Where are you located, Dennishky??

And welcome to the group nobody wants to join!  I hope you will find the
help and support you need by asking your questions here!

MikeH

I don't know where you are located but I had the robotic lapriscopic surgery
on Aug 24th at City of Hope National Medical center.  It is in Duarte CA.  I
was able to leave the hospital the next day.  They have a couple of very
talented surgeons.  My Doc was Mark Kowachi.  He appears to be the big dog
in this area in So Cal.

--
Bob
Age 50
PSA 8 5/04
biopsy 5 of 12 cores positive 6/04
LRRP Aug 04
IMRT 35 treatments 11/04
LRP 8/24/04
IMRT started 10/1/04 completed 11/26

Read 3-4-5 prostate cancer books. They are indispensable in the decision.
Authors such as Strum, Walsh, Lange, Marks, Grimm/Blasko/Sylvester are very
good, and they don't agree on everything. I'd recommend spending an intense
month in research, as you have several options and the decision is
complicated. Every choice (such as surgery or radiation) and subchoice (such
as laparoscopic surgery or seeds) has significant pros and cons, far more
than any of us could type in here. One thing I suspect no one here would
recommend unless you have other medical problems worse than your prostate
cancer is watchful waiting. WW is for people who have reason to believe
they've only got 10 years left; you have 21, by the actuarial tables, and
more if you're healthier than the average 56-year-old bear.

I.P.

Welcome.

Not many men your/our age choose watchful waiting.  What's the normal life
expectancy of men in your family?

jimhoney
standard RRP age 52, cured, no significant aftereffects

In addition to IP's recommendation, I suggest the following two of many
very
informative websites:

Us Too! (a support group): http://ustoo.com
and
Prostate Cancer Research Institute: http://prostate-cancer.org/index.html

Take the time to do the research and have the many additional diagnostic
tests; beginning with a second, expert, opinion on the biopsy results. A
Gleason 6 tumor is mid-range, not terribly aggressive, according to my
information (my first was a 9, second was an 8). Recommend consulting an
oncologist as well as the urologist. Do not be stampeded (as I was) into
a premature decision.

Dennishky"s life has fundamentally changed; he will never be the same as
he was. It has happened that way for all of us.

Regards,

Steve J
__
"Never give in--never, never, never, never, in nothing great or small,
large or petty, never give in except to convictions of honour and good
sense. Never yield to force; never yield to the apparently overwhelming
might of the enemy.''
--Sir Winston L. S. Churchill

  If you get it removed, it's all pretty much the same. With RP, you're on
the table much less time than the other surgeries and you're home in 2 days.
Unless you're willing to travel anywhere, you need to tell us where you
live? You want a surgeon that's done hundreds of them, and is willing to
give you the stats.

Not enough time to give you a full answer, but suffice it to way that
Watchful Waiting in a 56-year-old is analogous to choosing death over life.

Hi Dennishky...Sorry to read that your joining the outfit.  It was
about two years ago that they were running tests on me.  After the
biopsy procedure, my uro told me he was 95% sure I was OK.  When he
called with the results I felt like someone had punched me in the
stomach.  After a few days of "why me", I got on with dealing with the
disease.  Initially I had no idea what the various test results meant
and just figured "I had cancer, the end was in sight."  As I began to
learn about the disease, I realized that my stats meant that my
disease was manageable or treatable and that if you have to have
cancer, there are many that are a lot worse than prostate cancer.

Treatment selection is highly dependent upon your stats, like PSA, GS,
number of biopsy needles with PCa, % of needle with PCa, etc.  So one
thing you can do that will prove helpful is to collect as much of this
information as you can and start a log.  Get copies of all reports,
etc. that your docs receive.

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 an inappropriate (in terms of efficacy that
is) treatment method because their tumor GS was mis-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.

As to treatment selection it depends on how you weight life extension
and quality of life issues.  By the way, when I talk about QOL issues
I include psychological factors (some men just want the cancer "out"
of their body or they want the prostate to be pathologically examined
and therefore favor surgery, others could care less) along with ED,
incontinence and the other associated morbidities.

Focusing first on life extension, a recent paper (International
Journal of Radiation Oncology Biology Physics, Volume 58, Issue 1, 1
January 2004, Pages 25-33) compared the biochemical relapse-free
survival (bRFS) rates after treatment with permanent seed
implantation, external beam radiotherapy (EBRT) at less than 72 Gy,
EBRT at more than 72 Gy, combined seeds and EBRT, or radical
prostatectomy for men with clinical stage T1-T2 localized prostate
cancer.  At 7 years post-treatment, the bRFS rates were 75%, 48%, 81%,
77% and 76% respectively (note different failure cutpoints used for RP
[>0.2 ng/ml] and all others [ASTRO definition]).  Only EBRT at less
than 72 Gy separated itself as inferior to the other treatments; the
other treatments appearing statistically equivalent at 7 years.
However, the fact that different endpoints were used to determine
failure for RP and RT, seriously clouds the analysis.  Studies by
Critz (SI+EBRT) and Walsh (RP) show similar outcomes for "low-risk"
men (T1c, PSA<10, GS<7) 10 years post-treatment.

In the hands of an "artist", success rates are likely to exceed those
presented in the RJOBP article.  To my knowledge, only RRP, EBRT and
SI+EBRT have been practiced long enough in the same manner to allow
publication of statistically projected rates for biochemical freedom
from recurrence of disease at 10 years post-treatment.  Walsh's
biochemical disease-free rates for low-risk cases at 10 years post-op
(M. Han, A. W. Partin, M. Zahurak, S. Piantadosi, J. Epstein and P. C.
Walsh; J. Urol., 169, 517-523, 2003; the paper can be found at
http://www.prostate-help.org/download/jhnomo.pdf) are as follows:

T1c psa=4-10 GS=5: 97%
T1c psa=4-10 GS=6: 95%
T2a psa=4-10 GS=5: 96%
T2a psa=4-10 GS=6: 93%.

Keep in mind that robotic LRP is relatively new, therefore longer term
survival results are not yet available.  The RCOG SI+EBRT study (F.
Critz, W. Williams, A. Levinson, J. Benton, F. Schnell, C.  Holladay,
and P. Shrake; Poster Abstract 692 at the 2003 AUA meeting; NOTE, this
is a poster, NOT a peer-reviewed publication [caveat emptor]) finds
for GS<7, PSA<10, T1c plus T2a men, the biochemical freedom from
recurrence at 10 years equals 94%.  The actuarial 10-year biochemical
failure-free rate for EBRT at 10 years was 49% (even using a more
forgiving [ASTRO] definition of failure, A. Zietman, C. Chung, J.
Coen, and W. Shipley; J. Urol., 171, 210-214, 2004).

Since the "curative" abilities for RP and SI+EBRT appeared comparable
for someone with my stats, I selected surgery for QOL reasons, mainly
the psychological ones, but some morbidity data as well.  Since you
are a relatively young man, understand that there is some concern
about secondary cancer developing in the 10-20 post-RT timeframe.
Studies put this risk at 1 man in 70 at 10 years, 15 or 20 year
results are not yet available.  However, let me also add that, IMO, as
you move above GS6, or if your PSA>10, or you are T2, then radiation
therapies may be more effective since their effect typically extends a
bit beyond the prostate and has the potential to eliminate any PCa
cells that may have escaped the prostate to an immediately adjacent
area.

Another approach is watchful waiting (WW).  Typically, this is a
consideration for men who are 65 or older (or men who, for other
reasons, expect to live 10-15 years or less) with clinically
insignificant cancer (see http://urology.jhu.edu/news/6/8.html and
http://urology.jhu.edu/diseases/prostate/management.html).  As
practiced at Hopkins, 30% of the men in their WW program have been
removed from the group due to adverse findings on follow-up
examinations (this has been interpreted to mean that they were
initially mis-graded rather than that the disease has progressed), and
roughly 90% of these men were still curable.  WW involves changes in
diet and exercise along with frequent monitoring of the disease (PSA
tests, color doppler scan, etc.), you try to stack the odds in your
favor more than russian roulette would.  Some younger men with
insignificant disease are practicing WW as well.  It is generally
agreed that many prostate cancers are indolent and have very long
doubling times.  These would be the cases amenable to WW.  A recent
study by Moul (Journal of Clinical Oncology, Vol 21, No 21 (November
1), 2003: pp 4001-4008; Temporarily Deferred Therapy (watchful
waiting) for Men Younger Than 70 Years and With Low-Risk Localized
Prostate Cancer in the Prostate-Specific Antigen Era) found that
approximately 25% of the men is his study practicing WW had no
progression after 8 years of observation.  If the men in his study
practicing WW were limited to those with low-risk (low-volume) disease
the percentage would be even higher.  The problem today is that there
aren't any foolproof tests to differentiate the indolent disease from
the aggressive disease.  The following quote is attributed to Dr.
Thomas Stamey, a noted prostate cancer researcher, "I believe that
when the final chapter of this disease is written, which is unlikely
to be in my lifetime, never in the history of oncology will so many
men have been so overtreated for one disease.  After all we have a
very small death rate from prostate cancer, which is less than
1%......Clearly we are overdiagnosing this disease."  People who
equate WW, with the disease being actively monitored, to a death
sentence grossly misrepresent today's situation with WW.

So yes, it is all very confusing at first; so many options, so many
recommendations.  That is why it is important for you to learn what
you can about the disease so that you can make an informed decision
about your treatment, a treatment that is right for you.  It has also
been shown by Epstein and others that, for men with stats like yours,
taking a couple of months to learn about the disease and make an
informed decision will generally not affect treatment outcome.  Books
by doctors Walsh ("Dr. Patrick Walsh's Guide to Surviving Prostate
Cancer") and Strum ("A Primer on Prostate Cancer") are good places to
start, be sure to get the most recent editions.  Between these two
books you'll get a balanced perspective on all of the available
treatment modalities.  There are many web sites with loads of useful
information, as well as discussion groups.  Two of my favorites (but
there are many others) are

http://www.prostate-help.org/
http://psa-rising.com/

Best wishes and good health...Ron

You've already gotten this advice from everyone else.  I'll
add my voice to the chorus.

Get treatment!  You've already done watchful waiting.
You watched and waited while your PSA climbed
steadily from 3.5 to 7.8 in 2 years.

When PSA goes above 10, you move from the "low
risk" category to the "intermediate risk", for which the
statistical outcomes are not as good.  You're getting
close to that now.  It's time to act to get rid of the
cancer.  Now!

Your choice of LRP over other treatment modalities
sounds fine to me - if you can find a good specialist
to treat you.  It's one of a number of known, effective
treatments.

Treatment is a pain.  There will be some disruption in
your regular life.  If you are unlucky, you may have
some long term after effects - though you may have
very little of that and your young age will help you to
recover.  But in any case, neither the disruption to your
life nor the after effects of treatment are anything like
as bad as metatstatic cancer.

    Alan

Couldn't agree more with what others have said.  Nix on "watchful
waiting," especially at your age.  But don't be rushed into a quick
decision.  Your numbers do not suggest an aggressive can cancer.  I
had a PSA of 4.6 and Gleason of 3+3 with three cores positive.  I
spent 3 1/2 months researching the options before deciding to go with
seeds.

Good luck in this journey we'd all rather not be making.

Ron Carter

Staying local with Dr.Joseph Wagner at Hartford Hospital in
Connecticut worked well for me. He does Lap RP using the DaVinci
Robotic system.Among the things that impressed me about Dr.Wagner
were:
1.)He has kept a database of survey results about how all his patients
have done. Every visit includes a written survey about relevant
quality of life issues.
2.)At the initial consultation he gives out a list of patients who
said they are willing to talk about their experience. Any patient who
is willing is eligable. He doesn't limit it to guys with good results.
I called about 15 guys. They all liked him, and said they would chose
him again. Now I'm on the list. I'm 9.5 months post op, and very
pleased with my results and with him.
3.) Relatively large series of cases using DaVinci. He was a pioneer
starting this technology at Beth Isreal in NYC.

My PCa stuff is:
age 50 PSA 4.5
Bx showed High Grade PIN
5 monthes later PSA 5.6
repeat Bx 1/12 cores <1mm gleason 3+3=6 stage T1c
RLRP 2-11-04 at age 50
Favorable path, 5 small foci of 3+3, organ contained
Post op PCAs  <0.1

I was able to go home 20 hours later, and back to work day 6.
Good luck.
Steve

I have a little more time, tonight.

I don't think your age is within the group where WW is a reasonable
alternative.  7.8 is already double that which was the standard.  The longer
you wait, the better hold your cancer will get in your body.

You do have everything else open to you, however.  Surgery, radiation, etc.
should all be available to you at your age and biopsy results.

FWIIW:

1)  Get treatment.

2)  Get treatment fast as is reasonably possible.

3)  Get treatment by the most experienced doctor you can find,
regardless of whether he does traditional RRP,  RLP, or Nintendo RP.

Good luck to you.

Thank you.
David S.