And another might have recommended surgery, or a different radiation
protocol. The REAL question is what your OWN weeks of intensive research in
PC books and REPUTABLE PC websites and your consultations with both surgical
and radiation oncologists has led you to. Unless your urologist is
significantly better than average, knows you intimately, and HAPPENS to be
biased towards whatever treatment is REALLY your best solution, s/he is not
the person best qualified to decide your treatment. That person would be
YOU, with your wife's help.

Every PC treatment -- there are up to half a dozen different ones -- has its
own suite of immediate and/or long term benefits and side effects, every PC
case has its own set of parameters, every patient has his own set of
priorities, and every physician has her own treatment biases and
presumptions about their patients. There are two primary ways to resolve the
scores of dilemmas this complexity presents: put your life (both its span
and its quality) in the hands of a stranger by taking her word for
everything, or do a TON of research and manage your future -- which starts
tomorrow -- yourself with reality checks from your medical staff.

You MUST at the very least study one or two of the PC books we talk about
all the time [e.g., Walsh, Lange (Dummies), Scardino, Strum]. You must also
study a couple of the top websites, such as those of the ACS, NIH, and
especially the PCRI (Google will take you right to them). After you've done
a few hundred hours of research, you'll be ready to start asking your
urologists the right questions and telling them the right things about you
and your priorities so all of you can start thinking about the right
treatment for you and your cancer.

Start reading. Keep asking us questions. Start asking your doctors (at the
very least surgical and radiological oncologists), your SELF, and your wife
questions. You shouldn't even consider favoring one treatment over another
until you've read a couple of PC books; I'd suggest maybe Walsh and Lange as
your first choices, with Strum (from the PCRI) as a more technical
mind-blower for those who crave details, but there are 8-10 very good ones.
Many of us read 'em all.

I suspect that the only way to avoid years of second guessing is to keep
doing research until you KNOW in your heart that you've made THE right
highly informed decision FOR YOU. Then you can then act and get on with the
rest of your life secure in the knowledge that you've taken charge and done
your best. That will be extremely comforting if and when your cancer returns
some year way down the road, but maybe even more important it will comfort
you as you deal with side effects you WILL face -- some immediately, some
later.

I..P. Freely

First of all, Allan, welcome to the club for which no one ever applies.  You
are correct in your assessment that there are some pretty great guys here,
not to mention a couple of guys' gals, who provide a tremendously wide array
of anecdotal and sometimes nearly professional opinions and data.  We have
no doctors here, at least none dedicated to the group, per se; just a couple
who are also afflicted.  Now as to your post....

One of the more important data elements in making a treatment decision.  At
46, assuming there was no spread outside the prostate, my choices were
limited to surgery.  At 75, surgery is usually out of the question.  At 53,
generally, people lean towards surgery, but there are some who opt for
radiation and are very happy they did.

Two more relevant criteria in making a decision.  At 28 (that's pretty high,
but not devastating), your PSA might (and I say "might") cause one to lean
away from surgery only because it, combined with a high Gleason, might
indicate a progressive and/or advanced cancer and surgery might (that word
again) not get it all.  But, to be honest, you need to consider the Gleason
and Stage scores and you have not listed them here.  If your Gleason total
is a 6, you might make a different decision than if it is a 7.  Please let
us know.

I appreciate your doctor's recommendation.  But, there is no substitute for
personal knowledge and active participation in this battle.  Patients come
and go for doctors, especially cancer patients that are often passed onto
radiologists, oncologists, etc.  But, there is only one of you and there are
a few option with several suboptions for your to consider.  It is difficult
for any urologist to keep up with it and impossible for them to recommend a
perfect fit for you.  So, take the time necessary to research the options.
Read books by Patrick Walsh and Steven Strumm.  Ask questions here.  Search
the archives on the word "fired" and read how some people in this NG met
with less than satisfactory results when their doctors missed something or
recommended the right treatment for the doctor, but the wrong treatment for
the man, or his value system.  MAKE IT YOUR DECISION and then don't look
back with remorse that you didn't pick another.

Quality of life is tops on almost every man's list.  Personally, having
watched my father die from this bastard, I decided long ago I would never go
through what he did just to live.  I am pleasantly surprised, however, at
the advances that have been made in treatment, both curative and pallative,
since my father died.  So, I will probably fight it through to the end, but
only if I have some 'life' left.

Congratulations!  I can remember as a kid when 25 years was a minor
milestone, but even with people living decades longer, it seems now to be a
daunting challenge.  There is no substitute for a supportive wife.  Helping
to figure our treatment options is her first charge.  Taking care of you
when you get home is her next and making sure you don't get fat and lazy
closely follows.  There will be some sexual interruption, but a loving wife
can find ways to make you happy; and visa versa.

Casodex will not hurt, regardless of which treatment you choose.  But, I
caution again, do some research before exposing yourself to radiation.  I
had surgery, then radiation, and now hormone treatment.  They are all easy
to get through, but they all have serious side effects and some that last
the rest of your life.  Please don't choose one or another based on a
doctor's paradigm.  Even if you select radiation later, you'll be happy you
made the decision.

Our favorite role.......

Incontinence is immediate with surgery and almost always disappears or slows
to a trickle within a year.  While recuperating at home, you'll wear a
diaper.  Soon it will be a J-pad.  You can go to work with a J-pad and no
one will ever notice.  But, remember, that is surgery.  As I understand it,
radiation causes incontinence down the line, not always immediately.  So,
hold on for a radiation patient to tell you about that.

I had surgery and was off the job for six weeks.  I had to tell them.  Now,
people in my business (there are almost 1500 in my business) that get
prostate cancer come to me for advice.  There is no down side.  No one
treats me special, but I help people; at least one annually, I guess.  So,
it's up to you.

Surgery will immediately eliminate all the fluids that come with
ejaculation.  Radiation almost always causes the same effect.  But, there is
nothing wrong with a dry orgasm.  Your wife might like it.  At first,
however, there is some urine instead of semen, but it is clean and many
women don't mind (refer to "Loving Wife" paragraph).

Good luck.  We're all counting on you.

Allan,
I'm sorry for your trouble. I was 50 when I got the bad news. I picked
surgery as best for me, so my experience is not with radiation, but
there is overlap.
Be sure to check out all your options. There is no rush.

I went back to work day 6 with a leg bag. After the catheter was
removed at day 7, I was totally incontinent. It is more manageable than
you might think. There are diapers and pads that do collect ALL the
urine, and they don't smell if you change them often enough. They fit
under clothes very well, and I'm fairly thin. I was dry by 3 months.

I told people at work. They could all tell I was preoccupied anyway,
and once they knew the reason, things were more "normal". They were
very understanding, and all wanted to help me out. Let people help you!

My already wonderful 27 year relationship with my wife got even better.
Nobody wants adversity, but facing it together pulls people together in
ways that the good times can't. The erection drugs are wonderful. Don't
be afraid to try the shots. I've had a huge amount of fun with them.

I don't miss ejaculation at all. Pre-op, I was most worried about the
impotence side effects of surgery. My sex life after surgery has been
excellent. People on hormones can tell you better about the libido
effects.

The emotional suffering was 99% of the challenge for me, not the
physical stuff. I found that seeing a psychiatrist
Good luck.
Steve U

Last line was supposed to say "seeing a psychiatrist was very helpful".
Steve U

Allan wrote...snip...

Hi Allan...As Steve K. has already noted, a PSA of 28 is rather high.
While it may be caused by an infection, it may also be a signal of
systemic disease.  The scans that your doctor ran only detect systemic
PCa when it is quite advanced.  My point is that you might want to take
further steps to try and determine whether or not your disease is
systemic, before you try invasive therapies that can only cure local
disease.  Other staging information such as DRE results, pattern of PSA
progression, Gleason score, number of needles positive for PCa and
maximum percentage of PCa in any needle in conjunction with the Partin
Table (and other nomographs) might help shed light on this question.
Measuring your PAP (prostatic acid phosphatase) can also provide
information about the likelihood of systemic disease.

Radiation therapy or surgery can be a curative treatment for local
disease.  They can also help slow the growth of systemic disease (tumor
debulking).  For a man as young as you RT is practiced somewhat less
frequently than surgery for the following reasons:
1) If there is any indication of lower urinary tract issues (urination
problems), RT will exacerbate them.
2) Secondary cancers typically occur in the 10-20 year timeframe
post-RT.  These cancers have been found to occur at the 3-5% level at
10 years post-RT, with the number expected to increase further with
time.  For young men this is an issue that needs to be considered.

Under the old rubric of "two heads are better than one", it may well be
to your advantage to get additional opinions from qualified medical
personnel on your situation.  In particular discussing this question of
local vs. systemic disease, and then treatment options, with an
oncologist who specializes in PCa may prove helpful...Best wishes and
good health, Ron

You've already gotten a lot of good advice.  I'll weigh in
with a few more comments.

On the issue of radiation vs. surgery, there is good evidence
that both approaches are effective.  Each has its advocates and
its particular set of advantages and disadvantages.  Radiation
generally treats a larger area than surgery, and your doctors
may have recommended it on the theory that, with a PSA of
28, it is very likely that you have cancer at, and possibly beyond,
the margins of the prostate.  Surgically removing the prostate
might be less likely to treat all of the cancer than radiation.

However, as others said, it is a good idea to read as much as
you can and, possibly, get a second opinion from a surgeon,
if you haven't already seen one.

On the question of metastasis, as others have said, the bone
and cat scans don't prove there is no metastasis, only that there
is no _detectable_ metastasis.  There might be colonies of
prostate tumor cells that are too small to show up on the scans
established elsewhere in the body.  However, it seems to me
that, with no evidence of metastasis, and especially at your
relatively young age, it is worth taking the chance and trying
curative treatment, i.e., radiation or surgery.  If the treatment
fails and your PSA continues to rise after treatment, it might
still have given you some benefit in reducing the total amount
of tumor in the body.

Now as to specific questions you raised:

1. Incontinence.

This is rare with radiation. Although I don't remember where I
read it, the numbers I recall are 1-3% of radiation patients
experience incontinence.  The opposite problem, inability
to urinate, is much more common.  Usually it is treatable with
drugs and, usually, it clears up by itself a few months after
radiation ends.

2. Impotence.

The numbers I've seen on this are 30-50% of radiation patients
experience this.  As with surgery, older patients are more likely
to have the problem than younger ones.  Potency may decline
during a period of one to two years after radiation rather than
falling all at once.

Impotence is a relative problem.  Some men are completely
impotent.  Some are partially impotent - perhaps able to achieve
erections but not as hard, and not sustained as long, as before
treatment.  Men in the latter group can often benefit from Viagra
or similar drugs.

Even complete impotence doesn't have to end one's sex life.
Oral sex, manual sex, or any other form of sex not requiring
actual penetration, is still possible.  Orgasms are still possible
even with a limp penis.  Sex need not be any less satisfying
for either partner.  And for those who must have erections,
injectable drugs typically work for everyone - even those who
don't respond to any other physical or chemical stimulation.

3. Other issues.

Your doctors have acted very, very promptly.  It's very possible
that they are saving your life.  I particularly like the fact that they
got you scans and a biopsy in such short order (most of us had
to wait much longer), and immediately started you on hormone
therapy.  The HT should halt the progression of your disease,
and will reduce the size of the prostate, making it a better target
for radiation.

You can expect that your sex drive will disappear sometime
around 6-8 weeks after the HT injection.  That's unfortunate,
but if you try to engage in sex anyway, you may surprise yourself
by finding that the old feelings come back once you get into
it.

HT and radiation will both drain you of energy.  To compensate
I suggest getting plenty of rest, and plenty of exercise.  Start
now to build up your strength and keep it up.

Best of luck.

   Alan

  I don't have time to read all the responses you already have, so here's
my answers. Go and get another opinion for treatment ASAP.  Preferably with
a really great surgeon. Radiation is OK but you need to examine all your
options before you get "fried".   If radiation doesn't fix you, than there's
a pretty good chance you can never have the surgery afterwards. If you have
the surgery, than you can add radiation if need be later for a cleanup.
  You're the same age as I was when I got the news, and I am now 3 years
post surgery, and am doing pefectly fine in all departments.  I have
erections and sex, and now pee like a barnyard animal. Your wife is a good
egg, and by all means use her strength as much as you can.
  As for your office workers and being covert. Listen up man........ YOU
HAVE CANCER.  Most of us aren't ashamed or embarrassed in the least about
it. In fact we feel that's it's important to tell everyone we know, so they
can get it diagnosed early, as you and I have, and get it beat. Good luck,
I'm sure you'll be fine.