Surgery or Proton therapy? What do you think?

Hi,

I would do more consults and tests with your doctors.  What do they recommend? For radiation Proton seems a good choice since the beam stops at the intended spot, no exit damage. Do the doctors think surgery will remove all the cancer?

Dave 3+4

SantaZia,

I can relate to several of your issues, but in a different sequence.  I chose proton radiation at U of Pennsylvania over surgery in 2012. My gleason was 3+3 but my 2012 biopsy had 1/3 more positive cores than my 2011 biopsy, so it was time to act.  Halfway through my 44 proton radiation treatments I developed severe urinary retention (details are on my blog).  I needed to have a Foley catheter in place for the remainder of my treatments.  At that time I was the first of 240 prostate cancer proton treatment patients at Penn who had developed this condition.  My radiation oncologist said it was likely due to a higher than avaerage  degree of prostate inflammation. Once I finished my treatments it took 4 more weeks before I regained flow without catheterization.  My PSA dropped from 4.8 before treatment to 0.7 afterwards.  But my PSA continued to creep upward and doubled between 2016 and 2017.  My gleason was now 4+5.  My local urologist steered me to Memorial Sloan Kettering Cancer Center in NYC where there were surgeons skilled in doing salvage radical prostatectomies on patients like me who had failed radiation therapy.  The surgery was complex because of all the scar tissue left behind from my previous radiation, but ultimately successful.  The anastamosis where the urethra was reconnected to the bladder neck took over 9 weeks to heal...a record for my surgeon.  Two and a half months after my catheter was finally removed I needed emergency dilation because of a bladder neck contracture. I had a Foley catheter for 7 weeks. I eventually had a TUIBNC procedure during which the surgeon applied 1 cc of mitomycin to each of the 4 incisions he made.  The intent of the procedure was to open up my urethra and prevent scar tissue from forming again at the bladder neck.  The trade off was that instead of having repeated urinary retention problems I will be incontinent for the rest of my life.  The possibility of an artificial urinary sphincter may be a solution, but I have complications which might rule me out as a candidate.

I'm sorry for being long-winded, but, like you, I am a complex case.  MD Anderson is the #1 cancer center in the US and you will be in excellent hands regardless of which treatment option you select.  Be aware that if your treatment fails, as mine did, salvage radiation or a salvage prostatectomy at a top center exist as reasonable options.  Eight months after my salvage surgery my PSA is in the "undetectable" range.

Good luck with your difficult decision and treatment.  Let us know how you do.

Dino

Melvin10 said:

Something they never tell you

Something they never tell you is that after radiation failure, the recurrent cancer is more aggressive.

 

Please provide some (science-based) evidence for that statement.

VascodaGama said:

Higher number of high Gleason cases are common in RT failures

Melvin,

I cannot find any comment in the article pointed out by you above that substantiates your previous assertion on "...  after radiation failure, the recurrent cancer is more aggressive ...". What I read is that they found more Gleason 8 to 10 cases in radiotherapy failure than other scores. Such doesn't surprise me because when comparing with the number of patients doing radiation, those with high Gleason scores are the cases often recommended to RT. They outnumber the cases with lower scores.

I believe many of us are interested in the theme. Can you provide details?

Best,

VG

I also read the 2002 (!) paper in Reviews of Urology and agree that there is no good support in that review for the statement that recurrent cancer after radiotherapy is more aggressive. The authors refer to an even older paper (Sander et al; reference 3), but the latter paper is barely related to the topic that we are discussing. Here is the conclusion from the Sander et al paper:

Overall survival after conformal radiotherapy for prostate cancer remains high 5 years after biochemical failure. This high survival rate occurs even though the group of patients with biochemical failure has worse than average adverse preradiation prognostic factors. Thus, although biochemical failure can identify patients who have recurrent disease after RT, the ultimate relationship between this endpoint and death remains to be better defined.

And this is the abstract from the 2002 review:

Radioresistant or recurrent prostate cancer represents a serious health risk for approximately 20%–30% of patients treated with primary radiation therapy for clinically localized prostate cancer. The majority of patients exhibit large volume and poorly differentiated disease at the time of diagnosis, which limits the ability of salvage therapy to eradicate the cancer. Early detection with serum PSA monitoring and prostate needle biopsy following primary radiation therapy may identify residual adenocarcinoma at an earlier stage and increase the likelihood of successful salvage therapy. Radical prostatectomy, prostate cryoablation, and brachytherapy comprise the options for salvage treatment available for radiorecurrent prostate cancer. The goal of disease eradication must be balanced against the potential for serious treatment-related side effects. As a result, many patients receive noncurative therapy with androgen ablation despite the real risk of disease progression and mortality.

More in general, this discussion is of academic (?) interest only because SantaZia made his decision on therapy quite some time ago.