Diagnosed two weeks ago.

John M · Experienced user Joined: 27 Jul 2009 Posts: 59

My post consists of abstracts and quotes from two articles. You may disagree, but your disagreement is with these particular articles, not with me. I'm just trying to find the truth here.

In this Scandinavian study, if you select out the group of patients with Gleason score of 6 or less who were in the watchful waiting group (212 patients, although only 40 had 10 years of followup), at 10 years, about 7-8% had prostate cancer death, and almost 50% were on hormone treatment. That's a lot more than your chance of being struck by lightening. But, can you sort out which patients with a Gleason score of 5 or 6 are going to do poorly from the initial PSA level, or the PSA doubling time? Those who advocate active survelliance say that you can, but in the study I gave the abstract for, "Prostate-Specific Antigen Levels as a Predictor of Lethal Prostate Cancer", J Natl Cancer Inst 2007;99: 526 – 32, their stated conclusion was,
[b]"Although baseline PSA value and rate of PSA change are prognostic factors for lethal prostate cancer, they are poor predictors of lethal prostate cancer among patients with localized prostate cancer who are managed by watchful waiting."[/b]

So, if you disagree, you need to read this article and see if you can find a flaw in it. I warn you, it's a complex article which requires a good knowledge of biomedical statistics to understand. If you can sort this out and poke holes in it, that'd be great...if people with early prostate cancer can have a few blood tests, and reliably know that it's safe to wait, that'd be wonderful. But you'll have to knock some holes in this paper first.
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John

notme · Guest

HIFU has a success rate of 94% for low grade, so unless I was sleeping under a bridge--and couldn't afford it-- I just couldn't sit and wait. I guess it's because I think I will live a great life until 104 ~ in which case the cancer is sure to bite me in the arse at some point!

srtimmons · Posted: Sun Aug 23, 2009 7:05 pm Post subject: HIFU

The HIFU debate continues. My advice is to consider it an experimental treatment and act accordingly.

According to a recent Johns Hopkins article
The jury's still out … While HIFU is a technology with considerable promise, many doctors agree with Dr. Robertson of Duke University who remarked, "Although many centers in Europe have used it and achieve varying results with many patients, there have not been a lot of scientific publications. We are in the dark about how effective this treatment is long term."

Also, in the HIFU European study which notme likes to quote as to the 94% cure rate with HIFU. Actually, the study said 93% had negative biopsys after HIFU.

Important to note that getting a negative biopsy is a long way from claiming a cure.

Proceed with caution on HIFU. It may work and then again.....
_________________
Age 58
Dx 6/15/2009; PSA 7.1; 7/12 cores positive; Gleason 6 (3+3) and 7 (3+4); PNI observed. Bone Scan and CT scan negative.
Robotic RP 7/20/2009

Path report 8/11/2009 - clean margins, negative lymph nodes, negative seminal vesicles, Gleason 3+4, Stage T2c; 15% of prostate involved; NoMx.

PSA .006 September 2009
PSA .005 November 2009
PSA .005 February 2010

notme · Guest

continued...

......it probably does work....after all it causes complete death of whatever it cooks.....and the Europeans aren't as up to date as we are...because they mostly use the french Ablatherm which can only zap a small gland...if a portion sticks out of the scope then it won't get treated....you hope the doctor can notice this....but in Europe they have a 40% redo rate because of this...they also do a TURP as standard procedure before Ablatherm HIFU...which can cause scarring and incontinence....and I am not sure if they use a supra pubic catheter....that was a US invention after HIFU....so a negative biopsy in Europe of 93 or 94% sure looks better than the risk you know you are taking with surgery or radiation....

Proceed with caution on ANY treatment or "hide and wait" non-treatment.

JustJB

Since I met with a radiation specialist this morning, and had a call from the HIFU/Cryo trial right afterwards, it seems like time for an update.
Simply put, the radiation oncologist recommended surgery. That's the way I've been leaning too.
The trial would only offer me cryo treatment, and I'm not interested in that as a primary treatment. Given my age and desire to live a long, healthy life, I've tended to be very cautious of HIFU. I recognize that it is a great option for many, but for me I'd prefer to go with a more proven technique.
i meet with a Robotic specialist third week of September and will probably go that route.
I'd appreciate any feedback on robotic versus 'traditional' laproscopy.
Thanks for all your feedback!
_________________
Age 52
RRP 11-5-09
Post Surgical Gleason 3+4 = 7
Stage T1C
Pre-surgical PSA: 5.3
Post-surgical PSA: Undetectable at 13 weeks

Hawk · Senior User Joined: 22 Nov 2006 Posts: 425

Imagine that, a radiation doctor that recommends surgery. I had a medical oncologist recommend radiation. I guess maybe doctors are not just into the treatment that gets them the money as is sometimes suggested.
_________________
History: PSA's 6.7 neg. biopsy - PSA 16.6 neg. biopsy - PSA's 8.2, 8.1, 8.7 - Biopsy. 4+4 Gleason 8. Lap RP Apr 2004, age 52 All neg margins, nodes, and structures. (T2a). Post RP PSA: every 6 mo. <.1 until Feb, 08 (46 mos) PSA .1 - I then got sensitive tests (all in 2008) showing:
Feb .06, May .09, Jun .10, Aug .10, Nov .15 -SRT

JustJB · Posted: Mon Aug 24, 2009 8:41 pm Post subject: Re: Diagnosed two weeks ago.

[quote="Hawk"]Imagine that, a radiation doctor that recommends surgery. I had a medical oncologist recommend radiation. I guess maybe doctors are not just into the treatment that gets them the money as is sometimes suggested.[/quote]
Good point. I asked the doctor about that. It is a positive result of the Kaiser system. They treat to the benefit of the patient, not the doctor. I've been a member for almost 24 years and, especially in the past 5-7 years, have been very satisfied with them. Excellent doctors, wide availability of services, and - get this - NO PAPERWORK!
_________________
Age 52
RRP 11-5-09
Post Surgical Gleason 3+4 = 7
Stage T1C
Pre-surgical PSA: 5.3
Post-surgical PSA: Undetectable at 13 weeks

cantexplain · Posted: Tue Aug 25, 2009 10:11 am Post subject: Re: Diagnosed two weeks ago.

Just JB: again, our journeys are remarkably parallel. I met yesterday, too, with a radiation oncologist and went through the options with him. The oncologist strongly reinforced the position that you can't really do radiation, then loop back around if it doesn't work and go for surgery.
My wife is strongly leaning towards surgery and I think it is the best choice also, but I'm having issues with the post-operative catheter maintenance. I've had two major surgeries in the last 3 years and one included a catheter which was very uncomfortable. Even so, in a black and white sense, surgery is the right answer. I'm arranging a meeting with the surgeon who does the Da Vinci robotic surgery, then it's time to tally up and make a final decision.

Cantexplain
PSA 4.9
Gleason - 3+3 =7
stage t2a

lauriejo · Posted: Fri Aug 28, 2009 8:18 pm Post subject: hifu

I too was skeptical of HIFU. I thought it sounded too good to be true, but the doctors that perform this procedure are some of the best urologists in the country. I checked them out. I have spoken to many men that have had the procedure. They all are thrilled with the results. Very few side effects. Do your homework. Call US HIFU at 1-888-874-4384. Better yet call NYU and ask to speak with Dr. Scionti at 646-825-6328. Truly amazing man. After speaking with Dr. Scionti we feel as if we got our lives back. My husband in scheduled for the procedure on September 25. I will keep all you posted. I think some surgeons and radiologists forget that they are treating a man with cancer not just a cancer.
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55 years old, PSA 6, Gleason 6, T1c, 6 of 10 cores positive HIFU 9/25/09, PSA .1 @ 3 mos post hifu

John M · Experienced user Joined: 27 Jul 2009 Posts: 59

Here is the summary assessment on current evidence on HIFU from the European Association of Urology 2009 Prostate Cancer Guidelines (http://www.uroweb.org/nc/professional-resources/guidelines/online/):

11.3 High-intensity focused ultrasound (HIFU)
HIFU consists of focused ultrasound waves emitted from a transducer to cause tissue damage by mechanical and thermal effects as well as by cavitation (15). The goal of HIFU is to heat malignant tissues above 65 °C in order to destroy them by coagulative necrosis. HIFU is performed under general or spinal anesthesia, with the patient in the lateral (Ablatherm®) or supine (Sonablate® 500) position; the procedure is time-consuming, with about 10 g prostate tissue being treated in one hour. In a recent review, 150 papers related to HIFU were identified and evaluated with regard to various oncological and functional outcome parameters (12). No controlled trial was available for analysis, and no survival data were presented. No validated biochemical, surrogate end-point was available for HIFU therapy.

11.3.1 Results of HIFU in PCa
As with CSAP (Cryosurgery of the prostate), it appears to be difficult to interpret oncological outcome in patients undergoing HIFU since various PSA thresholds are defined and no international consensus exists on objective response criteria. The results of HIFU are limited, with outcome data from fewer than 1000 PCa cases having been published in the literature. According to the recent review paper mentioned above (12), HIFU showed progression-free survival (based on PSA +/- biopsy data) of 63-87% (projected three- to five-year data), but median follow-up in the studies ranged from 12-24 months only. In one of the largest single-centre studies, 227 patients with clinically organ confined PCa were treated with HIFU and their outcome data were analysed after a mean follow-up of 27 months (range = 12-121 months) (16). The projected five-year biochemical disease-free survival was 66%, and or only 57% if patients had exhibited a pre-therapeutic PSA value of 4-10 ng/mL. Incontinence and bladder neck stricture decreased over time from 28% and 31% to 9% and 6%, respectively. In one of the studies (17), a significant decrease in pre-treatment PSA serum levels from 12 ng/mL to 2.4 ng/mL was observed. However, 50% of the 14 patients demonstrated positive prostate biopsies during follow-up. In another study (18), a complete response rate defined by PSA < 4 ng/mL and six negative biopsies was achieved in 56% of the patients. Summarising the efficacy results of a European multicentre study comprising the data of 559 patients with mainly low- and intermediate-risk PCa, Thüroff et al. (18) reported on a negative biopsy rate of 87.2% in 288 men with a follow-up of at least six months. A PSA nadir after six months follow-up could be determined in 212 patients, and it was as high as 1.8 ng/mL. However, it could be demonstrated that the PSA nadir might be reached at 12-18 months following the initial procedure. Blana et al. reported on 146 patients undergoing HIFU with a mean follow-up of 22.5 months (19). The mean PSA level at initiation of therapy was 7.6 ng/mL; the PSA nadir achieved after three months was 0.07 ng/mL. However, after 22 months the median PSA level was 0.15 ng/mL. Of the 137 men available for analysis, 93.4% demonstrated a negative control biopsy. The PSA nadir appears to be strongly associated with treatment failure (20) (p < 0.001). Patients with a PSA nadir of 0.0-0.2 ng/mL have a treatment failure rate of only 11%, compared with 46% in patients with a PSA nadir of 0.21-1.00 ng/mL, and 48% with a PSA nadir of >1.0 ng/mL. Recently, the group updated its results, with a total of 163 men treated for clinically organ-confined PCa. Within 72 Update march 2009 the 4.8 +/- 1.2 years of follow-up, the actuarial disease-free survival rate at five years was 66%, with salvage treatment initiated for 12% of the patients (21).

11.3.2 Complications of HIFU
Urinary retention appears to be one of the most common side-effects of HIFU, developing in almost all patients, with the mean interval of catheterisation via a suprapubic tube varying between 12 and 35 days (15-17). Grade I and II urinary stress incontinence occurs in about 12% of patients. Subsequent TURP or bladder neck incision to treat subvesical obstruction is common, and is sometimes even performed at the time of HIFU. Post-operative impotence will occur in approximately 55-70% of patients.

11.5 Summary of experimental therapeutic options to treat clinically localised PCa
• CSAP has evolved from an investigational therapy to a possible alternative treatment for PCa in patients who are unfit for surgery or with a life expectancy < 10 years
• All other minimally invasive treatment options – such as HIFU, RITA, microwave and electrosurgery – are still experimental or investigational. For all of these procedures, a longer follow-up is mandatory to assess their true role in the management of PCa
_________________
John

lauriejo · Posted: Sat Aug 29, 2009 9:02 am Post subject: HIFU

I read all the same data. Believe me I was very skeptical also. I did my homework. A friend of mine works for an insurance company. She checked out the US HIFU doctors for me. She was amazed. These doctors are some of the best urologists in the country. Why would these incredibly successful doctors leave the country to perform this procedure unless they truly believed in it? It can’t be the money ($25,000) because they would be paid far more for surgery ($60,000+) or radiation treatment (110,000 +). I phoned many of the patients of US HIFU and not only were they thrilled with the outcome of the treatment, but many of them were reimbursed by their insurance companies. If this wasn’t a legitimate treatment for prostate cancer why would an insurance company reimburse? Rumor has it that one of the CEO’s of a very prominent American insurance company had prostate cancer and was successfully treated by US HIFU. American medicine is already using HIFU to treat uterine fibroids, no surgery, and no hysterectomy. There are also HIFU clinical trials for breast cancer tumors, brain cancer tumors, etc. Also, HIFU is the only prostate cancer treatment that can be repeated if the cancer recurs. Or the other treatment options can be considered afterward. What's to lose?
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55 years old, PSA 6, Gleason 6, T1c, 6 of 10 cores positive HIFU 9/25/09, PSA .1 @ 3 mos post hifu

John M · Experienced user Joined: 27 Jul 2009 Posts: 59

BJU Int. 2008 May;101(10):1205-13. Epub 2008 Mar 4. Links
High-intensity focused ultrasound in prostate cancer; a systematic literature review of the French Association of Urology.Rebillard X, Soulié M, Chartier-Kastler E, Davin JL, Mignard JP, Moreau JL, Coulange C; Association Francaise d'Urologie.
Collaborators (18)

Allègre JP, Averous M, Botto H, Coloby P, Conort P, Delmas V, Desgrandchamps F, Fourcade RO, Grall J, Grise P, Kouri G, Le Doze H, Piéchaud T, Prunet D, Roupret M, Rambeaud JJ, Vignes B, Villers A.

Clinique Beau Soleil, Montpellier, France.

We discuss the efficacy and safety of high-intensity focused ultrasound HIFU) in patients with prostate cancer, to define the best indications for HIFU in daily clinical practice as primary therapy. We searched Medline and Embase for clinical studies evaluating the efficacy and safety of HIFU in prostate cancer (July 2007), and abstracts presented at the 2005-2007 Annual meetings of the European Association of Urology and American Urological Association were screened. In all, 37 articles/abstracts were selected. As the data on HIFU as salvage therapy were limited, we focused on HIFU as primary therapy. Studies consisted of case series only. Included patients were approximately 70 years old with T1-T2 N0M0 disease, Gleason Score <or=7, a prostate-specific antigen (PSA) level of <or=28 ng/mL and a prostate volume of <or=40 mL. Negative biopsy rates with the Ablatherm device (EDAP TMS S.A., Vaulx-en-Velin, France) were 64-93%, and a PSA nadir of <or=0.5 ng/mL was achieved in 55-84% of patients. The 5-year actuarial disease-free survival rates were 60-70%.

The most common complications were stress urinary incontinence, urinary tract infection, urethral/bladder neck stenosis or strictures, and erectile dysfunction. For the Ablatherm device, the rate of complications has been significantly reduced over the years, due to technical improvements in the device and the use of transurethral resection of the prostate before HIFU.

In conclusion, HIFU as primary therapy for prostate cancer is indicated in older patients (>or=70 years) with T1-T2 N0M0 disease, a Gleason score of <7, a PSA level of <15 ng/mL and a prostate volume of <40 mL. In these patients HIFU achieves short-term cancer control, as shown by a high percentage of negative biopsies and significantly reduced PSA levels. The median-term survival data also seem promising, but long-term follow-up studies are needed to further evaluate cancer-specific and overall survival rates before the indications for primary therapy can be expanded.
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John

lauriejo · Posted: Sat Aug 29, 2009 4:04 pm Post subject: HIFU

You are quoting European websites. Call US HIFU. Speak with them and their doctors. My husband's doctor said he has done 500 treatments. He doesn't have one guy with incontinence. The American HIFU doctors sound as if they are taking extra precautions vs. the European doctors. It may be the difference between socialized medicine and private medicine. It may the difference between the Ablatherm (French) and the Sonablate (American). I don't know, but the American HIFU doctors have a very positive view of the outcome of the procedure. It's worth a call. It can't hurt to call and speak with someone at US HIFU. 1 888-874-4384.
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55 years old, PSA 6, Gleason 6, T1c, 6 of 10 cores positive HIFU 9/25/09, PSA .1 @ 3 mos post hifu

John M · Experienced user Joined: 27 Jul 2009 Posts: 59

The last quote, and this one, are not from websites, they are abstracts of reviews that have been published in the medical literature. These abstracts come from Europe, because the HIFU device is not approved by the FDA for use in the United States, so American experience is very limited. Treatment in the US is only possible as part of an approved investigational trial.

Eur Urol. 2006 Nov;50(5):927-34; discussion 934. Epub 2006 Jul 28.
Current status of HIFU and cryotherapy in prostate cancer--a review.Aus G.
Department of Urology, Sahlgrens University Hospital, SE 413 45 Göteborg, Sweden. gunnar.aus@vgregion.se

OBJECTIVES: To evaluate the current status of high-intensity focused ultrasound (HIFU) and cryosurgery as the primary treatment option in patients with prostate cancer.

METHOD: A MedLine search using specified search terms was done on February 28, 2005. This search rendered 150 papers related to HIFU and 566 papers related to cryosurgery. Very few of these papers presented original outcome data and are included in the present review.

RESULTS: No controlled trial was available for analysis, and no survival data were presented. No validated biochemical, surrogate end point was available for any of the two therapies. HIFU showed progression-free survival (based on prostate-specific antigen+/-biopsy data) of 63-87% (projected 3- to 5-yr data), but median follow-up in the studies ranged from 12-24 mo. Negative postoperative biopsies was seen in 82-94% of patients. Complications have been reduced by the combination of transurethral resection of the prostate and HIFU. Cryosurgery showed a progression-free survival of 36-92% (projected 1-7 yr data), depending on risk groups and definition of failure. Negative biopsies were seen in 72-87%, but no biopsy data were available for the currently used third-generation cryotherapy machines. Complications seem to be lower with the third-generation machines.

CONCLUSIONS: None of the evaluated therapies has enough data available to support their use as an alternative to established therapies (surgery, radiation) for localised prostate cancer. Until further data become available, the use of both treatments should be restricted to patients unfit for established therapies who still have the need for local therapy.
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John

lauriejo · Posted: Sat Aug 29, 2009 4:50 pm Post subject: HIFU

My husband and I choose to believe HIFU will be successful in curing the cancer with less side effects. We have spoken to the doctors and they are very confident. If you choose not to believe in HIFU that's okay. I know it's a lot of money, but if we didn't spend it and my husband had all the terrible side effects that his urologist surgeon (Da vinci Robot) told us to count on, we would kick ourselves for being cheap and not doing all we could do to minimize the side effects. It is very important to us to do everything possible to preserve our quality of life if you get what I mean.
_________________
55 years old, PSA 6, Gleason 6, T1c, 6 of 10 cores positive HIFU 9/25/09, PSA .1 @ 3 mos post hifu

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