Surgery vs. Radiation

[jona]

I was diagnosed with prostate cancer on 10/06/2009. I am currently in research mode. I met with Dr. Patrick Walsh at John Hopkins on 10/30. He said he would operate on me, but warned me about the incontinence issue. His concern was because I am 70. I am in good physical shape: runner, walker, skier, weightlifter.

Dr. Walsh also recommended that I consider radiation and I have a meeting with a radiation oncologist on 11/18. After that meeting, I will decide on the course of treatment I will pursue.

I would like to get feedback from any members of the forum in my age range who have had surgery.

[Replicant]

Hi jona, and welcome to the forum.

Would you mind telling us about your PSA history?

R.

[jona]

Thanks for the quick reply.

I added my PSA History and stage to my signature. I'm not sure if the 5.32 PSA is valid or not. I think my blood test was taken after a digital exam, which I unerstnd can elelvate PSA. I also understand that the PSA can spike with prostatitis (which I have had lately), and sexual activity (day before the PSA test).

The question marks indicate that I could not find my PSA on the blood tests for those years. It appears that tests weren't done..

[Otago]

Gleason Grade 3+3=6 discontinuously involving from 10% to 90% of 8 of 9 cores, T2C

Given his stature as the top surgeon for prostate cancer, I'm sure he wouldn't be recommending you consider radiation unless he had some real concerns about doing surgery on you.

I'm guessing its not only because of the incontinence issue, but also with 8 of 9 positive cores, up to 90%, he may well be more concerned about the likelihood of the PCa not being confined to the prostate which would then require radiation anyway. (meaning positive margins)

Go to the Brady Urological page and run the Partin tables.
Discuss it with your radiation guy.

http://urology.jhu.edu/prostate/cancer.php

Ask Walsh or others about the data, your cores, and all the probabilities.
If there is little to be gained from surgery and there is a fair chance of the PCa not being confined, then it might make sense to go with radiation first and avoid all the surgical complications.

Take your time in making the decision.

Otago

[Replicant]

Walsh is also a believer in radiation over surgery for patients 70 and over, according to his book. On page 240 he says the ideal radical prostatectomy patient is under 70, and the ideal radiation therapy patient is over 60 (but later he says that radiation is a valid choice for men of any age). On page 243, he says surgery "is not ideal for older patients."

He likes radiation for all stages, while he recommends surgery for T1b, T1c, T2, and some T1a patients. (p. 240).

He goes on to say (p. 243) that age is a factor because men over 70 often have cancer that is more advanced than the biopsy would lead the doctor to believe initially, and less likely to be curable, because it's been growing longer.

He also doesn't like the fact that surgical side effects get worse the older the patient is at the time of surgery.

Finally, and remember who's talking here (the best known prostate surgeon) on page 244 he says "because men over age 70 aren't likely to live as long as men twenty years younger, it's difficult to show that radical prostatectomy actually does more than radiation therapy to lengthen life expectancy in these men."

I highly recommend Walsh's book, "Dr. Patrick Walsh's Guide to Surviving Prostate Cancer" (2007 ed.)

[jona]

Thanks to both Otago and Replicant for your responses.

I don't think Dr. Walsh was that hesitant about operating, but did tell me that if you compare 500 surgeries against 500 radiation treatments, the statistics for long term cure are about the same.

I have plugged my numbers into the Partin tables and also the calculators at Sloan-Kettering and UroPredict Bostwick Laboratories Staging System. Sloan-Kettering numbers show a better 5 to 10 year history for surgery versus IMRT, but about the same for brachytherapy. Walsh told me he didn't think I was a good candidate for brachytherapy.

I've also been looking at proton beam therapy (PBT). The frustating thing about choosing a PCa treatment so far is that all of these institutions do heavy marketing for their methods. The PBT people act like this is the best treatment out there, but I haven't seen any statistics.

Anyway, I have a consultation with a radiation oncologist at JHU on 11/18. I'll see what he says and then decide. Meanwhile, I'll continue the research.

[rowejack]

I just finished a 43 treatment radiation program last week ...Had very few problems ...Used IMRT method and it went well , except the last two treatments were done just using the external tattoo markers as the ultrasound was down for those two days . Those two sessions caused a lot of bowel and bladder problems for about 4 days ...Fine now .
Overall ,the radiation was a very easy way to go for this 71 year old ...
I did months of research and decided on radiation .Glad I didn't go the surgery route . Now I wait another 6 weeks for first post radiation PSA

PSA ...2.5
Scored as a T2 C .

Jack

[Otago]

Jona,

I wonder...

"I have plugged my numbers into the Partin tables and also the calculators at Sloan-Kettering and UroPredict Bostwick Laboratories Staging System. Sloan-Kettering numbers show a better 5 to 10 year history for surgery versus IMRT, but about the same for brachytherapy."

Did any of those calculators have a input allowing for
" involving from 10% to 90% of 8 of 9 cores",
or did they just ask for the PSA and gleason score, etc,?

They ask for "unifocal" yes or no, but I'm guessing that even 2 cores of 12, at 10% and 20% each, would qualify as NOT being "unifocal"...
Whereas, and I don't know, it would seem there may be a significant difference between 8 of 9 ranging from 10% to 90% vs 2 of 12 going from 10% to 20%.. in terms of the potential for extraprostatic extension.
Yet both would be entered into the calculator as the same value.

PS... ( I see the Sloan-Kettering" asks for number of positive cores, but I don't see them asking about the percentage of each core)
(also... did you fill in the "Enter Advanced Details (for Medical Professionals)" section? I realize you may not have all those details but it seems to make quite a difference on the data, perhaps dropping the "organ confined" from 66% to about 50%.. Yet oddly leaving the "Progression Free Probability after Radical Prostatectomy" numbers up at about the same place???

As I said, I really don't know, but you ought to explore that dimension and speak to your doctors about the different probabilities.

Otago

[jona]

I again ran the numbers I have through the Sloan-Kettering calculator. I did add the details I have so far including % cancer at left and right base. Here were the results:

Extent of Disease Probability:
Organ Confined Disease 75%
Extracapsular Extension left 25%
right 41%
Seminal Vesicle Invasion 1%
Lymph Node Involvement 2%

Primary Treatment Outcomes:
Progression Free Probability after Radical Prostatectomy: 5 Year 95%,
10 Year 93%
5 Year Progression Free Probability with External Beam Radiation Therapy:
I plugged in the highest radiation and got 90% at 5 years
5 Year Progression Free Probability with Brachytherapy 96%

--------------------------------------------------------
Uropredict:
Organ Confined Disease 77% / Extracapsular Extension left 24% / seminal vesicles 0 / lymph nodes not listed

------------------------------------------
Partin Tables:
Organ confined: 74 (68-80)
Extraprostatic extension: 23 (18-29)
Seminal Vesicle Invasion: 2 (1-5)
Lymph Node Invasion: 0 (0-1)

I am currently leaning toward surgery, but have a consultation with a radiation oncologist at Hopkins on 11/18.

[jona]

Yesterday (11/18/2009) I had my consultation with the Dr. Song, the radiation oncologist at Johns Hopkins. He told me that I was a good candidate for IGRT (Tomo), but admitted that it was a tossup with surgery.

He would like to do an MRI to check if I have any extraprostatic extension
--if I go the radiation route--so he can factor that into the plan.

This like the old story of "The Lady or the Tiger." Choose a door and behind one is a beautiful woman; behind the other is a tiger: a 50/50 chance. In this case, choosing between surgery and radiation is like there is a tiger behind one door and a leopard behind the other. No perfect answer. Both can have bad side effects.

The main fears I have about surgery, of course, are the incontinence problem because of my age (70) and ED. On the other hand, if I can beat the first problem, I've found that there are a lot of posssible solutions for the ED problem.

I think it would give me peace of mind no matter where I stand because of the accurate staging and the fact that PSA in this case is such a good indicator post-surgery of any cancer progression. This is not so accurate with radiation and harder to assess--and would seem to be a bigger worry.

Would like feedback on the following:

1. Is there anyone out there over 70 who has had surgery? Would like to know your experience post-surgery. (My surgeon would be Dr. Patrick Walsh at John Hopkins.)

2. Experience with radiation, especially at Johns Hopkins

3. Experience with salvage radiation after surgery, if needed.

4. Do Kegel or other exercises before surgery help with gaining continence after surgery?

I am in good physical shape (run, bike, etc.), so that is why I am currently leaning in the direction of having surgery. I'm looking for at least another 15 to 20 good years. (Hey, I'm optimistic!). Also, my gut feel from research is that surgery is still the better way to go even though the experts tell me both approaches are about even for being cancer-free down the road.

I know it's my decision in the end, but it is a tough one. You all already know that!

Thanks

[jona]

I just finished a 43 treatment radiation program last week ...Had very few problems ...Used IMRT method and it went well , except the last two treatments were done just using the external tattoo markers as the ultrasound was down for those two days . Those two sessions caused a lot of bowel and bladder problems for about 4 days ...Fine now .
Overall ,the radiation was a very easy way to go for this 71 year old ...
I did months of research and decided on radiation .Glad I didn't go the surgery route . Now I wait another 6 weeks for first post radiation PSA

PSA ...2.5
Scored as a T2 C .

Jack

What problems have you had post-radiation?

-------------------------------------

[johnT]

Jona,

There a couple of things that don't make sense that you should question your doctors on.
Your Biopsy indicates a large volume G6, but your psa is fairly low. There are formulas that use the size of your prostate, Gleason score and tumor volume size to calculate your expected psa. This should match your latest psa if it doesn't you have to question it.
Your low stable psa history suddenly rose rather quickly. G6 tumors normal don't do this; they grow slow and steady.
There are a lot of PC varients and whenever something acts differently than it's supposed to you have to double check to make sure what your looking at. "You have to establish Status before you can talk Strategy" as Strum often says. You may want to get an opinion from a Prostate Oncologist before you decide on a treatment strategy. He can also give you an unbiased recommendation on treatments.
JohnT

[jona]

Jona,

There a couple of things that don't make sense that you should question your doctors on.
Your Biopsy indicates a large volume G6, but your psa is fairly low. There are formulas that use the size of your prostate, Gleason score and tumor volume size to calculate your expected psa. This should match your latest psa if it doesn't you have to question it.
Your low stable psa history suddenly rose rather quickly. G6 tumors normal don't do this; they grow slow and steady.
There are a lot of PC varients and whenever something acts differently than it's supposed to you have to double check to make sure what your looking at. "You have to establish Status before you can talk Strategy" as Strum often says. You may want to get an opinion from a Prostate Oncologist before you decide on a treatment strategy. He can also give you an unbiased recommendation on treatments.

---------------------------------------------------------------------------------
The PSA blood test was taken after ejaculation the night before and a DRE. Johns Hopkins did another blood test yesterday (probably because of the discrepancy) and I am awaiting the results.

JohnT

[jona]

[quote="jona"][quote="johnT"]Jona,

There a couple of things that don't make sense that you should question your doctors on.
Your Biopsy indicates a large volume G6, but your psa is fairly low. There are formulas that use the size of your prostate, Gleason score and tumor volume size to calculate your expected psa. This should match your latest psa if it doesn't you have to question it.
Your low stable psa history suddenly rose rather quickly. G6 tumors normal don't do this; they grow slow and steady.
There are a lot of PC varients and whenever something acts differently than it's supposed to you have to double check to make sure what your looking at. "You have to establish Status before you can talk Strategy" as Strum often says. You may want to get an opinion from a Prostate Oncologist before you decide on a treatment strategy. He can also give you an unbiased recommendation on treatments.

---------------------------------------------------------------------------------
The PSA blood test was taken after ejaculation the night before and a DRE. Johns Hopkins did another blood test yesterday (probably because of the discrepancy) and I am awaiting the results.

----------------------------------------------------------------------
Forgot to mention that I've been having bouts of prostatitis. I'm not sure that was the case when I had the PSA jump. All these things muddies the water. Also, I've had 3 recent DREs and all doctors mentioned that my prostate isn't very large. I don't have any specific volume measurements.

[rowejack]

Jona
I finished 43 radiation IMRT treatments on Oct 26 ... So far I have not experienced any significant problems ( age 71 ) . Still have BPH . Urinate 4 times a night , and minor leakage , But don't know if that is residual from radiation or BPH . No bowel problems after a few incidents at the end of my treatment ...
I'm very satisfied that I went the IMRT route ...
Word of caution ...I had markers inserted for IMRT accuracy and thats the way to go ..On two treatment days , the ultrasound machine which aligns you was down and they lined me up with the tattoos on my stomach ..I definitely noticed problems with bladder and bowels for several days after that .
I'm sure you'll do enough research to satisfy yourself in the right way to go for you ...

Jack