surgery or radiation?

hopeful and optimistic said:

My best wishes for you

I am glad that you did research so you could make a decision that you are comfortable with.....I hope that this will bring peace of mind to you....wishing you the very best.

 

Bill (Mounty) and TP23

Your exchanging experiences made me recall the time when I was diagnosed, back in 2000. I also confronted the dilemma in choosing a treatment. Interestingly, I was given the same choices as that of yours (2013) and the same “views” in all aspects including the “sequentials” (salvage radiation after surgery failure, etc, etc.). However I was confronting a low risk diagnosis.
Not much has changed regarding the way doctors advice on radicals. These two forms of treatment are still the ones linked by most studies to cure, and in young guys like you (with long life spans ahead) these therapies are commonly recommended; however, the successes belong to cases of localized and contained cancer. This is also more common to low risk cases with low Gleason scores.

In fact the first though it comes to us is to get rid of the whole tumour “scrapping” it out or “zapping” it whole with rays. We will accept anything proposed by a well spoken doctor without realizing that most of the procedures are based on “guessing”, and the choice leans through wards the higher percentage of successes of past experiences. We forget about the failures and the consequences we will have to endure and live with. In high risk cases one should recall that “debulking” makes part of the decision process by the doctors and such idea has nothing to do with intent at cure but with intent in extending life and continuing sequential therapies. Failure may follow failure and the effects will superimpose the ones already existent.
Considerations to the Quality of Life in the initial decision process are important, and we need to think about the possibility of a life with the unwanted guest.

I am very please for your exchanging opinions and believe you have followed the best way to get into a conclusion on a treatment. This will help many reading your threads, even if the situations differ.
Your high risk status in particular, has been commented in this forum before but not to the extent you have done. I feel sorry for the lack of feedback from those G9 participants in regards to the accomplishments in their treatments. They would have been very useful to you and all us.

I wish you both the best of lucks in your treatments. You have done your “work” excellently and your choices will be the best you could get. They will lead your cases to success. 

Best wishes.

VGama 

Mounty said:

surgery vs. radiation decision

 

It's been two weeks since I asked for help from this forum deciding whether surgery or radiation + hormone therapy is the best course of treatment for the prostate cancer I was diagnosed with in late April. After numerous medical consults and valuable advice from many of you and other friends, I've arrived at a decision about treatment. I’m going to describe this decision and the reasoning behind it with the hope this information may help others with similar cases of high grade localized prostate cancer.

 

A brief summary of my recent medical history: I'm 61 and in very good health other than PCa. There's a family history of PCa (father and one brother).  Gradually escalating symptoms of urinary blockage for several months eventually led to bloodwork that produced a PSA reading of 34. A biopsy several weeks later detected 30 - 90% malignant cells in 14 out of 14 cores, all  Gleason grades of 4 + 4 or 4 + 5, leading to a Gleason score of 9 (4 + 5). A second read of the slides by a pathologist at a NCI Cancer Center was similar except that the fraction of malignant cells was increased to 50 – 100%. A bone scan and multiple CT scans have failed to detect metastatic disease in bones or in pelvic lymph nodes.

 

I consulted with five doctors after receiving the diagnosis from the community practice urologist who performed the biopsy - three were surgeons and two were radiation oncologists. All three surgeons were Chairs of Urology at major academic medical centers, including an NCI-designated Comprehensive Cancer Center. One radiation oncologist was the Chair of Radiation Medicine at the NCI Comprehensive Cancer Center. The other radiation oncologist practices medicine in a community practice setting. I'm lucky to have insurance that pays for multiple consults (although I did have to turn down one recommended consult because it was out of my insurance network).

 

I've also obtained an enormous amount of information from books, this forum and other internet sources that I trust (National Institutes of Health and other government websites and organizations such as the American Cancer Society) and from the primary medical literature - that is, peer-reviewed studies published in medical journals. In evaluating all this information I employed two criteria to define what for me would be an ideal treatment outcome, in order of importance: 1. long term disease-free survival; 2. a quality of life that includes the following ranked in importance to me - no urinary or bowel incontinence > no permanent loss of sexual ability > no long term side effects of hormone therapy such as diabetes, heart disease and breast enlargement (the last was a big one). In deciding on treatment I also considered logistical factors that mostly applied to radiation therapy, which would take place over a period of several weeks. These included the ability to be treated without a requirement to travel great distances each day or the need to arrange for temporary housing in a distant city for a period of many weeks.

 

Initially one surgeon recommended surgery and two recommended radiation + hormone therapy. The radiation oncologists rendered a split decision, one for surgery and one for radiation + HT. Recently the arguments for radiation + hormone therapy became so compelling that all these doctors now agree this is the best course of action for me. Their reasoning is that the combination of high Gleason score, high PSA, large tumor volume and digital rectal exams performed since the biopsy that strongly suggest extraprostatic invasion of the tumor into surrounding tissues all argue that surgery would be unlikely to remove all of the tumor and would carry a high risk of urinary incontinence. The argument for radiation therapy + hormone therapy for treatment of localized advanced disease is in my opinion supported by the medical literature.  Although some studies suggest (based on statistical analyses) that surgery might be the better option, many of these studies have been criticized by other experts as flawed. Other studies more clearly point to a small but statistically significant advantage to radiation + hormone therapy.   It's important for anyone reading this post to keep in mind that all of these considerations specifically apply to localized (i.e., not metastatic) advanced disease (Gleason 8 - 10 with evidence for extra-prostatic extension), and not less advanced prostate cancer.

 

Consequently, I have decided to pursue image-guided radiation therapy + hormone therapy at the NCI Comprehensive Cancer Center I visited for consults. I considered a number of other treatment modalities as well. These included brachytherapy (radioactive implants), high-intensity focused ultrasound (HIFU), Cyberknife and proton beam therapy. Although each of these modalities has proven successful in some cases, I ruled them out in my case for a variety of reasons, mostly related to a lack of a well-established track record for success for treating prostate cancer or because they were inappropriate for treatment of more advanced prostate cancer.

Please keep in mind that I'm describing what I think is the best decision for me; the best decision for others would need to take into account factors that are unique to other individuals, in addition to those that might be common to my case. I'm very grateful to everyone who posted valuable information to this thread and to many others who posted valuable information to other threads as well, all of which helped me to reach this decision.   If I didn't know any better, based on what I've learned from this forum I would argue that prostate cancer mostly afflicts people (men and women) who represent the best of humanity. I will continue to post  to other threads but I do not plan to post to this thread again except to respond to  questions, which I would be happy to answer.

 

Best wishes,

 

Bill (Mounty is my beloved dog)

 

hope it all works out....looks like you've done about all you could do to come to your conclusion....all the best....

p.s. say hi to mounty too....dogs are a great friend for sure.....

Mounty said:

Mrs. PJD,

The MRI has not yet been performed but is scheduled for later today (Monday, May 20) at a NCI CCC. It was scheduled earlier but I postponed it until I was able to confirm that 3-tesla EMRI technology is available at this institution (otherwise I would have gone elsewhere). The ECE determination and T3c staging were based in part on DREs by two urologists, one at this institution and one at another high patient-volume academic center 100 miles down the road. These two urologists compared notes and both agreed that the combination of Gleason 9, high tumor volume, PNI (I did not mention this finding earlier but this was  the read of the second group of pathologists who looked at the cores) and what they found in their DREs puts the odds of ECE at 100%, even in the absence of the MRI data. I don't know whether an ECE determination can be made in the absence of imaging but I guess I'll find out tonight if they were right.

Frankly, I'm suffering from prostate cancer information fatigue and I was planning to let the radiation oncologists and physicists prepare a detailed plan without further research and input from me. Your post convinced me that I can't stop here.  I'll track down the studies by Zelefsky and Roach and get back on PUBMED to track down others as well - if you have any additional suggestions of relevant authors I would be grateful if you could pass them on.

I have three questions I'm hoping you can answer if you can spare a little more time. First, do you think it would be worthwhile to pursue a more thorough assessment of whether metastasis has occurred, by PET for example? I understand how it might help to develop the RT plan if pelvic lymph nodes and/or seminal vesicles are found to have disease that escaped detection by the CT and MRI scans but my understanding is that radiation is planned for these areas regardless. An underlying question is this: what difference would it make at this point if distant metastases are found? I'm already on hormone therapy and so it's not clear how this would impact the treatment plan. Third, would you mind if I emailed you a few questions regarding the specific cancer center where I plan to be treated? Perhaps you don't have access to this sort of information and if so, not a problem, but if you do it would be helpful.

Thanks very much again. The information in this post was enormously helpful and could very well make a big difference in outcome for me.

Bill,

Unfortunately, I have no hard and fast “answers” to your questions—only opinions based on what I’ve learned with my husband over the last three years.  With everything PCa, there is a wide variance of opinion among medical professionals and non-professionals alike.  As you know, even study data may be interpreted differently by different people. 

I understand all too well the PCa info overload fatigue syndrome after initial dx.  Seems like all we did was eat-breathe-sleep (if possible) PCa.  My husband and I continue to learn about PCa.  The education process is never ending but it does get less intense.  I actually like reading PCa medical literature now.  With PJD’s T3 high risk PCa dx, and with three grown sons, we’re not naïve, but we remain hopeful and actively engaged in the face to face PCa community.  I have posted frequently to this forum in the past and some questions may be addressed in previous posts.  Here are some thoughts about the questions you asked above: 

In the absence of diagnostic imaging that confirms ECE, PCa medical professionals may determine that ECE is suspected based on high risk PCa features, including those confirmed by an expert 2^nd opinion path lab analysis on biopsy cores.  EMRI results, sometimes along with a CDU, may validate that ECE suspicion.  It did in PJD’s situation.  If local LN involvement is suspected due to inconclusive imaging studies, a lymph node biopsy may be preformed.  The findings may or may not change the RT tx protocol.

If you’re having an EMRI later today and obtaining results the same day as you indicated, I’m impressed by your medical team.  It took a few days or longer for us to have the imaging results read, interpreted and a report generated.  Keep in mind that it’s possible that the ADT you started may have already begun to shrink tumor cells thus making the EMRI findings inconclusive or negative (that could be a good thing).  I’m a little confused about how/why the RO and dosimetrist are preparing a detailed tx plan without first considering the EMRI results. Perhaps I misunderstood or they didn’t feel the results would impact their tx plan.  PJD’s EMRI results influenced his RT tx decision and protocol.  

You’ll be able to access the work of other relevant authors of related PCa studies when you search PubMed separately for Zelefsky and Roach. 

The decision to pursue a “more thorough” diagnostic imaging assessment (not really sure what you mean by “more thorough”) will be based on the results of your EMRI and, possibly a CDU.  The F-18 sodium CT/PET (bone) and the C-11 Choline PET (soft organs/tissue) are usually indicated in cases of recurrence in the context of rising PSA when primary, adjuvant and/or salvage txs have failed.  IMO, this may change in the future and the tests may be offered to newly dx’d high risk patients sooner than later.  However, you can ask your PCa oncologist about this and even request the F-18 PET/CT.  Currently, the C-11 Choline PET (non-acetate) is only offered at the Mayo Clinic in MN and it’s somewhat experimental.  (It’s best to be off ADT for that test.) 

Re your “…understanding that radiation is planned for these areas regardless.”  Perhaps, but we learned that with PCa you don’t “assume” or take anything for granted.  Ask questions; confirm answers (opinions) by continuing with your own research.  You are your own best medical advocate.  Obtain written copies of everything—doctors meeting notes, imaging tests and results, path reports, etc.

Take a deep breath, exhale slowly, and repeat as necessary.  Include your wife.  Things have a way of working out. As trite as that may sound, trust me, they will.

Be well.