tp23 said:

All of the above

Mounty -

     I was recently diagnosed with prostate cancer.  11 of 12 positive cores with Gleason 8's and 9.  CT scan negative but seminal vesicles most likely invaded.  My urologist immediately placed me on bicalutamide and a few days later I received my first injection of Lupron.  The short term goal as he described it is to shrink the tumor to make it more resectable.  His theory, and mine as well, is remove what you can, and mop up with radiation.  He's stated that the ADT will be long term.  I should add that I just turned 50.  My PSA is only at 4.2 so there are concerns that it isn't a good indicator in my case.  I was suffering from frequent urination, couldn't fully void (Flomax didn't help), at times it was almost painful, like the hold your legs together to hold it in, weak stream, double digit starts/stops, total loss of sexual function (even with Viagra), and pain when sitting.  My urologist told me to expect an imprvement in my symptoms within 2 weeks and that would be a good sign indicating that the tumor is most likely hormone dependent (a good thing).  Well, it's been about 2 weeks now, and I've got to say, my symptoms are all improving.  Stream is full and no pain when sitting.  I've been doing my research too and most everyone I've spoken with and consulted with agree that if you can get it out, do so.  The target will be smaller for raditation and the radical prstatectomy will allow for lymph node investigation and biopsy of the tumor, as well as sampling of the margins.  From what I've read, surgey after radiation is not impossible, but not likely, and some doctors apparently won't perform it.  My urologist also stated that the lymph nodes would be removed and tested first, and if found positive, he would not continue.  He told me that podst op radiation would be like an insurance policy, and given the aggressiveness of the 8-9, should be part of my treatment.  No negative effects from any of the medications thus far.  One very informative source for me was NCCN.org.  You may want to give it a once over.

Good Luck - My best wishes for you & your family

Thanks TP,

Your post is also really helpful, especially because you're in about the same boat I am with regard to high Gleason score and a large number of positive cores.

The radiation oncologist I met with yesterday (after my first post the day before) made a similar recommendation for surgery. So now I have a recommendation for radiation from a surgeon and for surgery from a radiologist! At least I know their advice is not tainted by financial considerations. Once again, both these guys are really smart - I think their different suggestions highlight the complexity of the problem.

In fact the radiation oncologist's recommendation yesterday was very similar to the recommendation you received - androgen deprivation therapy followed by surgery followed by radiation and more ADT. I'm beginning to think - and your post  reinforces this notion - that this might be the best approach for those of us with high grade localized disease, although I also realize that everybody's case is different and nobody has the same disease.

Unlike the community practice radiation oncologist I consulted with earlier, this one works at a large academic cancer center (actually, one of the members of the NCCN) and in the past he's participated in the development each year of the annual guidelines for prostate cancer treatment by the National Cancer Institute. You might be interested to hear that he told me the next set of guidelines will be published soon and he thinks it may recommend intermittent hormone therapy (or perhaps shorter term ADT) as a way to reduce the potential for the development of ADT-refractory disease in the longer term. I plan to follow this closely and will post information once the new guidelines are issued.

Boy do I sympathize with your description of pre-ADT problems peeing.  It was a a big relief (no pun intended) how quickly the first ADT injections fixed that problem for me.

Good luck -  I'll be looking forward to hearing how it all works out for you.

Rickey001 said:

Similar choice

I also had the same choice to make that you are having to do. After talking to both the Surgeon and the Radiation Oncologist(who both said I would get better results fron radiation)I began a series of 45 concentrated radiation treaments, that began in 12/2011. The radiation was directed toward only the tumor on my prostate. After the radiation treatments, I then began Elegard injections every 4 months. Currently my PSA's are as close to 0 as is statistically possible. I get my 5th Elegard shot later this month.

The radiation treatments were brief and there was no overt discomfort from the radiation per se. The thing that got me was they made me drink at least 24-30 ounces of water about 30 minutes prior to the treatment. I was having trouble holding my water anyway,due to the cancer, so you can imagine what it felt like if there was any delay what so ever in getting the treatment. After the treatment, I literally ran to the bath room.

The follow-up homone therapy does have some very aggravating side effects: easy fatigue,loss of sexual desire with erectile dysfunction, hot flashes, mood swings and depression. My wife says it's like going through Menopause.

I dont know if this helps any. I am attaching an article for you read, concerning radiation followed by homone treatments, which might be helpul.

Best Wishes..

Radiation Plus Hormone Therapy Extends Life in High-Risk Prostate Cancer

But, surgery might even improve survival more, expert says

By Steven Reinberg
HealthDay Reporter

WEDNESDAY, Nov. 2 (HealthDay News) -- A combination of radiation and hormone therapy prolongs survival among men whose cancer has spread beyond the prostate, Canadian and U.K. researchers report.

These men have what is called high-risk, or locally advanced, prostate cancer. Among men with prostrate cancer, up to 25 percent fall into this category. In the past, these men have often been treated with hormone therapy alone, the researchers noted.

"In patients with locally advanced prostate cancer, combining radiation therapy plus hormonal therapy gives much better results than hormone therapy alone," said lead researcher Dr. Padraig Warde, deputy head of the Princess Margaret Hospital Cancer Program and a professor of radiation oncology at the University of Toronto.

"Specifically, it reduces the risk of dying from prostate cancer 43 percent and the risk of dying overall by 23 percent," he said, adding that this is the first study that shows that the combination of radiation and hormone therapy improves survival.

"These patients were often felt, in the past, to be incurable, because the disease has spread locally outside of the prostate, but not elsewhere in the body," he said. "But they shouldn't be discarded, we are showing that going for a cure is worthwhile."

Treatment options for patients with locally advanced prostate cancer are limited, Warde said. Most of these patients are not candidates for surgery because of the size of their tumors, he said.

The report was published in the Nov. 3 issue of The Lancet.

For the study, Warde's team randomly assigned more than 1,200 men with high-risk prostate cancer to hormone therapy alone or in combination with radiation.

After seven years, 66 percent of men who had hormone therapy alone were still alive, compared with 74 percent who received both hormone and radiation therapy. In the group of men who had hormone therapy alone 26 percent died from prostate cancer, compared with 10 percent who had combination therapy, the researchers found.

Warde noted that while men had the predicted side effects of hormone therapy, such as erectile dysfunction, hot flashes and mood swings, the addition of radiation did not affect overall quality of life three years after treatment.

When the study began in 1995, the protocol was to use hormone therapy for life, and radiation was given in lower doses, but not as precisely directed as it is today, Warde said. Currently, hormone therapy is used for a shorter time, usually two to three years, and radiation is given in higher doses but more specifically targeted to the tumor.

"There is reason to think that with modern radiation approaches that the results would be much better," he said.

Prostate cancer expert Dr. Anthony D'Amico, chief of radiation oncology at Brigham and Women's Hospital in Boston, said that "this doesn't change practice, because we already do this, but it's a validation that you cannot leave out one or the other treatment when treating someone with locally advanced disease."

Dr. Matthew R. Cooperberg, an assistant professor of urology at the University of California, San Francisco, and author of an accompanying journal editorial, said that "high-risk disease needs to be treated aggressively."

However, this study doesn't determine what is the best treatment for high-risk prostate cancer, Cooperberg said. "There are studies showing that the best treatment for high-risk disease starts with surgery and then radiation and hormones as necessary," he noted.

"Men with high-risk disease need multi-modal therapy," Cooperberg said. "Whether the approach should be surgery possibly followed by radiation, is still the big open question that we need to answer."

These patients are not candidates for what is called active surveillance, where doctors wait for the disease to advance before treating it, Cooperberg said.

Cooperberg also noted that the urinary side effects from radiation are not as mild as the study suggests, and can, for some patients, be severe

Thanks Rickey, in fact this does help. I'm not a candidate for hormone therapy by itself over the long term (at least not yet) but it's good to know the combination of radiation and hormone therapy can be pretty effective.

I'm jealous of your statistically close to 0 PSA, and I hope it stays that way. 

So far I've been lucky to have avoided most of the side effects of ADT.  I almost peed in my pants though when I read  you have to drink up to 30 ounces of water.   Sympathetic reaction I guess . . .

Best wishes

tp23 said:

Second Opinion

Mounty -

     While I wish our circumstances on no one, it is reassuring and helpful knowing the recommendations that others facing similar challenges are receiving from completely unrelated, independent, health care professionals, even from different specialties.  I find the differing recommendations from your urologist and radiological oncologist refreshing in the sense that both truly seem to be putting your interests first and foremost.  Not even from just the financial standpoint, but from the philosophical aspect.  I'm sure other doctors might believe their specialty superior.  I have a consultation scheduled with a urological oncologist at a University cancer center in about a week.  While I have already decided on my current course of treatment and urologist, I would like to affirm my decision with another opinion and gather even more information on the treatment options available to me after the surgery, especially those that might only be available at a facility specializing in cancer treatment.  I hope to hear of your success story in the near future.

Thanks again TP,

Your insights into the differing opinions I've received is right on the mark.  I think the disagreement between these docs about treatment plans  is mostly related to the relatively few patients they treat with more advanced disease, which makes it more difficult for them to know for sure how to proceed.

Under the circumstances, the more information the better of course. If you're up to it, I would like to hear what the urological oncologist you will visit later this week has to say.  I'm scheduled for a consult with a urological oncologist at a university cancer center (not the same one I visited last week) on Thursday and I'll post what I learn on Friday after I return home.

I learned something else at my consult last Friday that might be useful to know. Although the community practice urologist I've been seeing did a great job with the biopsy, he made some serious mistakes in other respects , none of which will have negative effects in the long term, but they could have if they had not been caught by the academic cancer center oncologist I met with on Friday. I won't be going back.  I'm sure there are community practice physicians who are up to the job, but for guys with our parameters, I think it's a good idea to look for treatment by doctors at a major academic cancer center if this is possible.  I suspect you knew this before I did, but in case not . . .

I've read other posts you've made for other members and they've also  been helpful.

Take care

hopeful and optimistic said:

Here's a thread that is germaine to you.

http://csn.cancer.org/node/257782

 

Except for some exceptions, in my opinion most  academic center iare the best place for treatment...overall best docs and facilities....you are making some good choices...you will do fine.......

US news and report ranks hospitals by specialty.....you can google this

Thanks Hopeful; this was a valuable thread considering how similar Kc's husband's cancer profile is to mine and a few other members of this forum. Kc's wife hasn't posted again since her original post. I hope things are going well for them.

I'm familiar with the U.S. News and World Report rankings. There's been some discussion of the validity of these rankings and I'm somewhat skeptical.  Other rankings from the National Institute of Health may be more accurate.  I'll try to dig this information out and post it in the next few days.

Best wishes