an MRSI (magnetic resonance spectrographic imaging) scan that detected the location of choline (which is a marker for cancer) using a Tesla magnetic coil inserted in my rectum.  This scan revealed that there was NO cancer remaining in my prostate or anywhere near by.  The same test can be used to determine the existenence and exact location of prostate cancer and its spread locally.  If you still want to opt for CK, I'd suggest you get this (or any similiarly effective) scan to determine whether or not CK would be effective in treating the existant cancer.

BTW, for those men who undergo laparoscopic surgery and later find that they require follow-up radiation treatment, CK is seldom used.  Instead, IMRT or IGRT are used to treat the prostate bed and adjoining areas because the object is not to deliver the radiation to a precise area (as CK does) but to a larger area where cancer may or may not be present.  It's kind of a water hose approach - spay and hope for the best -- because they really don't know exactly where the cancer is located.   With open surgery, there would be less (if not any) doubt about the location of any cancer that has spread.

 

 

Pathfinder

Thanks for that info, much

Thanks for that info, much appreciated. I think CK is probably better if the Gleason was lower in our case, as getting 'cofident' determination of PC containment in China isn't easy.