Surgery vs. Radiation

Solon · New User Joined: 12 Nov 2009 Posts: 8

Wow im surprised with the amount of knoweldge regarding the biopsies, statistics and potential choices.

I never really understood whether this positive margin finding or the differency in gleason numbers between cores should be obtained with initial biopsy.

My father just stated that 30% of his cores where positive. Number of cores taken where around 30. I told him to obtain the pathology report from the hospital so we could look at more detail and i will remind him today, because i see here that there is a lot of info i havent considered till now.

How can there be such a variability and how can some of cores be involved and some not "Gleason Grade 3+3=6 discontinuously involving from 10% to 90% of 8 of 9 cores, T2C "

can someone explain more info??

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Usually PC manifests itself in multiple tumors in the prostate, it is a multifocal disease and patients usually have more than one tumor and these can be different gleason grades. Also a biopsy is just a small sample of a tumor, if the needle hits the edge of the tumor it may pick up a lower gleason grade and a much smaller % of core than if it hits the center of the tumor.
johnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

jona · Posted: Fri Nov 20, 2009 2:49 pm Post subject: Surgery vs. Radiation

I just got my results from my PSA yesterday. It has dropped from 5.32 to 3.4, just as I had suspected it would because of the DRE, prostatitis, etc. before my last PSA. I still have a bit of prostatitis, so this is probably still a bit high.

I plugged the numbers into the Sloan-Kettering nomogram:

26% probability of extracapsular extension on the left and 43% on the right
97% chance of no progression after 5 years with surgery
88% with EBRT

This is confusing because both the surgeon and radiation oncologist said the statistics for both are about the same. [b]Then I discovered that the supporting radiation publication had a date of Oct 1, 2000.[/b], meaning the supporting statistics probably cover the previous 10 years. I think radiation therapy has come a long way since then. All of the other supporting publications are at least 3 or more years old.

Certainly that doesn't give me much faith in the S-K nomograms to use in my treatment decision.
_________________
Jona
-------------------------
DX : Adenocarcinoma of the prostate on 10/6, Gleason Grade 3+3=6 discontinuously involving from 10% to 90% of 8 of 10 cores, 1 core suspicious, 1 core small focus, T2C
PSA History:
06/17/03 2.6
09/28/04 1.5
06/27/05 ?
02/13/06 2.2
07/06/07 2.2
01/08/08 ?
07/29/09 2.9
09/01/09 5.32
11/18/09 3.4

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

The nomograms are just statistics based on thousands of patient stats; some times they just don't make any sense. For example a patient going into salvage radiation plugged in his stats and it showed a much better survival rate getting 65 gy than 70gy or 81gy. this doesn't make any sense until you realize that the worst patients get the higher gys and the patients that are not as agressive get less gys. The initial stats should reflect this. but they don't.
Use the nomograms as they are intended to be used; only as broad guidelines. PC is very individual and must be treated as so. The nomograms for my G4+3, psa of 40 were pretty bad, but when you individualize it with PAP, PSADT, PCA3, Color Doppler, MRIS and Combidex scans you get a completely different picture of the PC which was local and non agressive.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

jona · Posted: Fri Nov 20, 2009 8:54 pm Post subject: Surgery vs. Radiation

JohnT,

I noticed you had seeds plus IMRT. Was that because of your high PSA?Also, was the IMRT 360 degree Tomo or something similar?

My oncologist mentioned that seeds plus IMRT was an option, but didn't really push it. It might be good for me because I have a large volume G6. I'm not sure I want the side effects of both, though. Was that a problem for you?

I am now leaning toward radiation because I'm afraid the cancer might be outside the capsule and it appears radiation is a better choice if that is the case plus my age and ED and incontinence concerns. I would hate to go the prostatectomy route and then find out I needed radiation anyway.
_________________
Jona
-------------------------
DX : Adenocarcinoma of the prostate on 10/6, Gleason Grade 3+3=6 discontinuously involving from 10% to 90% of 8 of 10 cores, 1 core suspicious, 1 core small focus, T2C
PSA History:
06/17/03 2.6
09/28/04 1.5
06/27/05 ?
02/13/06 2.2
07/06/07 2.2
01/08/08 ?
07/29/09 2.9
09/01/09 5.32
11/18/09 3.4

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Jona,
I had a high volume G7 that was close to the uretha and a clear margin would have been difficult for surgery.
My high psa was due to the fact that it was a transition zone tumor; but I ruled out lymphnode involvement by taking a Combidex MRI in Holland, so I was pretty sure it was contained.
I took Casodex and Proscar for 3 months to shrink my 60mm prostate to 34mm and my psa dropped to .6 before treatment. It was 0.02 after treatment and is <.1 three months later. I think this is still the result of the Casodex not yet wearing off yet.
I have no side affects from either seeds or IMRT; my urinary and bowel functions are now better than before treatments. I had about 4 weeks of , urinary frequency and urgency that was eaisly controllable with Flowmax and didn't prevent me from doing anything. I had no radiation fatigue and played golf from the day after seeds and through out my IMRT sessions. The Casodex really affected my Libido, but I have had no issues with ED.
My results are probably better than most and certainly would not suggest that everyone will have the same results from seeds and IMRT. I think it is key to get a good brachytherapist and a good radiologist as they can definately mimimize the side affects. The IMRT was 360 Tomo and I had to drink 32 oz of water before every treatment. This was the hardest part of the treatment .
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

jona · Posted: Mon Nov 23, 2009 12:34 pm Post subject: Radiation vs. Surgery

Well, I just had a final telephone consutlation with Dr. Walsh. He didn't seem to be bothered by the fact that I had a high volume T2C cancer that had 25% discontinuous cancer at the left base and 50% discontinuous at the right base. He said that the fact that my PSA had dropped back to 3.4 was a very good sign. He again stressed that incontinence was the big issue with surgery and ED problems would probably be the same in either case.

Surgery would seem to give me peace of mind. At least I would have a better idea of where I stand, my prostatitis would disappear, and the fear of the radiation not killing all the cancer would not be there. Also, the option for salvage radiation is available with the surgery.

What I would like to know before I make a final decision is what kind of experience members of this forum had with incontinence following radiation.
_________________
Jona
-------------------------
DX : Adenocarcinoma of the prostate on 10/6, Gleason Grade 3+3=6 discontinuously involving from 10% to 90% of 8 of 10 cores, 1 core suspicious, 1 core small focus, T2C
PSA History:
06/17/03 2.6
09/28/04 1.5
06/27/05 ?
02/13/06 2.2
07/06/07 2.2
01/08/08 ?
07/29/09 2.9
09/01/09 5.32
11/18/09 3.4

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Incontinence is very rare in radiation, urinary constriction occurs in a small % of patients as does bowel issues. Taken as a whole, the side affect from radiation are less severe than the side affects from surgery.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

problem · Regular Joined: 12 Sep 2009 Posts: 44

Here are comparative studies at MEDLINE: http://www.annals.org/content/148/6/435.abstract

And then to look at quality of life issues read this:
http://www.bmj.com/cgi/content/abstract/339/nov27_2/b4817

ChrisB · New User Joined: 03 Dec 2009 Posts: 3

It took me three months to make my mind up between surgery and radiation. Both looked similar but in the end there are more options if the cancer comes back if you have had surgery.

After surgery you can have radiotherapy but not the other way around.
_________________
I wrote a blog on my experience of being diagnosed with prostate cancer and how I reached a treatment decision. Many people helped me, I hope to be able to give something back through this.
http://experiencingprostatecancer.blogspot.com

Travelingman · Posted: Thu Dec 03, 2009 6:06 pm Post subject: Re: Surgery vs. Radiation

[quote="ChrisB"]It took me three months to make my mind up between surgery and radiation. Both looked similar but in the end there are more options if the cancer comes back if you have had surgery.

After surgery you can have radiotherapy but not the other way around.[/quote]
Chris, thanks for taking the time to write your blog. Like you it took me a long time to decide. when my surgeon told me that my pathology report showed more cancer & a higher grade than the biopsy, I was also glad I made the choice for surgery. BTW, I sent you a private message. Did you get it? How are you doing on the incontinence issue? I am still using 5 to 8 pads a day. Still can't stop my urine stream with the pelvic muscles. Dr. has prescribed a drug & biofeedback. So far, not very good results.
_________________
PSA 18, Gleason 3+3+6, Age 58, Rising PSA since 1999, Biopsy 5% of one core
Robotic surgery 10/26/09 T2B Tumor 30% of prostate involving left & right lobes NOMX Gleason 3+4=7 Urethral Resection margins & resection surface clean Seminal vessicles clean

ChrisB · New User Joined: 03 Dec 2009 Posts: 3

No I did not get your private message.

Regarding my blog, I still have a lot to add and I am glad you found it useful.

Regarding incontinence, my catheter only came out yesterday.
I am dripping but I did my pelvic floors for 2 months prior to the op so seem to have some control. Nurse told me yesterday was worst day so here is hoping.
_________________
I wrote a blog on my experience of being diagnosed with prostate cancer and how I reached a treatment decision. Many people helped me, I hope to be able to give something back through this.
http://experiencingprostatecancer.blogspot.com

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Chris,
Not entirely true. After seeds you can be reseeded or have HDR Brachy. After External radiation you can have HDR Brachy, cyrosurgery or HIFU, you can also have surgery, but it is much more difficult.

The argument sounds good, but to me the logic is faulty when you consider what causes a reoccurrance.
1. The cancer is systemic, not local and no local treatment will work.
2. In surgery you have extra capsular penetration, or the tumor is located in a hard to get to place adjecent to other organs. In this case you were not a good candidate for surgery in the 1st place and radiation would have resulted in a cure.
3. In surgery some prostate tissue was left behind that had pc cells. there is always some tissue left and the good doctors leave less. Again radiation would have gotten this.
4, You have a poor surgeon who screwed up.
5. In radiation an occurrance will occurr if there are dead spots as a result from a poor radiation plan and a poor execution.
6. There was not a high enough dose to to overcome a large tumor burden. A combination seeds and IMRT will overcome this with a much higher soes.
In general radiation or a combo of radiation and seeds will kill every PC cell in the prostate and 10mm to 15mm in the bed. Most reoccurrances are systemic and not local.
In any reoccurrance, any salvage therapy has about a 70% failure rate.
JohnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

ChrisB · New User Joined: 03 Dec 2009 Posts: 3

John,

Interesting remarks. I can only report what I was advised. In my case the cancer was thought to be very early i.e. fully localised . Complete removal of the prostate in this case would hopefully result in a clean removal but I will find out the results in a couple of weeks when the disscection results are in. This will tell me if it was fully localised.

I spoke via a cancer charity to a few people who had had brachy.
No one told me it was possible to reseed and the surgeon himself spoke about tradional radiotherpy, hormone treatment and HIFU as follow up treatments. I am sure you are right in what you say though.

I guess this sums up why making a decision is so hard. It is not clear cut with so many options and opinions. Everything changes as well with the degree of how advanced you are which is not always clear in itself.

Interestingly when I spoke to people who had had brachy, they told me the worst part was there is no "result" you can hang your hat on. You just have to wait. One person told me if he had his time again he would have gone for surgery because of this. At least with surgery they disscect and tell you if they think they have got it all.

What was clear to me though is both brachy and surgery are both proven treatments and for a long time I lent towards brachy myself.
_________________
I wrote a blog on my experience of being diagnosed with prostate cancer and how I reached a treatment decision. Many people helped me, I hope to be able to give something back through this.
http://experiencingprostatecancer.blogspot.com

johnT · Senior User Joined: 27 Apr 2009 Posts: 235

Chris,
Yes it is really hard to acquire and sift through all the information and try to separate the hype from the facts. Every study one looks at comes to a different conculsion, and most doctor's are ignorant about treatments outside their own fields of expertise and are more apt to give false information about them.
I realise that it will take years to know if my treatments worked; this doesn't bother me at all, but it may strongly affect other men's choice and is a valid consideration. We all make decisions based on what is important to one's self and what is important to one individual may not even be a consideration for another. Having a salvage option wasn't a consideration for me at all as I would go straight to HT unless it was positivitily identified that it was a local reoccurrance.
The cure rates for localized, non agressive PC are similar for all treatment options. The doctor you choose will impact your outcome more than the treatment option. The only difference is side affects and each option has its own side affects that you have to risk living with.
johnT
_________________
psa at diagnosis 40 in nov-08
gleason 6 and 7
Treatment choice seeds and IMRT

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