Maybe your doctors know something I don't.  I only know what I have
learned by fairly extensive reading, starting with Patrick Walsh's Guide
to Surviving Prostate Cancer.  It is my impression that few urologists
consider salvage surgery after external radiation a good idea.   On the
other hand, it does appear that surgery may not be a good option for you
for initial treatment, and there are some specialists who can do salvage
surgery if necessary, albeit with difficulty.

In any case,  the results from external radiation, as it in practiced
today, seem as good as surgery at least for 10-12 years.  The results
may also be as good for longer periods of time, but the data isn't in
yet because the current methods haven't been in use long enough.
Earlier, radiation therapists couldn't apply enough radiation because of
fears of damaging surrounding tissues,  but modern methods let them
focus the radiation much better, and they use quite high doses safely.

Jim,

I have had 3DCRT (3 dimensional conformal beam
radiation therapy).  IMRT is a little more advanced
form of the same thing.  It is very good at delivering
high intensity radiation to the specific targets while
sparing surrounding tissues as much as possible.
It's done with computer guided equipment that looks
like it's right out of Star Trek.

You may very well experience some side effects.
Inflamed hemorrhoids are a possibility.  Inflammation
of the prostate that makes it difficult to urinate (you
wind up getting up often at night to urinate out a
little bit) is common.  Some radiation burns of the
skin, like sunburn, are common.  Blood in the semen
is common.  Tiredness is common.  I also lost
some pubic hair at the time.  But in my case,
within a few months after the end of radiation
all the symptoms were gone and even
the hair grew back.

A possible longer term side effect is impotence.
In my own case, I didn't do as well after the
treatment as I did before, but Viagra has worked
pretty well for me.  Some guys have no problems
at all, some have more problems than I do.

All in all, IMRT is probably one of the easiest
treatments to handle.  The treatment is totally
painless.  No anaesthesia or other drugs are
required.  There is no incision.  You don't even
have to miss work except for the actual times
of treatment every day.  I would drive to the clinic
in the morning, get my treatment, then go on from
there to work.

One thing you should do is ask your doctor about is
neo-adjuvant (i.e., therapy starting before the main
therapy) hormone therapy.  There is evidence to
indicate that men who have received HT before
and during RT have a statistically better long term
survival than men who have had RT alone.

If you opt for HT, they can give you some pills
immediately, followed by an injection.  Then they
wait, maybe 2 months more or less, then do the
radiation while continuing the HT.  Your treatment
effectively begins when you swallow that first pill.
The HT starves the cancer of testosterone,
apparently kills off some cancer cells, possibly
including some that might have made it outside
the prostate, and shrinks the prostate, making
the radiation target smaller and easier to saturate
with xrays.

HT has it's own side effects - loss of libido and
hot flashes.  But it's bearable and, again in my
case, all the side effects disappeared after the
drugs wore off.

One last thing.  When they put you down on the
IMRT table, freeze.  Don't move a muscle.  You
want them to be able to target the cancer as
precisely as possible.

Best of luck.

   Alan

Hi Jim...A PSA of 28 ng/ml is relatively high.  It may be falsely
elevated by an infection of some sort (has your doc put you on a
course of antibiotics and had the PSA remeasured?).  However, if your
baseline PSA is actually 28, then that may indicate that your PCa is
systemic.  If the disease is systemic, then local therapies such as RT
or surgery will not be curative and only cause you to unnecessarily
experience side effects.  Why does your doc(s) think your PCa is
localized?

Regarding your Gleason score, it is relatively difficult for a
pathologist to grade PCa.  There's not one big solid tumor to examine;
rather PCa is typically a diffuse, multifocal tumor.  It becomes even
more difficult when all you have to examine are small biopsy
fragments.  That's one of the reasons that an expert PCa pathologist
(there are roughly a dozen or so around the US, see
http://www.prostate-help.org/cagleex.htm
for a listing) should examine PCa biopsy slides.  Because many people
don't have their Gleason Score determined by one of these experts,
there is a documented "under-grading" of Gleason scores from PCa
biopsy specimens (to be accurate, I should say that there is both
over- and under-grading, but, on average, there is more
under-grading).  Said differently, the GS from the pathologic specimen
obtained after RP frequently comes in higher than the GS determined
from the biopsy specimen.  This means that sometimes people pick the
wrong treatment method because their tumor GS was under-graded.  It
would probably be worth having your biopsy slides reread by an expert
since so much hinges upon the GS.  Insurance often covers this
re-reading.  BTW, if you are taking any hormonal medications
(Propecia, for example), it is important to let the pathologist know
this as there is some data to suggest that changes in hormonal levels
can affect Gleason grading.

Finally, I'm not sure what you mean when you say your tumor "has
protruded from the edges."  Does this mean that you have extracapsular
extension?  If so, then you would be clinically staged as T3 instead
of T1.  I guess I'm just having some difficulty putting the PSA=28
together with the other clinical stats (T1c, GS=6 and 1 of 12 cores
positive).

If you've already discussed all of this with your doc(s) and have
answers you are comfortable with, then that is all that counts...Best
wishes and good health, Ron

If you mean that the cancer is already outside of the prostate, then, in my
experience and research, an RRP is not indicated.  Radiation is then the
next best option.  I would think brachy and EBRT has proven to be more
successful than IMRT, but I could be way wrong.

You may want to investigate proton treatment...the psa of 28 is a
definite concern but the other stats are in line with the treatment
criteria....call 1-800-PROTONS and request the info pack from Loma
Linda.....Good Luck with whatever your treatment choice will be...

Keith Lundy/So. California
40 Proton Beam Radiation Treatments
Loma Linda  Univ.Med Ctr..3/03-5/03