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  1. #1
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    Post undecided

    Hello
    This is my first post. Age 59. PSA of 4.7 on 9/14/2014, PSA of 6.3 on 11/12/2014. Urologist performed DRE and said slightly enlarged but was fairly confident that nothing would be found in a biopsy. Biopsy performed on 12/16/2014. 12 samples, 5 benign 7 positive with the highest being 3+4=7 in 2 cores. the rest were 3+3=6. Cancer seems to be confined to prostate. Negative bone scan.

    He suggested RP but also gave me a brochure to Cyberknife (SBRT). I did a lot of reading and decided to go with the Cyberknife until I had my appointment to talk with the Oncologist. The Dr. said he was surprised that I would consider it over surgery considering my age and my cancer being considered of medium risk. He also said that he would want to do HT for about a year.

    The HT was nothing I had considered. I read up on the side effects and I talked with the wife and grown Daughter and they both said I was moody enough and depressed enough already(which is true) to have the HT. I called the Dr. and asked if I could do the SBRT without the HT. He said I could but strongly advised against it. I thought OK I will have the surgery.

    I then talked to my Urologist and told him this and he didn't understand why the oncologist would not want me to do it without the HT saying that the cancer was on the low side of medium risk. He also said he would do the surgery without the HT. BTW both DR.s have very good reputations and several awards in their fields and I researched them both and found no bad reviews.

    Sorry for the babbling but just going a bit nuts trying to decide which way to go. So if anyone has any comments I would sure appreciate it
    Last edited by HighlanderCFH; 02-14-2015 at 06:46 AM. Reason: No editing, just added some white space.

  2. #2
    Administrator Top User Didee's Avatar
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    Moving this to the Prostate forum for you. The crew there are very informed and helpful.
    My best wishes to you.
    Aussie, age 61
    1987 CIN 111. Cervix lasered, no further problems.

    Years of pain, bleeding, women's plumbing problems. TV ultrasound, tests, eventual hysterectomy 2007, fibroids in lining of Uterus.

    Dx Peripheral T Cell Lymphoma stage 2B bulky, aggressive Dec/09.
    6 chop14 and Neulasta.
    Clean PET April/10, 18 rads 36gy mop up. All done May 2010
    Iffy scan Nov. 2011. Scan Feb 2012 .still in remission.Still NED Nov 2012.
    Discharged Nov 2014.

    May/2012. U/sound, thyroid scan, FNB. Benign adenoma.

    Relapse Apr 2016. AITL. Some chemos then on to allo transplant. Onc says long remission was good. Still very fixable.

    SCT Aug 2016

  3. #3
    Senior User
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    Quote Originally Posted by hopper View Post
    Hello
    This is my first post. Age 59. PSA of 4.7 on 9/14/2014, PSA of 6.3 on 11/12/2014. Urologist performed DRE and said slightly enlarged but was fairly confident that nothing would be found in a biopsy. Biopsy performed on 12/16/2014. 12 samples, 5 benign 7 positive with the highest being 3+4=7 in 2 cores. the rest were 3+3=6. Cancer seems to be confined to prostate. Negative bone scan. He suggested RP but also gave me a brochure to Cyberknife (SBRT). I did a lot of reading and decided to go with the Cyberknife until I had my appointment to talk with the Oncologist. The Dr. said he was surprised that I would consider it over surgery considering my age and my cancer being considered of medium risk. He also said that he would want to do HT for about a year. The HT was nothing I had considered. I read up on the side effects and I talked with the wife and grown Daughter and they both said I was moody enough and depressed enough already(which is true) to have the HT. I called the Dr. and asked if I could do the SBRT without the HT. He said I could but strongly advised against it. I thought OK I will have the surgery. I then talked to my Urologist and told him this and he didn't understand why the oncologist would not want me to do it without the HT saying that the cancer was on the low side of medium risk. He also said he would do the surgery without the HT. BTW both DR.s have very good reputations and several awards in their fields and I researched them both and found no bad reviews. Sorry for the babbling but just going a bit nuts trying to decide which way to go. So if anyone has any comments I would sure appreciate it
    Sorry about your diagnosis but welcome, hopper.

    It is fairly common to use neoadjuvant hormone therapy prior to radiation to sensitize the cancer cells to the radiation and make it more effective, but I've never heard of having to do it for a year. There is not generally considered to be a similar benefit to neoadjuvant HT prior to surgery, so that makes sense.

    SBRT and surgery both seem like potentially good options for you although SBRT is newer and does not have the same long term results available. Surgery provides more conclusive data on your disease state, which may give peace of mind, but the outcomes with surgery are MUCH more dependent on the skill and experience of the specific practitioner than they are with external beam radiation.

    Prostatectomy is any extremely delicate and challenging procedure -- even when done roboticly. It takes many hundreds (some studies suggest well over 1000) surgeries for a surgeon to optimize his technique.

    And experience is necessary but not sufficient. The few best surgeons in the world seem to have a unique talent that allows them to significantly outperform by objective measures most other equally experienced surgeons. A key such measure of effectiveness in achieving cure through surgery is the positive surgical margin (PSM) rate, which is a measure of how often the surgeon leaves some cancer behind. In particular I recommend you look at a surgeon's PSM rate for pathological organ-confined (pT2) disease.

    As shown in the following a spreadsheet, world-class PSM rates for pT2 patients are <2% but many other well-known and highly-experienced surgeons actually have PSM rates several times higher than that:


    So I'd encourage you to ask your urologist for his personal stats. And how you ask the questions is very important so that you can compare apples-to-apples. Specifically you should ask:
    "What is your positive surgical margin rate for pathalogic stage T2 (stage pT2) patients?"
    "What is your positive surgical margin rate for pathalogic stage T3 (stage pT3) patients?"

    If the answers are significantly higher than 2% and 35% respectively (particularly if the PSM rate for stage pT2 is much more than 2%), then you can probably significantly improve your chances by going elsewhere. And many guys travel for this procedure, so don't let that deter you -- you only get one shot at this!

    Have you considered low dose rate Brachytherapy (i.e. seeds)? It is a simple procedure with low side effects and high effectiveness since it allows higher and more uniform dosing throughout the prostate compared to external beam radiation. However a downside, like surgery, is that the effectiveness is more sensitive to the skill of the individual practitioner.

    If you have not done so already I would strongly recommend picking up Dr. Walsh's Guide to Surviving Prostate Cancer which explains many of these concepts and the various treatment options.
    Last edited by njs; 02-14-2015 at 03:22 PM.
    Jan '13: PSA 1.23, small nodule on DRE (1st screening @ age 40)
    Mar '13: Biopsy 2/12 cores positive GS 3+3: rt mid 10% and rt apex 20% w/ PNI+ Stage cT2a
    Apr '13: Biopsy confirmed by Dr. Epstein @ Hopkins
    May '13: eMRI: lesion imaged in rt mid and apex (but not most inferior apex). Did not have typical diffusion-weighted features of high-grade PCa. No evidence of ECE, NVB, SV or LN involvement.
    May '13: Open RRP by Dr. Burnett @ Hopkins. Both nerves spared.
    Final Pathology: GS 3+3, organ confined (tumor extent moderate), SV and 11 nodes all negative (pT2a). Negative margins!
    Post-op PSA: 0.01 @ 6wk, <0.01 @ 21wk, 0.01 @ 17mo, 0.01 @ 30mo
    http://www.cancerforums.net/threads/...t-op-(my-story)

  4. #4
    Moderator Top User HighlanderCFH's Avatar
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    7,206
    Hi hopper,

    Welcome to the forum with thanks to Di for moving you over here.

    Njs gave you a beautiful "clinic" with lots of good information and suggestions. I also agree with him that SBRT is still a relatively new option that hasn't been around long enough to offer longterm results.

    That's just my opinion, though, and it is by no means a professional one.

    With that said, your other options would be external beam radiation, radioactive seeds or surgery.

    You do have the "good" type of Gleason 7 because it is a 3+4 instead of a 4+3. Such a Gleason 7 (which is intermediate risk) often behaves more like the low risk Gleason 6.

    Are you having any urination problems? Probably not if your prostate is only "slightly" enlarged. But I would caution that this could be the onset of BPH (benign enlargement of the prostate). Every case is different, but my situation included a prostate that grew faster than the national debt. The result was lots of slow starts, weak streams, fine sprays, taking 15 minutes, etc.

    So, when my PC was diagnosed, I ended up choosing surgery over radiation even though radiation could have cured me as easily as surgery. But only surgery could eliminate the urination problems. Today, without the prostate squeezing on the urethra, I urinate like a firehose.

    Chances are that your prostate will never get as large as mine was, but only time can tell this.

    If they believe the cancer is still confined to the prostate (your PSA suggests that it IS still only in the prostate), I don't know why they would want to do any HT before surgery or any other treatment. If it is still confined to the prostate, surgery and/or radiation should be enough for a cure.

    But, as I caution, THEY are the doctors, not me. So their words need to be strongly considered.

    In any case, I would think that external beam radiation OR surgery would do the trick. The advantage to surgery is that you can still do salvage radiation if the cancer comes back to the local prostate bed (the reverse is usually not possible) -- and you also have a detailed analysis of EXACTLY what was going on in the prostate after it has been examined in the lab.

    We're glad to have you here, although sorry about your diagnosis. Stay tuned as others will be offering their own thoughts and experiences.

    Good luck with whatever you decide!
    Chuck
    July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA 9/ 2011 = 5.7.
    Local uro DRE revealed significant BPH, no lumps.
    PCa Dx Aug. 2011 age of 61.
    Biopsy DXd adenocarcinoma in 3/20 cores (one 5%, two 20%). T2C.
    Gleason 3+3=6. CT abdomen, bone scan negative.
    DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
    Surgeon was Dr. Matthew Tollefson, who I highly recommend.
    Final pathology shows tumor confined to prostate.
    5 lymph nodes, seminal vesicules, extraprostatic soft tissue all negative.
    1.0 x 0.6 x 0.6 cm mass involving right posterior inferior, right posterior apex & left
    mid posterior prostate. Right posterior apex margin involved by tumor over 0.2 cm length,
    doctor says this is insignificant.
    Prostate 98 grams, tumor 2 grams.
    Catheter out in 7 days. No incontinence, minor dripping for a few weeks.
    Seven annual post-op exams 2012 through 2018: PSA <0.1
    Semi-firm erections without "training wheels," usable erections with 100mg Sildenafil.
    NOTE: ED caused by BPH, not the surgery.

  5. #5
    Hi, and welcome here, you are in the right place to get information. There are several guys here with similar diagnosis as you, me being one of them. When I made my choice I leaned towards radiation but later changed my mind to surgery mainly because you get an answer weather you are cured quicker and because there is the opportunity to get radiation at a later stage.

    But that was my reasoning and there are others who reasoned differently and are happy. In either way (as others already have stated) you should try to find an experienced doctor who you also trust.

    I also think you should remember that with your diagnosis (3+4 confined) you have time to get informed but it does need treatment so when you have decided you probably should not wait. But your doctors can make that judgement better of course.

    Good Luck
    Born in 1962
    PSA 6.5, free PSA 10% Oct 2014
    10 biopsies taken Oct 2014
    6 biopsies G 3+3
    2 biopsies G 3+4
    T1c
    Total of 30 mm cancer of 130 mm biopsy samples
    da Vinci surgery jan 7th 2015, nerves spared on one side and "almost all" on other side
    Catheter out jan 23
    Feb 2nd, one shield/day almost continent
    March 17 2015 PSA<0.1
    Final stage pT2, no external invasion, no vesicles invasion, no lymph node invasion, small positive margin
    August 24 2015 PSA <0.1
    February 18 2016 PSA <0.1
    September 12 2016 PSA <0.05
    April 14 2017 PSE <0.05
    October 2017 PSA 0.05....
    Jan 2018 PSA 0.05
    Aug 2018 PSA <0.05
    Feb 2019 PSA 0.06
    Aug 2019 PSA 0.06

  6. #6
    Senior User
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    Feb 2014
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    177
    As the others have said, make sure you are completely comfortable with any treatment you go with. Did you send your slides for a second opinion? That is never a bad idea to confirm initial findings. the first urologist seemed pretty off thinking it would be nothing and then having 7 cores positive (although that may be common - not sure). Even talking to different doctors specializing in the same procedures can help. You are interviewing them and should want the best. After talking with a few different doctors, my choice was pretty easy because one just seemed to be the perfect mix of confidence, skill and compassion. I never would have found him if I went with the first one I saw. Best of luck.
    BD - 1972
    PSA #1 - 4.1 October 2013
    PSA #2 - 4.6 January 2014
    Biopsy 2/3/14 - 1 out of 12 positive. 60%. 2 PIN and 1 atypical
    DRE - normal
    Gleason - 3+3=6
    Staging - T1c
    RALP - 3/26/14
    Final Pathology - 7 Lymph Nodes - No Tumor
    Gleason 3+4=7
    Perineural Invasion - Present
    Tumor Location - Peripheral zone Volume Estimate - 10%
    High Grade PIN - Multifocal
    Seminal Vesicles - Negative for Tumor
    All Margins Negative for tumor

  7. #7
    Suggestion:
    Google "patient satisfaction" with Cyberknife (SBRT).
    Of the many prostate cancer treatment options available, it is by far the least popular.
    People looking for shortcuts (only 5 visits using massive doses of radiation) frequently endure painful radiation burns.
    LUNG
    Age: 71 -- 12/2013 - Cat Scan sees new irregular 1.8 cm nodule in right middle lobe.
    3/13/14 - PET Cat Scan confirms presence of same nodule -- same size. Nodule lights up indicating likelihood of lung cancer -- Location not conducive to biopsy.
    3/17/14 - Three top doctors say it MUST come out via a wedge re-section. If cancerous, the entire right middle lobe must be surgically removed.
    6/13/14 - Nodule shrank by 1/3. Not cancer. Surgery cancelled. Next scan 9/14. Nodule "resolved" - gone.

    PROSTATE
    Age: 67 -- 2/2010 - PSA: 4.05
    8/2010 - PSA: 4.95
    9/2010 - Biopsy - 2 out of 12 cores positive - Gleason: 3+4=7
    11/8/2010 - DaVinci RALP - small positive margin - was told it was meaningless.
    2/11 - PSA: 0.02; 8/11 - PSA: 0.04; 2/12 - PSA: 0.06; 8/12 - PSA: 0.08; 2/13 - PSA: 0.11; 5/13 - PSA: 0.16 - referred to oncology radiologist.
    9/2013: 40 sessions of IMRT salvage radiation completed.
    1/14, 4/14, 7/14, 10/14, 1/15, 8/15, 3/16, 8/16, 3/17 - All PSA: 0.00

  8. #8
    Hopper,
    I had just about your numbers when I was told the bad news I also was 59 years old. I had IMRT which seems to have worked well. Its going on ten years now. No HT was ever memtioned to me. After reading a number of posts and hearing from guys I often wonder if dollars and cents pops in to our doctors head when they mention HT.. What ever treatment you decide on don't ever look back.

  9. #9
    Regular User
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    Feb 2015
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    13
    Hello and thank you all for the comments. I have read them all several times and they have led me to further reading. (I haven't read this much in a long time) I am still undecided but am leaning towards the surgery because of stop and start urinating and low flow. It is not to serious but is troublesome. My wife will go with what ever I decide but likes the surgery option also. We both also have confident feelings about the urologist. I still have some questions for him though. Questions as mentioned above by njs. I will update this when I know more. Again thank you all for the support.

  10. #10
    Two questions which your Urologist (or someone here) may help answer and may affect your decision:

    1. Does SBRT, seeds, or any other kind of radiation help (or hinder) urinating?
    2. Say you are 100% cured of your PC due to some sort of radiation. How would that affect your options for future urinary treatment (for example, a TURP)?
    BD: 1959 PSA 4.9 11/2012 (no symptoms)
    Biopsy 12/2012 Negative
    PSA 5.9 05/2013 (still no symptoms)
    Biopsy 6/2013 3+4 (thank goodness for PSA tests)
    1 core positive (upper left), 1 suspicious (lower left) out of 12
    DRE: bump right side T1c; PCA-III = 20 (normal)

    Da Vinci 7/18/2013: Invasive carcinoma involves left lobe of prostate only, extends from left apex to posterior mid region of left lobe Gleason 7/10 (4+3); G4 tumor comprises 75% of invasive carcinoma present
    Estimated total volume of carcinoma in entire prostate gland: 10%
    TNM: T2b NX MX (Stage IIA)

    8/13 11/13 2/14 8/14 2/15 8/15 3/16, 8/16, 3/17,9/17,4/18, 9/18 PSA undetectable
    3/19: .1 (damn), 4/19,6/29 retests: .1 (damn)


    My Story:
    T-Minus-36-Hours-until-da-Vinci...
    Catheter is Out!

 

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