Rethinking treatment options

Many thanks to you who responded to my questions on catheter management. It is very encouraging to know that there are wise and sympathetic friends from whom to seek counsel.

Being conservative and looking for a "second opinion" I consulted a oncology radiologist. I came away even more confused about the options and merits of alternative treatments. To make a long story short, I retraced all the information I had and spoke with several specialists, and concluded that for me, the best option is Robotic Prostatectomy. I wrote myself a decision memo, which for those interested I am adding below. This decision process can be very confusing.

The good news is that my PSA has dropped from 6.8 to 5.2. I was concerned it was headed up.

Again many thanks for the good wishes, Richard

Here is the information I have gathered to date.

I have had 3 "separate opinions" from top specialists plus have used
the various online "decision" systems from Sloan-Kettering, American Cancer Society,
and The Prostate Research Foundation and have come up with the same conclusion each time.

Given the test results, and the combinational analysis tools, something is going on in my prostate and it has begun to accelerate. My concern now is: the Adenocarcinoma is not "early stage" but is at a point of spreading to other tissue.

PSA jumped from 2.2 a year ago, to 3.2 in May to 6.8 in September. 5 of 8 biopsy samples were positive. Gleason Score: 3+4=7 in two regions, 3+3=6 in three regions, Stage: T1c, . Biopsy samples from right central and right apex lobe are 100% CA, Right bottom and central regions 70% CA, One sample from Left Lobe edge, 5% CA. Three samples from Left Central lobe show no CA. Perineural Invasion (PNI) found in one right sample. No palpable tumors on DRE. Bone Scan negative for metastatic disease. MRI results: No obvious extracapsular disease. Central gland is enlarged by stromal benign prostatic hyperplasia. There is evidence of chronic outlet obstruction given mild diffuse bladder wall thickening.

"Watchful Waiting" is not an option. Nor is cryo freezing of the gland. My choice is surgery, OR massive radiation 8200, OR radiation at 4600 plus implant of radioactive seeds with radiation 8500 for a total dosage of 13,100. I have an enlarged prostate making radiation more difficult. If I have radiation now, it is very difficult to have later surgery if the cancer recurs. The side effects of radiation seem to be more profound then surgery, particularly robotic surgery. I have some constriction now in the urethra and radiation tends to aggravate this.

With surgery, they are able to exactly determine if there is any spread to lymph nodes, seminal vesicles, or surrounding tissue. This surgeon performs biopsy examination of all margins during the surgery and keeps "shaving" tissue until he comes up with a cancer free margin.

Following surgery and pathology analysis, a determination is made as to whether radiation is appropriate at that time do to invasion of the cancer beyond the prostate. If the cancer appears contained, I then monitor my PSA monthly for the next 12 months. It should be less than 0.1. If not, that indicates that the cancer remains in some form.

Given my test scores there is a 15-20% probability of recurrence in 5-7 years.

As my very wise internist said: "Waiting is not an option. Of the treatments, each one has shown to have an 80% cure rate. Each patient who is cured is sure that he made the correct and only choice. Those that are not cured, usually have an aggressive form of cancer."

My conclusion is that I need to find out what I have and that the Robotic surgery is the best option for both cure and detailed diagnosis. It also has the best prognosis for regaining urinary control and erectile function. In my case, the surgeon will take part or all of the right nerve, given the PNI on the right side.