I don't agree with that approach if the patient or his partner is
willing and able to do the research necessary to make one's own choice.
My reasons include:
1. Doctors are biased by oath and mindset to maximize life span at any
cost. That's optimal only if the patient's priorities agree.
2. It would be the very exceptional patient and doctor who had the
ability, motivation, and time to educate the doc so thoroughly in the
patient's personal priorities that the doc could make the choice for the
patient. i.e., There are probably more patients who can learn enough
about their treatments options to make a valid choice than there are
docs who can or will learn a patient's life's priorities sufficiently to
make the same choice a savvy patient would have. Why? Because most of us
don't even KNOW our priorities until we face this dilemma, and
communicating them adds a whole 'nuther layer of complexity. I suspect
its easier to learn cancer stats than to learn another's psyche.
3. It has been established in many arenas that people heavily involved
in their own decisions -- from what to have for lunch to whether to have
 major medical procedures -- fare much better than those who delegate
their choices to others. Better outcomes, less second guessing, etc.
It's US, not the doc, who has to live or die and balance our side
effects based on our decision (complicated by luck).
4. Many patients base their choice of physician on personality or karma
rather than true competence, so a doc-based decision process often
starts out flawed. (e.g., my obese in-laws loved their doctor because he
told them it's perfectly alright to live on candy and cake.)

I.P.

[snip]

Heh, I have one.  I would describe it more accurately as the "Marketing
Approach"  :-)

Kegles help.  But you have to do them.  That' my biggest problem.  I don't
remember to do them.

Incontinence is often the Number 1 concern; almost always before sex and
sometimes before life.  But, we who leak find pads are a reasonable
accommodation.

It's all about statistics. Individual answers range from absolutely yes
to absolutely no for just about any question you could ask, including
those. It looks like I'll be in pads or diapers for the rest of my life,
 but at least there IS a rest of my life now, and Mormons CHOOSE to
wear funny underwear. Beats the HELL out of a burning rectum.

I.P.

All I can tell you is why I made the decision to have RRP (radical
prostatectomy). Your priorities and circumstances might be totally
different from mine, so you must make your own mind up.

I was diagnosed T1 and Gleason 3+3=6 at age 47. So my case was a little
less bad than yours. Being 47, I had the ambition to live another 40
years or so. I watched my father die unpleasantly of PCa (prostate
cancer) at age 64, two years after he was diagnosed because of severe
symptoms (he couldn't pee and needed a catheter). Given my age and
family history I was disinclined to choose "watchful waiting".

I was willing to take the (low) risk of urinary incontinence and the
(much higher) risk of impotence associated with surgery. My mother died
of colon cancer in her early forties, so I was concerned about the
(small) additional colon cancer risk from radiation. I was unwilling to
risk faecal incontinence (a slight risk with radiation).

Psychologically, I wanted the cancer out of me and I wanted to know how
much of it there really was (biopsies are a bit of a crap shoot), plus
I wanted to know for certain if lymph nodes, seminal vesicles, etc.
were involved. You only get those certainties with surgery. I had no
great fear of surgery, anaesthetic, pain, etc. and my health and
fitness were good.

I liked the fact that you can always "mop up" with radiation after
surgery, but it is nearly impossible to use surgery as a second
treatment once you have had radiation.

I chose open surgery over the laparoscopic (with or without robot)
version because I am fortunate enough to live 20 minutes away from one
of the world's best specialists in open surgery. Being young, slim(ish)
and fit, I found recovery very easy with no need for painkillers after
the first couple of days.

Coming up to 2 years after surgery I have absolutely no regrets. I know
(from the detailed pathology report on the bits they cut out of me)
that my cancer was contained within my prostate, so I really don't
worry about it ever coming back (of course, there's a chance it had
already spread to some distant spot, but I choose not to believe that).
I was almost perfectly continent from the moment the catheter came out,
and continence continues not to be an issue for me. Impotence is still
a problem, but I can manage satisfactory sex with the aid of a vacuum
pump or even just a "cock ring", so it isn't a big problem. To put that
in perspective, I am on the very lucky end of the scale for
incontinence, but I'd say I was slightly unlucky on the impotence scale
(given my age, health, sexual function prior to surgery, and the fact
that both nerves were easily spared). I'd rather be limp than leaky
anyway.

As I said, it's up to you to judge how relevant any of the above is to
your situation.

I'll respond to both your questions with one post.  You're going to get
a lot of opinions on what constitutes incontinence and the value of
Kegel exercises.  Some doctors claim you are continent if you need only
one pad/day, others say you are incontinent even if you only dribble
occasionally.  Also, what constitutes a pad changes from time to time.
I use Depends Guards for Men and the buggers who make them changed the
absorbing characteristics in January of this year (made them smaller)
and raised the price to boot.  So, where I used to be a one or less
pad/day guy, I'm now over one/day thanks to the manufacturer's need for
an improved bottom line.

Some guys swear by Kegels, others think they're a waste of time.  I
fall into the latter group.  I think they may have some value in stress
incontinence - where you get a dribble with a sneeze or cough.
Sometimes just a yawn will do it or moving your body one way or
another.  There is another incontinence, I'm not sure if it has a name
or not, but it's the one where you leak for no damned reason, even with
a near empty bladder.  It may be caused by a small bladder spasm.
Kegels don't seem to do squat for these.  Don't fret over incontinence.
If you are one of the unlucky five percent or so who end up with some
incontinence (as I am), it's not a big deal.  You put on a pad in the
morning just as you put on your socks.  Nobody knows unless you tell
them.  Crotch-sniffing dogs seem to know though - they head right for
me.  :)  No matter, don't worry about incontinence.  You'll most likely
have some right after treatment but almost all guys are dry in six
months or so.

As for the Gleason score, (3+4) is a whole lot better than (4+3).  The
first one behaves statistically very much like a Gleason 6, the latter
behaves statistically more like a Gleason 8.  The problem is, you'll
never know exactly what you have unless you get the prostate yanked and
the pathologist looks at the whole gland.  I forget the stats right now
but I think somewhere around 30% of all Gleasons go up after the doc
gets a look at the whole prostate.  Very few go down.  Remember, the
biopsy is only a sampling - kind of like looking for raisins in raisin
bread by poking with a straw.

Anyway, your Gleason, your PSA, your age, your overall health all give
you an excellent chance of beating this thing.  Good to see you're
already asking questions and getting educated.  Keep up the good work.

Dave Perry

The Gleason grading system is well-explained on the website of the
Prostate Cancer Research Institute that I recommended earlier today.
Again, the website is:
http://prostate-cancer.org/index.html

The difference between a 3+4 and a 4+3 is this: the proportion of Grade
3 PCa cells as compared to Grade 4 cells. BUT it should be understood
that, in the case of a 3+4 for example, the amount of Gleason 4 cells
could be anywhere from 5% to 49% of the specimen. All it tells us, then,
is that the pathologist saw more of one grade than the other; it does
NOT quantify the difference.

The grading depends utterly upon the skill of the pathologist who is
examining the slides. This is the reason that it is strongly recommended
that the biopsy specimens be sent to a specialist for a second opinion
(which is probably covered by insurance, if that's an issue. Anyhow, it
only costs about $350). Dr. Stephen B. Strum, famous PCa author,
recommends Bostwick Laboratories:

David Bostwick, MD
Bostwick Laboratories
4355 Innslake Drive
Glen Allen, VA 23060
T: 1-866-816-4793 (Jennifer)
F: 804-545-9725
www.bostwicklaboratories.com
Gleason 2nd opinion $400; ploidy $360
Need patient demographics, insurance info, call to site that has
slides/blocks
Corrine @ ext 1103 re: second opinion

Medics know about Bostwick and other such specialist labs, but usually will not volunteer the information.

Scoring is based upon the pathologist's opinion of how
well-differentiated the PCa cells are. The less differentiated, the
higher the score and the higher the risk level.

I'm not sure what is being requested, here. The Gleason score requires
no translating; it is what it is. The higher the score, the higher the
risk. Please see the PCRI site.

As for a "grading" of 2a, that is not related to the Gleason score.
Possibly it is related to the clinical stage, which is expressed as, for
example, T2a, which means palpable lump (by DRE) on one side of the gland.

The patient (what is his name?) must do his homework, as there is so
much to this subject that no one could cover it adequately without
writing a book such as Strum & Pogliano's _A Primer on Prostate Cancer_
or a huge website such as the Prostate Cancer Research Institute's
(PCRI) site, previously recommended.

This information is available; it is up to the patient to reach out for
it. We on this newsgroup try to be helpful, but at our best we can give
only anecdotal information. And references to authoritative sources.

(snip)

I am active with UsToo! and find it to be of great help. Especially when
discussing the merits of various medics.

Regards,

Steve J

"The thing is to expect nothing in particular, but (to) be aware of the lack
of enforceable guarantees or enforceable contracts with
nature/god/entropy as to the condition or durability of our bodies."
-- Brian Brunner, PCa survivor, December 12, 2005 on The Prostate
Problems Mailing List
Thank you, Brian.

4+3 is slightly worse that 3+4.  The score comes from determining the grade
of the most prevalent mass and adding it to the 2nd most prevalent mass.
So, if 3 is the most prevalent, then you're better off than 4 being the most
prevalent.  Either is still within surgery specs.

An addendum regarding incontinence since I don't think I answered your
question.  The word is used to describe any amount of uncontrolled
leaking.  Many guys are totally incontinent right after surgery with no
control at all, using six or more pads/day, others are dry from day one
(the day the catheter comes out).  Even the worst leakers gradually
gain control over the next few weeks and months until almost all are
dry at six months.  The few remaining leakers need less than a pad/day,
even a wad of toilet paper is often sufficient for some and others use
nothing at all if it's only a few drops a few times a day.  A very few
need two or three pads per day and of course there are surgical
interventions that can often improve things.  No matter, you are way
too early in the game to worry about pads and besides, if you do end up
with urinary incontinence, I think it is probably the best side effect
to have if you have to have one although others may (and probably will)
disagree.
Dave Perry

Welcome to our elite and wise inner-sanctum!

You're hearing a lot here, and a lot of "bias". I have mine! I know of
only one way to be sure about the extent of your cancer with today's
technology - that's surgery.

Toward a cure, there are several treatment alternatives and when you
get "down-and-dirty" the statistics  just don't converge. Not enough
data, not enough time, and big data organizational issues as much of
the stats involved cover a period of time when the technologies
involved and the detection protcols have changed radically. So no one
treatment can be proven to be better than the other. Major side effects
for all treatment protocols are about the same; incontinence and sexual
performance. Getting "down-and-dirty" again, incontinence happens, but
it is not that common. Permanent sexual disfunction is quite common.
There are options to minimize the impacts of both side effects.

IMHO watchful waiting is not an option you want to consider unless
you're over 70, particularly once the biopsy comes back above stage 1.

So do your homework, identify and apply your issues and priorities,
make a decision and stand by it. There is no "Right" answer, and
attitude is everything.

By the way, feel free to listen to us zealots, but take everything we
say with your own personal grain of salt. We are not you!

Good Luck and God Speed toward your cure!!

Our Gleason at the original lab was 4+3, at the second (specialist)
lab, 3+4.  At surgery, it was a 9.  So I don't hold too much stock with
Gleasons.  However, your PSA is not bad, and that is good.  Have you
seen the Sloan Kettering nomograms?  I'll enclose a quote and link.

Also, whoever is sending you to the PCRI.org (prostate cancer research
institute), I heartily second.  They have good nomograms also.  (And
much, much more information)

http://www.mskcc.org/mskcc/html/10088.cfm

Prostate Nomogram
Calculate Treatment Options for Prostate Cancer

Our Prostate Nomogram is designed to help physicians and patients
decide which treatment approaches will result in the greatest benefit.

Pioneering Calculator
Researchers at Memorial Sloan-Kettering have pioneered the use of
computerized tools called nomograms to help patients and their
physicians decide among the major treatment choices for prostate
cancer. A combination of disease factors including stage of the cancer,
prostate specific antigen (PSA) level, biopsy pathology, use of hormone
therapy, and radiation dosage have been incorporated into the nomograms.