Decisions, Decisions

RiverRider said:

Kongo, your numbers are
Kongo, your numbers are very similar to mine. Age 60, had a psa up at 4.6 but the follow up ones were about 3.6. Still my overall psa velocity is higher than yours.
Here is the one difference, my biopsy was clear.
Thus, I did not have that one 15% positive Gleason 6 core.

On the other hand, I have very little doubt that with enough samples, they'd find one core of 15% Gleason 6. (btw, my father had prostate cancer)

So I just assume I've got some Gleason 6 cooking in me. My doctor agrees that I have about a 70% chance of turning positive before age 70. My father diagnosed at age 63.

BTW, I've been following this prostate cancer business for a very long time, especially the past 3+ years. I've read heaps, studies, news, forums until I had it coming out my ears.

My opinion on your decision. With all due respect, I think its crazy.
Mostly because you have come to your "choice" after only 5 weeks, when by all standards and results, you could almost certainly take a year and not put yourself at any substantial risk. You are too close to your flood of information to make a good decision.
You have totally over-thought this decision. You have failed to allow your thinking to mature and gain some wisdom. You are going entirely on what you think is logic.
I can almost assure you your thinking will mature with more time.
Not impossible you might still choose the same course of action, but the odds are you won't.

You really need to reconsider your approach to this matter. I simply do not believe you understand the entire issue. Yes, I know how much you've read and how logically you've come to your conclusion. I still believe your process is faulty.
You need more time and you almost certainly have more time.
Heck, as I've said, I've been reading about this for years, and if I got a 1 in 12 15% result, Gleason 6, I'd take my sweet time thinking about what I might or might not do.
I might say to the doctor, well let me think about it, and well meet again in 6 months to discuss it.

There is considerable reason to do nothing now. You might enjoy your current "untreated" state and then a couple years later do a treatment if needed.
Not really even "watchful waiting" but tactical delay.

You say you've read everything but I wonder if you've read the recent writings of one of the most well respected surgeons in the nation. He has recently changed his mind about treating men like yourself.
His name is Peter T. Scardino, MD and he is the leading surgeon at the Memorial Sloan-Kettering Cancer Center.

Here is a link to a article about his presentation to the New York Section of the American Urological Association.

http://www.wellsphere.com/cancer-article/is-surgery-best-reserved-for-first-line-treatment-of-higher-risk-prostate-160-cancers/924818

Then log in and see/listen to the actual presentation.

http://www.urotoday.com/61/browse_categories/prostate_cancer/aua_ny_2009__long_term_outcomes_of_radical_prostatectomy_will_open_rp_survive__multimedia_presentation12162009.html

Now, to be sure he is talking about surgery as a first line treatment, but some of his concepts about treating early stage prostate cancer still apply regardless of suggested treatment. Anyway, its a interesting presentation in the ocean of information. (just what you needed, more info )

Part of that article says the following...
"Also during the course of this presentation, Scardino more than once makes the point that surgery is so successful at preventing prostate cancer-specific deaths for patients with low-risk disease that “one has to ask oneself” whether many of those patients couldn’t just be monitored and treated later if necessary."

Its that "monitored and treated later if necessary" aspect that I was leading to.
He, the great surgeon, is now coming to the conclusion he has been treating to many patients too early. I suppose depending on one's data, I'm feeling more that way as the ground seems to be shifting in the urological community. A definite change in the past 3 years.

If you allow yourself a break from your intensity you will have time for wisdom and perspective to surface.

You said the following...

"Some may say "take your time"...and I believe I have done that. I put together a matirx with 20 individual Quality of Life and other factors and rated the procedures against each other from my perspective."

That alone says you have gone off the deep end. "A matrix with 20 individual Quality of Life and other factors...and rated the procedures against each other"

Please sir, "take your hands off the keyboard and step away from the matrix"

OK.... I mean well. Hope you don't take offense.
I think you've gone off on this in a manner uncalled for given your condition.

Have you considered that they could do 3 men with your exact condition and NOT even hit one positive biopsy sample in 2 if them. Those two would go through the next year fat and happy without a care or the need to rush. Yet when diagnosed a year or two later, they'd have 99+ percent the chance of success that you currently do.

So thats my take on your post and situation. From everything you've presented thus far, I'd simply do nothing for some time. Then I'd get another PSA in 6 months and see whats cooking. I don't think I'd officially say I was doing active surveillance, but I'd just be taking some time while keeping a eye on it and allowing my thinking to progress from a matrix to wisdom.

Given all your choices, I'd not think the Cyber-Knife would be on the top.
While I have not read as much as you about it, the data is rather limited compared to other treatments. I'll read some more, but to me, its still some ways to being proven as equal. I may be wrong on that.

Oh, about my father, back in the 70's he did external beam radiation, then took some hormonal (DES) and lived the next 25 years, dying of other causes at over 88.
At the time of his diagnosis he was deemed inoperable (extra-capsular) and thought he would die soon. Not true. Perhaps that plays into my more relaxed perspective.

Well thats my take.. Perhaps you'll find a useful nugget somewhere in there.

Kongo said:

Ira
I respect your AS decison and understand why you're there. FYI, I do plan to have an MRI and spectroscopy scheduled (it's part of the early prep for Cyberknife) and I have some built in exit strategies calculated if I do end up going forward with Cyberknife.

Kongo said:

No Offense Taken
River, no offense taken but we clearly have differing personalities and approaches to problem solving. In fact, I had read the articles you referred to but the context upon which Dr. Scardino based his comments were based on the RP procedure in general and not really comparing other forms of treatment. While I agree that there is no need for an urgent decision in my case, I don't see much benefit in waiting just to wait and perhaps acqire some sort of "maturity" or "wisdom" during the process. In fact, I believe there are some downsides to waiting for some indefinite period, as you infer, until the cancer assumes a more aggressive profile.

One of the biggest advantages to treating early stage PCa is that most of the treatments have very good success rates. Later stages have a declining degree of success and more complications regardless of the treatment course chosen. The key to me here is EARLY stage. Waiting gradually turns and early stage cancer into an intermediate or advanced cancer. While a few months probably doesn't make much difference, I don't see the value you place on arbitrarily waiting a year or more to make a decision.

Waiting a year or more won't change the fact that I have cancer and that it is slowly growing. Waiting a year or more will not change the side effects of various courses of action available today. Waiting a year or more is unlikely to see a revolutionary new treatment that obviates existing choices.

I think that when you have enough information to make a decision, you should make the decision. I really don't get your point about letting it percolate and simmer while waiting for some ambiguous wisdom to manifest itself that might change the decison outcome.

You questioned my building a matrix to compare the pros and cons of each treatment option. Frankly, I just don't understand the point you're making. I frequently build matrices to compare potential courses of action when there are many variables to consider. For me, it is a good way to rank my priorities and focus on the essential elements of the decision I need to make. In fact, almost all of the various protocols construct matrices to show treatment courses of action and potential success and side effects. I didn't invent the process.

I know there is much more to learn about PCa than the several books and studies I've read. The more I have learned, the more I realize that the nuances of this disease are very, very complicated. Having said that, I believe that in my stage today, I have learned enough to make an intelligent decision.

A major factor in deciding to act now rather than wait was the realization that eventually I will probably have to do something about this cancer. Unless I'm hit by a bus, or my plane crashes, or some other unforseen event occurs, I can reasonably expect to live another 20-25 years. I don't wish to limit my future options by not taking advantage of the stage and otherwise good health I find myself today. If I were 5-10 years older and diagnosed with the same pathology that I have today, I would very likely choose to wait and be more cautious about choosing a course of action. But at 59, I don't see any advantage in waiting and do see a potential downside.

If I were in your shoes where I had a history of rising PSA but negative biopsy results I would probably be waiting too. But I'm not in your shoes. As you point out, I've got a positive biopsy which means I KNOW I have cancer, and I KNOW it will eventually grow. I also lead an active life and have a demanding career that requires me to travel constantly. I want to be able to have some confidence that plans, campaign rollouts, vacations, golfing trips, and overseas travel will not always be under a cloud if a new PSA shows up which forces me to take more urgent actions to address the cancer.

I don't agree with you that waiting and mulling over information improves your decision process. In fact, my own life experiences, education, and training has taught be the exact opposite. I would agree with you if I had come to my decision after only investigating one treatment option, or consulted with only a single doctor, or read only a single book. But I've done a considerable bit more than that and regardless of how much information you receive, eventually you get to a "tipping point" and have enough information to go forward. Another disadvantage in waiting, from my point of view, is that over time your impressions of conversations with experts tends to dim, blur, and run together. I prefer making a decision while the conversations, body language, and tone of the conversation are clear in my mind.

We all have different personalities and life experiences. These affect how we approach problem solving and decison making. As I mentioned earlier, we're clearly polar opposities in our approach but I am sure your methodology (as quirky and dawdling as it may seem to me) is right for you.

Your post did cause me to pause and rethink my position and I remain confident that my decision process is the right one for me (although clearly not the right one for you). For that I thank you.

Good luck and I hope that your situation resolves itself one way or the other soon.