Tough decisions

jeffsch

June 2019 I had triple by pass surgery.In February of 2021 I was diagnosed with Prostate cancer with a PSA of 6.23. Gleason score of 9 4+5=9.Fisrt urlogist from M Fairview at the U of M told me I should have surgery.He said no radiation and  no chemo "yet".He didn't explain any options in depth at all.When I asked him about the CABGx3 and my blood clot issues he told me to ask my primary care providor.Needless to say he was proptley fired .POS.I talked to some urologists and radiologist at Mayo clinic.The urlogist suggested radiation because of my other health issues.He said I could have a heart attack or stroke while under anesticia.He said I'd need some tests to make sure it would be ok to do surgery.He also refered me to a radialogist that explained the different types of treatment that fit my diagnoses.They were very good and explained everything and answered all my questions.After that I talked to an oncologist at Minnesota Oncology.He also explained both procedures to me and he suggested surgery over radiation.So,thats 2 docs favored surgery and 1 favoring radiation.This is so confusing.I'm leaning towards surgery.My girlfriend has been with me to every appointment.And it is a good thing to have an extra set of ears and a better memory with me.Any suggestions?

hopeful and optimistic

.

surgery is a major operation so , as you were told, you would have a greater risk of dying during the procedure.

surgery is a localized procedure so with aggressive cancer of 4+5 it very likely that the cancer has escaped the prostate and other treatment will be required. The side effects of various treatments are cumulative. 

radiation can extend outside the prostate so is more likely to catch the cancer than survery. Generally in your situation there is a combination of hormone treatment and radiation. 

i wonder if you had any imaging tests ie t3 mri or a pet scan to effectively diagnose. A t3 mri may show extra capsular extension immediately outside the prostate and show the likelihood of suspicious lesions being a significant cancer within the prostate so you can have an idea of volume. A pet scan views the body looking for spots of cancer. 

the american urological association recommends a bone scan for men with Gleason 8 and above. 

best

VascodaGama

Radiation cardiotoxicity

Jeff,
Without information on your clinical stage (full PCa diagnosis) it is harder to provide you a comprehensive comment on options of treatment to your case but in regards to the possible effects from PCa surgery or radiotherapy (all forms) in your heart health issues, I think you will risk lesser by choosing radiation.

RT to the middle portion of the chest (for instance breast cancer) can raise your risk for radiation cardiotoxicity but RT to the pelvis (prostate area) the risks can be thought to be minimal to the same toxicity. You would need to be vigilant in regards to blood count, having regular blood tests during your treatment to certify that the red and white blood cells and platelets are accountable.
Blood clots in urine can turn common occurrences in radiation treatment several years after exposure however this is formed in the bladder or urethra due to cystitis (scar tissue from radiation).
Here is a link from CSN site on RT issues;
https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/effects-on-different-parts-of-body.html

I agree with Hopeful comment that Gs9 cases would typically have extraprostatic extensions requiring a wider intervention to mitigate those areas surrounding the prostate gland, which are not covered in PCa surgeries. I also would choose carefully the type of ADT if such is included in the RT protocol. However, even if you decide on radiotherapy, in your shoes I would do more investigation to obtain a better and due clinical stage of your status. You cannot throw arrows in the dark expecting to hit the bullseye. I think that the outcome from your choosen treatment is not affected if the intervention is done in two months.

Best wishes and luck in your journey.
VGama 

CMO2021

Dear Jeff,

Dear Jeff,

I have only recently started my PCA journey.  I have Gleason 9 aggressive PCA diagnosed in March 2021.  I had a t3 MRI that showed a PIRAD 5 lesion and a fusion biopsy that showed likely extraprostatic extension, perineural invasion, and suspected seminal vessical invasion accompanied with unfavorable histoloby showing cribiform and intraductal PCA morphology.  Bone Scan was negative, CT scan was mostly clean with one suspect node I also have had some cardiac issues hypertrophic cardiomyopathy that subsequently resulted in  me developing Atrial Fibrillation which I  actually had a cardiac ablation for in January 2021 which has mostly successful.  Enough so that I can stop my blood thinner (Xarelto).  I expect post your CABG that you are on a blood thinner.  The blood thinner presented some challenges around my biopsy but it all worked out with no significant issues (other the PCA diagnosis).  I chose to go to MSKCC in NYC and met with a Medical Oncologist, Surgical Urologist Oncologist, and two  Radiation Oncologists ( One for External beam radiation and a second for  HDR Brachy therapy).  I agonized over the decision surgery vs ADT plus Radiation.  The physicians did not try to influence my decision one way or the other but patiently answered all my questions and told me the only bad decision was  to do nothing.  The right decision for me was ADT plus Radiation, but you have to  make the decision that is best for you.  I have no idea what the final outcome will be for me but I am confident I made the best decision for me.  Just remember despite all the statistics  available to you that you are an N of 1 and you have to make the decision that you determine is the best for you.  The members of this board have been immensely helpful and supportive.  So continue to ask questions here and  I encourage you to solicit the advice of  an RO, MO and surgical ongologist at a Medical center identified as a National Cancer Center of Excellence.  I wish you well as you work through your options and decisions.

Best regards,

Chris

Clevelandguy

More tests?

Hi,

If I was in your shoes I would want to know where the cancer is located in my prostate via Image testing(MRI and/or PET scan).  4+5 is aggressive and if it has escaped the Prostate I would not choose surgery. If the cancer has escaped the gland then surgery would probably not get all the cancer.  But if the scan tests show it is fully contained in the Prostate then surgery could be an alternative. With your medical conditions that would be your choice on the least stress to your heart and body.  I would be talking with my cardiologist and getting their input.  Radiation could be a less stressful treatment path.  Great doctor's +great facilities = great results.

Dave 3+4