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Medical Forum / Diseases and Disorders / Prostate Cancer / November 2004Time for the Big Decision
I was diagnosed with PCa, by biopsy, about a month ago (65 years old, PSA 4.1 ((after 3.1)), T1c, Gleason 3+4=7, 4 of 14 samples positive, prostate size 85 ml, apparent location of the cancer well within the prostate). Since then I've "lurked" in this newsgroup and I am very grateful for all of the information and motivation I've found here. Now, having talked with my urologist and a radiation oncologist, and researching the living hell out of the internet, I (and my wife) have to make the big decision as to the choice of therapy. Both doctors, and everything I've found during my research, indicate that my survival and cure probabilities are very good, and equal, for both RPP and IMRT (which is the radiation available in my area). I understand the side effects of both procedures. Brachytherapy is not a choice due to the size of my prostate. My urologist has said that the size and location of my prostate makes it more likely that incontinence after RPP might be a larger-than-normal problem. I understand that IMRT has a short history (less than 8 years), and that there may be as yet unknown long-term side affects. I also understand the time requirements for radiation surgery; but I'm retired, and live five minutes from the IMRT facility. I could probably get laparoscopic surgery, but I'm not convinced that the benefits (easier recovery, etc) are worth it. I am not afraid of surgical procedures (I've had a couple of big ones). I'm in pretty good physical condition. I'm a Christian, and I pray for (and expect) healing and guidance from God. Given all of that, I am leaning toward IMRT, because of the equal likelihood of cure and the relative side effects. Somewhere in my research I came upon a site that said that, other things being equal, one should choose the doctor and procedure he feels most comfortable with. That criteria would lead me to IMRT. And so, the reason for my finally posting to this newsgroup: do any of you know of anything that might lead me to believe that IMRT is the wrong choice for me? Am I missing something? Thanks in advance for your advice, and my prayers are with all of you who are or have been going through the PCa struggle. Jim Thomas Jim, IMRT would not be my choice given my current knowledge and your age and numbers. However, that does not presume my knowledge is greater or that IMRT is not YOUR best choice. You have researched and gotten opinions from professionals. There is no refereed data indicating there is any statistical advantage ot RRP or LRP. If IMRT is what you are most comfortable with, go with it and never question your decision.  SignatureProstate Cancer Survivor (so far), not a doctor PSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Erection 05/12/2003 @ 48 HTbegins 07/21/2003 @ 48 PSA .07 .05 Lupron 7/03, 8/03, 12/03, 4/04 non illegitimi carborundum > I was diagnosed with PCa, by biopsy, about a month ago (65 years old, > PSA 4.1 ((after 3.1)), T1c, Gleason 3+4=7, 4 of 14 samples positive, [quoted text clipped - 38 lines] > > Jim Thomas Jim I had the same choices as do you except, I also was given the choice of seed implant if we could shrink my 90+ gram prostate with hormones. I choise RRP so that at a latter date, if the Ca re-occured, I could still have radiation as a "salavage" method. My research seems to indicate that "salavage surgery" after radiation is very difficult to do and has been likened to removing a tennnis ball from concrete. I am not a doctor, the above info is anecdotal and your milage may vary. It is ultimately your choice to live with and your reasoning and homework seem very sound to me. We in this NG will support and confort and try to suppy you with the knowledge we have all gained from our journeys. Your will be in our thoughts and prayers, Please keep in touch Mike Spivack To all who answered my original post, and any other interested parties: Thanks for your information and encouragement. You provided me with additional questions for my urologist and radiation oncologist, which they answered. Considering everything, I finally came to the conclusion that, as I suspected, there is, for my particular case, no black-and-white answer. It really is a crap-shoot, and I have to drop back on my faith that God, having provided no obvious revelations or spiritual traffic lights, will be with me whichever I choose. So we (my wife and I) have chosen radiation therapy (IMRT) for these reasons: Statistically, the 5-year and extrapolated 10-year cure rates are about the same for RPP and IMRT. The IMRT technology is mature, and is designed to both focus larger doses of radiation to the prostate (higher success rate) and minimize the possible damage to surrounding tissue. And my radiation oncologist appears to be very good and vary smart about all of this magic. IMRT is designed to zap the margins, as well as the prostate itself. Although the biopsy results show the the cancer is probably confined to the gland, my Gleason score (7) and PSA (4.1) indicate that statistically (Partin tables) there is a 20-30% chance of capsule penetration. As one of you correctly observed, positive margins found after RPP would require radiation anyway. IMRT should fry the little buggers the first time, if the margins are positive. The size of my prostate makes long-term incontinence more of a possibility with RPP, because of the difficulty of cutting the urethra in just the right place. This is not a consideration for IMRT. Short term IMRT side effects are bothersome but treatable, and should disappear when the treatment is over. There is a fair chance that I will lose some or all erectile function with IMRT. The same is true for RPP. IMRT will allow me to retain what I have for some time, and tomorrow? Who knows. I'm 65. My body doesn't recover from things (surgery) as fast as it did 10 years ago. And it makes me not worry so much about survival for 20 or 25 years. Those are the main things. Here's an observation: all of the men I know who have prostate cancer, and most of those of you on this newsgroup, have had RPP, and mostly successful. I just haven't seen many first-hand experiences with EBRT, particularly IMRT. I don't know why this is: maybe most of them are dead, or so cured that they don't need the newsgroup. But I suppose it's mainly because RPP has been the therapy of choice, for all the reasons you all have mentioned. And we all tend to follow the tried-and- true. My next step is to have something called a "visicoil" implanted in my prostate, and have a CT scan done. This provides the current location of the gland and a point of reference that the IMRT equipment can pick up to adjust for any movement of the prostate from treatment to treatment. And so, thanks again. I will promise to keep the group informed of my progress. At least, I can be an IMRT data point of one, and help someone out there to make this very difficult decision. Jim Thomas >There is a fair chance that I will lose some or all erectile function >with IMRT. The same is true for RPP. IMRT will allow me to retain what >I have for some time, and tomorrow? Who knows. In my case, erectile function slowly dropped to about 90% of pre-radiation performance after about a year. Ejaculate slowly diminished from "normal" to a small amount of clear to milky fluid. The orgasm experience is markedly less intense than before; libido has decreased accordingly. It's a gradual process, and like everything else in life, you adjust to it and move on. > I was diagnosed with PCa, by biopsy, about a month ago (65 years old, > PSA 4.1 ((after 3.1)), T1c, Gleason 3+4=7, 4 of 14 samples positive, [quoted text clipped - 38 lines] > > Jim Thomas I was in a similar situation about four years ago, as was a friend who lives in California. We were both Gleason 7=3+4, but he had a higher PSA than either of us. I chose surgery because I felt my urologist was pretty experienced and would do a good job. I also wanted "to get the thing out". My friend didn't have access to as good a surgeon but did have access to world class radiation therapy. He opted for radiation. Four years later we both seem to be doing well. I don't think you are missing anything. There are lots of studies and statistics about recurrence rates, but there is enough uncertainty that it is pretty much of a flip of a coin between the two approaches. The biggest single factor leading to recurrence is that some cancer cells which can survive outside the prostate have already taken up residence outside your prostate. If so, neither treatment will be effective. But there is a good chance that hasn't happened yet, and so there are about equal chances either will work. Sometimes people will argue that surgery is a better choice because you always have the option of radiation afterwards. It is certainly true that followup radiation can often resolve the situation if PSA starts rising after surgery, but in a sense that radiation has already been applied if radiation is the primary method of treatment. So the argument is more psychological than medical. Surgery is often recommended for younger men because the long term data for current methods of radiation are not in yet. But I think you are probably old enough that this argument doesn't apply as much. The 8 year period for IMRT is not the only relevant issue. It appears that the major factor in radiation is the dose. Earlier, not enough radiation was delivered to be effective, but with current methods of focusing, they do deliver effective doses. IMRT is just one way of doing that. Overall, higher dose radiation has been in use for closer to 10-12 years. > I was diagnosed with PCa, by biopsy, about a month ago (65 years old, > PSA 4.1 ((after 3.1)), T1c, Gleason 3+4=7, 4 of 14 samples positive, [quoted text clipped - 38 lines] > > Jim Thomas Having read what the others have to say, let me suggest you ask your doctors about the points we have raised. After all, they know a lot more about the matter than any of us here do. I made my treatment selection two years ago.....have yet to look back on my decision....current psa is 1.,next result will be in november (age 59).....Loma Linda has published the results of its 10 year study on proton treatment for pca....do your own investigation and call 1-800-POTONS....Good Luck with your treatment choice. Keith Lundy/So. California 40 Proton Beam Radiation Treatments Loma Linda Univ.Med Ctr..3/03-5/03 >Given all of that, I am leaning toward IMRT, because of the equal >likelihood of cure and the relative side effects. Somewhere in my [quoted text clipped - 5 lines] >of you know of anything that might lead me to believe that IMRT is the >wrong choice for me? Am I missing something? I chose IMRT at the youthful age of 52 for exactly the reason above: it was my gut choice after getting opinions on treatment from more than one physician. If your radiation oncologist advises that you are a good candidate for the procedure, and that is what your heart tells you, then I say go for it. I would venture to say that IMRT and other radiation treatments tend to be the choice of patients who are concerned more about qualify of life post treatment (less chance of incontinence and impotence) than longevity (less evidence of long term cure rates than RP). At least that was the case for me, but I am liberal kind of guy and enjoy my earthly life in the here and now. Questions of eternity I find less compelling. Quoting Shakespeare (Julius Caesar, Act 2 Scene 2): "Of all the wonders that I yet have heard. It seems to me most strange that men should fear; Seeing that death, a necessary end, Will come when it will come." --dt Belatedly (I was busy with research, testing, and surgery), here are my rationale for choosing RRP over radiation: Gleason 8 w/full lobe involvement reduces odds radiation will match surgery's prognosis. Post-op pathologic staging improves assessment of choices, prognosis and planning, all very important to us. Hands-on procedure helps surgeon to "follow a trail" until healthy cells are reached. Radiation can easily follow surgery if necessary, but not vice versa. 90% reduction in rectal risks; I sure as hell don't want long-term bowel incontinence. Slight potence advantage of radiation is not an overriding factor, especially if nerves already involved. My impression that surgery is more discrete than radiation, thus more controlled. My Grade 8 discourages brachytherapy. I had to cut anyway for an unrelated carcinoid colon tumor. Prostatectomy's extra five years' track record is important (unless my 2.3 PSAV renders that moot). The sural nerve graft option, if appropriate in my case. QOL more important than eking out a couple of extra years of hell on earth. Radiation's greater risks of exacerbating my existing overactive bladder, bowel urgency, and modest urine flow are biggies Beats hormone or chemo therapy. I'm cranky enough as it is, and I USE my muscles. Neither protocol scares us, I tolerate surgery and recovery well, and I have time for surgery. What the hell . . . windsurfing season is ending anyway, which minimizes the immediate impact of surgery on my QOL. A radiation oncologist agreed with several surgeons that surgery was my top option. If the carcinoid bowel tumor cuts my expectancy to <10 years, why not treat the PC aggressively anyway if it adds several years of high QOL? I had the U of WA's first dual RRP/bowel resection surgery on Thur Oct 28, with no second thoughts yet. If I were a working stiff with an office job, I'd return to work this Monday, 10 days later, with confidence in anything short of heavy thinking through these narcotics. I.P. >I was diagnosed with PCa, by biopsy, about a month ago (65 years old, > PSA 4.1 ((after 3.1)), T1c, Gleason 3+4=7, 4 of 14 samples positive, [quoted text clipped - 4 lines] > researching the living hell out of the internet, I (and my wife) have > to make the big decision as to the choice of therapy. IP: Thanks for your input. I pray that your choice will be successful, as I pray that mine might be, as well., Jim > Belatedly (I was busy with research, testing, and surgery), here are my > rationale for choosing RRP over radiation: [quoted text clipped - 54 lines] > > I.P. |
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