Newly Diagnosed - Gleason (3+4)

I suggest that you have an image test, one is a T3 MRi. This image test can show extra-capsular extension, that is if the cancer is outside the prostate. Other image tests are pet scans.

If the cancer is outside the prostate, surgery which is geared to cancer that is localized would not be effective , and another treatment choice will be necessary. The side effects of various treatment choices are cummulative.

With radiation, not only can the prostate be treated, but the perimeter of radiation given can be extended beyond the prostate, and is more inclusive.

Surgery has the most potential side effects of all treatment types, except Active Surveillance( you case does not warrent Active Surveillance, you require an active treatment).

Consider SBRT for which cyberknife and novalis among other machines t are able to provide this treatment..  I along with Swingshift workeer suggest that you explore this treatment type.

Whatever treatment type you choose, you want an expert's expert.  For surgery there is a very steep learning curve for robotic. ...If you choose surgery, I suggest that you do research to determine the best, there are a few in the USA that shine above others...ie surgical margins, number of surgereis, fellowship trained, etc.

Hi there, hate to hear the diagnosis of Gleason 7. That does make AS less likely, especially with so many cores positive for cancer, and some having upwards of 80% involvement with cancer.

I know in a post about gleason 6 cancers, I would not sway anyone one way or the other in regards to treat. But G 7 is a bit more aggressive, and does have a higher propensity to escape the prostate, though it certainly is not the worst one can be diagnosed with. 

A gleason of 3+4=7 and 11 cores positive likely puts him in the intermediate risk category, so treatment will likely be recommended.  Radiation and surgery are both options for this cancer. I would think either one would be a good choice, but in the case of G7 disease with so many cores positive, surgery is the best option here to be more sure that the cancer is not escaping the prostate.

With surgery here, you get the pathological stage, and full representation about the state of the cancer. Surgery can tell if it is actually higher grade cancer, can tell more precisely the extent of it. And with G7, I think many surgeons prefer to sample lymphnodes as well to examine for possible local metastasis.

I think with 11/12 cores positive, your cancer is likely to be involving both lobes, and this is another reason, along with the gleason score that I think surgery would be the best bet here.

And remember, if it was to return after surgery, radiation would still be an option, and could still offer a potential cure. As mentioned in another post, it is difficult to operate on an irradiated area, as scar tissue forms, and it becomes tough and leathery and this,makes cutting tissue difficult, though there are surgeons who can do it in certain cases.

PSA being under 10 is a good prognostic factor, and the 3+4 G 7 is much better than the 4+3.  Young age of 55 is extremely favorable. I think you will do well with whatever modality of treatment you decide on.

The following is a duplicate of one that I have posted in various threads on this forum to give men newly diagnosed w/lower risk prostate cancer (Gleason 6 or 7) an overview of the treatment options available to them.

Anyone newly diagnosed with prostate cancer rated Gleason 6 (and usually Gleason 7) has all treatment options available to him and, since this cncer is considered "low risk", he has time to decide which choice is best for him.  So, the first thing a new prostate cancer patient should do is to do research on the available options before he actually has to make the decision regarding which treatment to choose.

The following is my response to other men who asked for similiar advice about the treatment choices avilable to them.  It's a summary of the available treatment options and my personal opinion on the matter.   You can, of course, ignore my opinion about which treatment choice I think is best.  The overview of the choices is still otherwise valid.

Choices You Need To Consider:

 . . .  People here know me as an outspoken advocate for CK and against surgery of any kind.  I was treated w/CK 6 years ago (Gleason 6 and PSA less than 10).  You can troll the forum for my many comments on this point.  Here are the highlights of the treatment options that you need to consider:

1)  CK (SBRT) currently is the most precise method of delivering radiation externally to treat prostate cancer.  Accuracy at the sub-mm level  in 360 degrees and can also account for organ/body movement on the fly during treatment.  Nothing is better.  Accuracy minimizes the risk of collateral tissue damage to almost nil, which means almost no risk of ED, incontinence and bleeding.  Treatment is given in 3-4 doses w/in a week time w/no need to take off time from work or other activities.

 2) IMRT is the most common form of external radiation now used.  Available everythere.  Much better accuracy than before but no where near as good as CK.  So, it comes with a slightly higher risk of collateral tissue damage resulting in ED, incontienence and bleeding.  Unless things have changed, IMRT treatment generally requires 40 treatments -- 5 days a week for 8 weeks -- to be completed.  I think some treatment protocols have been reduce to only 20 but I'm not sure.  Still much longer and more disruptive to your life than CK but, if CK is not available, you may have no other choice.

 3) BT (brachytherapy).  There are 2 types: high dose rate (HDR) and low dose rate (LDR).  HDR involves the temporary placement of rradioactive seeds in the prostate.  CK was modeled on HDR BT.  LDR involves the permanent placement of radioactive seens in the prostate.  1/2 life of the seeds in 1 year during which time you should not be in close contact w/pregnant women, infants and young children.  The seeds can set off metal/radiation detectors and you need to carry an ID card which explains why you've got all of the metal in your body and why you're radioactive.  Between HDR and LDR, HDR is the better choice because with LDR, the seeds can move or be expelled from the body.  Movement of the seeds can cause side effects due to excess radiation moving to where it shouldn't be causing collateral tissue damage -- ED, incontinence, bleeding, etc.   Both HDR and LDR require a precise plan for the placement of the seeds which is done manually.  If the seeds are placed improperly or move, it will reduce the effectiveness of the treatment and can cause collateral tissue damage and side effects.  An overnight stay in the hospital is required for both.  A catheter is inserted in your urethra so that you can pee.  You have to go back to have it removed and they won't let you go until you can pee on your own after it's removed.

 4) Surgery -- robotic or open.   Surgery provides the same potential for cure as radiation (CK, IMRT or BT) but which MUCH GREATER risks of side effects than any method of radiation.  Temporary ED and incontinence are common for anywhere from 3-12 months BUT also sometimes permanently, which would require the implantation of an AUS (artificial urinary sphincter) to control urination and a penile implant to simulate an erection to permit penetration (but would not restore ejaculative function).  Removal of the prostate by surgery will also cause a retraction of the penile shaft about 1-2" into the body  due to the remove of the prostate which sits between the interior end of the penis and the bladder.  Doctors almost NEVER tell prospective PCa surgical patients about this.  A urologist actually had the to nerve to tell me it didn't even happen when I asked about it.   Don't trust any urologist/surgeon who tells you otherwise.  Between open and robotic, open is much better in terms of avoiding unintended tissue cutting/damage and detection of the spread of the cancer.  Robotic requires much more skill and training to perform well; the more procedures a doctor has done the better but unintended injuries can still occur and cancer can be missed because the doctor has to look thru a camera to perform the surgery which obstructs his/her field of vision.

 4) You may also want to consder active surveillance (AS), which is considered a form of treatment without actually treating the cancer.  You just have to get regular PSA testing (usually quarterly) and biopsies (every 1-2 years, I believe) and keep an eye out for any acceleration in the growth of the cancer.  Hopeful and Optimistic (who has already posted above) has already mentioned this and is your best source of info on this forum about it. 

 I personally could not live w/the need to constantly monitor the cancer in my body.  Like most other men, I just wanted it delt with.  Some men gravitate to surgery for this reason, thinking that the only way to be rid of it is to cut it out, but I did not like the risks presents by surgery and opted for CK, which is a choice I have NEVER regretted.  I am cancer free, there is no indication of remission, there were no side effects and my quality of life was never adversely affected.  Other men on this forum have reported similiar results.

 So, for obvious reasons, I highly recommend that you consder CK as your choice of treatment.  The choice seems obvious when you consider the alternatives but you'll have to decide that for yourself.

 Good luck!

Joe Doe,

Sorry to hear of your diagnosis.  Know that you are in my thought and prayers.  All of our situations are different and thus we can only tell you what we have been through. 

In your favor, your PSA is still under 10.  However your Gleason is 7, and if you have 80% involvment, You need to get moving on treatments.

I was diagnosed in October of 2013.  Purely by accident.  I had an internal bleed that we thought was from an injury several years back.  They found my prostate cancer as they were doing blood work.  I had no symptoms.  When diagnosed my PSA was 69, and I had a Gleason of  3+4-7.  I was given the options of Robotic Surgery or Radiation.  I wanted the cancer removed.  So I went with the Robotic Surgery.  The Surgery was done in early December of 2013.  Post surgery showed that there was 40% involvment and there was one very tiny spot in one lymph node.  That spot was so small that it hadn't shown up in my MRI's.  I was listed as a Stage pT3bN1.  They said my cancer was aggresive (Gleason 7).  My doctors said they were going to be very aggresive and they treated me as a Stage 4.  The surgery was not the end of the treatments.  My PSA started to drop as soon as the surgery was done.  Then they started me on Lupron (Hormone Therapy) and then I had 8 weeks of Radiation.  Radiation to the prostate bed area as clean up.  My PSA dropped to <0.010 where it  stayed for almost three years.  They had my testosterone knocked down to 17.  Normal is 250 - 1,100.  Three years and two month later my testosterone is back up to 380.  Which is still low.   But, Feeling better.  My PSA has come up some, as expected, and as of last month it is at 0.145.  This was expected.  Now we are watching the rate of PSA rise.  If needed I will have to go back on Intermitent Lupron.

Make sure and know that having the surgery is not the end of treatment.  Depending on how aggresive the cancer is the treatments go beyond just the surgery.  Also be aware that there are other problems can occur from doing the surgery.  I don't just mean bladder control problems, ED etc.  Because of my muscle development and muscle mass from being a Road Cyclist, My surgeon (Dr. "M") had trouble finding the lymph nodes in my right groin.  He was in that area a rather long time.  My surgery was supposed to take about 3 hours. But, becasue of a birth defect , Abdominal Hernia repair mesh, and my muscle mass, the surgery took 5 1/2 hours.  My surgeon told me at 10PM the night of the surgery that I would probably develop a hernia in my right groin.  He said that was because he had to be in that area for a long period of time with the robot.  The left side is fine, because he did a mirror image with the robot and went right to those lymp nodes.  So, 1 1/2 years post surgery, We realized I had developed a Hernia in my right groin.  Plus there was a "mass" showing up in my MRI's.  That was a Fatty Mass (Name slips my mind) that sometimes occurs from injury done by surgery.  That "mass" never changed up to this point.  My Surgeon (Dr. "M") wanted to work with another surgeon (Dr. "K") and do a second robotic surgery and they were going to fix the Hernia and remove that "mass" at the same time.  However the Hernia Surgeon said after 5 1/2 hours with the robot in my body that was too soon and he would rather do the Hernia repair the open way.  The hernia was not causing a problem.  The opening was big enough that the hernia was going in and out without getting stuck.  So, we decided to wait on that repair. In the mean time Dr. "K" has moved to another city.   Well, a week and a half ago the Hernia acted up. My wife took me to the ER at 3AM on Jan. 27.  I had just been to my Urologist (Dr. "M") that morning and all was well.  They did CT Scans, and decided I needed surgery to repair the Hernia.  The Hernia was back in place, but I still had pain.  ER doctor (Dr. McK") called surgeon (Dr "H").  He came in at 4:30AM.  Checked me over and said I'd be OK and that he would see me on Wednesday, Feb.1.  He scheduled surgey for me on Feb.3. In the CT Scans, that "mass" showed up, but they checked all my other CT Scans and it had not changed.  My new surgeon said if the "mass" was in the area he would remove it while he was in there. However he said he would not go "looking for it"  Turned out that the "mass" was in the way to get the hernia repair done.  So, Dr."H" removed the "mass" and did the hernia repair.  He said the hernia was very large.  I now have two layers of mesh and permanent stitches.  Since the Hernia is repaired and that "Fatty Mass" is removed my bladder control problems have subsided.  Dr. "H" thinks the hernia and that "mass" were putting pressure some where and causing my slight bladder control problems.  My Urologist/Surgeon  gave his "blessings" for the Hernia repair.  However at this point he doesn't know we got the "mass/cyst" removed. He will learn that in three months when I go in for my next 4 month check up.  My urologist was sure that "cyst/mass" was a results of the surgery.  However my Chemo Oncologist (Dr. "S"- she has since left the area) threw a fit and wanted to put me on strong chemo of that "cyst".  We shot that down.  She was not happy.  But Dr."M" was right, and knew what we were dealing with from all of his previous experience. Make sure your selected surgeon has done many of these surgeries.   Also please be aware that all the radiation treatments can also cause bone density problems.  I am dealing with that at this time. I have gained bone density from supliments and diet, but had lost some bone density in my femurs, where the radiation hit.   I was put on Prolia for Bone Density by my new Chemo Doctor (Dr. "B").

So, study like crazy and know all the side effects, and possible complications that can occur while these treatments are going on.  One treatment can lead to something else and something else, as you can see from my story.  There is good advice in the posts above.  You will need to decide what works best for you and what you are comfortable with.

This is a hard battle but I'd do the surgery all over again, since I am now a three year survivor, and my doctors are still talking plans way off in the future.  Live each day as if it is you last, and enjoy the simple things in life. Sunsets, Snow Falls, Thunder Storms, Drives in the Country, things in Nature, and the Love and Support of your Significant Other" are very important. However don't give up, Fight like the devil and hang in there.  We are all here if you want to ask questions.  This is a life changing thing and many times it changes one's self  for the best.  Especailly when it comes to relationships with others, no matter what their sex, race, color or religion. You are in your doctor's hands.  I love them all.

Love, Peace and God Bless

Will

Hi,

Does cyberkife kill all of the prostate tissue as Swingshift workers says or just the tumor and very little tissue surrounding the tumor?  This is from the Cyberkife website:  "As the only system capable of delivering beams that move in real-time with 3D respiratory motion, the CyberKnife System significantly reduces the treatment margins commonplace with other radiation delivery systems.  With smaller treatment margins, the CyberKnife System focuses the prescribed dose to the intended target – not the surrounding healthy tissue. Radiation therapy, (as opposed to stereotactic radiosurgery), usually treats larger areas that include not only the tumor, but large amounts of healthy tissue, increasing the risk of possible complications. Patients are not required to be hospitalized during treatment and the procedure is almost always performed on an outpatient basis." 

I would talk with your oncologist and make sure the Cyberkife kills ALL of the prostate tissue and not just the tumor.  I wounder if in the future some of the healthy tissue left behind(if there is any) could turn canerous?  Just a thought.

Dave 3+4

JoeDoe said:

Treatment Center Video (NYC)

Treatment Center Video (NYC) which discusses why Cyberknife affects less of the surrounding tissue (less margin than other radiation therapies).  Somewhat balanced presentation in that he talks about various treatments but still seems to be pushing Cyberknife. 

https://www.youtube.com/watch?v=XsGmMtCGptk

Fox News Video with Dr. David Samardi (Surgeon) claiming new meta-study suggests surgery outcomes twice as good as radiation for long term longevity.  Would love some opinions on this. 

https://www.youtube.com/watch?v=-AxdBgtGnCI&nbsp;

Dr. Oz talks about options.  (1:35) Study shows no difference in outcomes between RP, Radiation, Watchfull waiting.  This seeems misleading. 

https://www.youtube.com/watch?v=ENHJrf1JmtA&amp;t=230s

 

It is really hard to know the right treatment when there is so much conflicting information out there.  I don't think Doctors are intentionally pursuing a conflict of interest but it does seem that everybody argues for what they personal do as a service.

a new patient under stress is put in a position to choose from various undesirable options for treatment, with limited knowledge, that can be conflicting.

SBRT 9 year study

https://prostatecancerinfolink.net/2016/01/06/nine-year-outcomes-after-treatment-with-sbrt/

The perimiter of SBRT can be adjusted, so if there is cancer outside the prostate, it is possible that SBRT can cure, while surgery would not. SBRT is very precise, actually more so than other radiations, so the SBRT  is very accurate.

(To be honest, this is the first that I heard about any difference in the margins of SBRT versus other radiation treatments)

.............................................

Just checked out " Fox News Video with Dr. David Samardi (Surgeon) claiming new meta-study suggests surgery outcomes twice as good as radiation for long term longevity."

I notice that the European Association of Urology is the source of this particular study. ...so I would think that the study would be biased toward surgery, and this is only one study..one has to look for a consensus. In addition, this study has been done in Europe ( and the dates of the study are not given----Radiation treatment has improved thru the years.  Additionally I am not familiar with the levels of radiation treatment in Europe, and how it compares with the USA where I am located.....)

As you might agree, it is difficult to comment on the study that has been referred without reading the the study.

By the way David S is a very good doc in NYC, and better than most, however there is another doc in NYC , who if I were to have robotic surgery, which I will not, is Ashutosh Tewari

http://www.mountsinai.org/profiles/ashutosh-tewari

I understand that he developed a procedure to avoid erectile dysfunction. ( had a typo...it's erectile dysfunction)

Joe, by the way where do you live?

Clevelandguy said:

Cyberknife kill area?

Hi,

Does cyberkife kill all of the prostate tissue as Swingshift workers says or just the tumor and very little tissue surrounding the tumor?  This is from the Cyberkife website:  "As the only system capable of delivering beams that move in real-time with 3D respiratory motion, the CyberKnife System significantly reduces the treatment margins commonplace with other radiation delivery systems.  With smaller treatment margins, the CyberKnife System focuses the prescribed dose to the intended target – not the surrounding healthy tissue. Radiation therapy, (as opposed to stereotactic radiosurgery), usually treats larger areas that include not only the tumor, but large amounts of healthy tissue, increasing the risk of possible complications. Patients are not required to be hospitalized during treatment and the procedure is almost always performed on an outpatient basis." 

I would talk with your oncologist and make sure the Cyberkife kills ALL of the prostate tissue and not just the tumor.  I wounder if in the future some of the healthy tissue left behind(if there is any) could turn canerous?  Just a thought.

Dave 3+4

 

In response to Cleveland,

A major bragging point for Cyberknife since its inception is its microaccurate aim; how it kills only the progammed areas it is directed at, and avoids adjacent tissue.

Understanding that, it seems counterintuitive that it would also radiate borders.

While I am NOT studied in this area, every casual reference to second-line radiation to the prostate bed and sentinal nodes I've ever read here or elsewhere has stated fractionated radiation was used, not SBRT.  

Also, I would question the first sentence of the quotation provided by Cyberknife:  Three years ago, a radiation oncologist said he would use breathing-gated, 3-D IGRT on me if that were my choice.  What is cutting edge one year becomes passe' the next.

It becomes easy to over-analyze the choices against PCa.  Actually, doing so is fairly common.   The general facts regarding how well the different modalities work, and what side-effects each might have, and at what statistical liklihood these side-effects might crop up, are all already known.  This will not be overturned tomorrow by some new study, or next year.   Ultimatly, a guy just has to choose and go with what his gut tells him.  There is no perfect choice in treating PCa now, and probably never will be one.

max