Hi Jacko.....

I will give you my husband's stats and the treatment he chose as you two
are the same age roughly.....but he had no heart problems and is in
perfect health for 'an old guy'.  (G)

Age:  71, retired
PSA: 11.47 Feb. 03, up from 6.0 six month before
PSA: 10.08 June 03 just prior to radiation (no DRE before would probably
account for the drop......I was astounded actually......thought it would
be higher)
Biopsy:  March 19.....T2b.  80% of samples (I believe) and on left side
only.
Gleason:  4 + 3.

So.......you can see that his was a bit more advanced than yours.  He
considered surgery for about a week then said 'no way'.  We discussed it
with the urologist who recommended either radiation or surgery at his
age.  As he said, why go thru major surgery if radiation has the same
results at 70.

Spoke to oncologist......recommended radiation.....his own father was
currently having it.

Due to SARS, had to wait for bone & cat scan.......both negative.  Btw,
as we are Canadian, we do not pay for these tests or for surgeries,
radiation, hospitals and medications.  Just so you know.

Got really lucky and sent to radiation oncologist who was doing HDR
brachytherapy radiation (high dose rate)......the only hospital in
Canada doing it and apparently it costs $50,000 in the US.  Cost us two
nights at a hotel because of driving distance and two Druxy's bagels for
breakfast in the recovery room.  (G).

Had two HDR procedures in hospital and then 25 EBRT's after that, which
were a breeze.

Speaking as a non-medical person......our urologist said if men over 70
had heart or other problems, surgery was not usually recommended.
Particularly with your moderate stats.  And with your heart procedures,
I would certainly get at least 2 more opinions......certainly with a
heart specialist.

Blunt, yes.  But I am surprised that you were not offered seeding or
radiation.

All the best and do check with other specialists......please!!

Heather (and Ron)

hi jack - since the wife has three angioplasties and if she was given a
situation where the outcome would be basically - the same - without the
risk of surgery, to me it would be a no brainer.  i would not want to
put my wife in a situation that could possibly cause more problems than
want she has.  

that would be the advice i would give here - given the situation you
described.  

i guess - what you have to ask yourself and only would know the answer
because you know your body - is the risk of surgery worth it.

just my .02 cents

~ curtis

knowledge is power - growing old is mandatory - growing wise is optional

Jack,

Did you specifically ask the doctor about the risks of watchful waiting?
These treatments could all harm your quality of life, trying to cure what
(in my non-medical opinion) is not a life-threatening case of PCa.

jimhoney

IMRT is certainly a valid choice for a 72-year-old with your low numbers.
If were were just a little older, you could do nothing at all and still live
out your normal life-span.  However, I would not call IMRT revolutionary.
The only treatment coming close to that description in my humble opinion is
robotic LRP, for which you would be a great candidate I would think.

There are lots of treatments available to a 72-year-old in good physical
shape:  seeds (brachy), protons, cyro (freezing the prostate), RRP, LRP,
EBRT and IMRT (radiation), and now LRP using DaVinci.  None has been toasted
as all that better than the rest, but robotic LRP, until there is a cure,
sure looks to be the least invasive.

I underwent IMRT treatments last winter at age 52.  It is not
revolutionary, but rather an evolutionary improvement over 3D
conforming radiation treatment.  The equipment is able to concentrate
high dosages of radiation to a precise location, avoiding healthy
surrounding tissue.

In my personal, humble, unprofessional, unscientific and completely
biased opinion, there is absolutely no reason for a person your age
with your stats to undergo RP; the medical equivalent of killing a
mouse with an elephant gun.  It makes no sense whatsoever to risk ALL
the complications possible with surgery when less invasive and equally
effective treatments are available.  IMRT has a cure rate equal or
better than RP over 10 years and is incomparably easier for the body
to endure.  You will experience fatigue and some minor urinary and
bowel irritation during treatment, but nothing comparable to the
recovery process experienced after major surgery.  There is scant
chance of incontinence, which may be a real problem for a 72 year old
surgery patient.  Impotence?  If you aren't now, you may not be after
IMRT.  You WILL be after RP.  As a retiree, the 5 days a week 20
minute treatments for 9 weeks will not be such a problem for you to
schedule.

I STRONGLY recommend a second opinion from a radiation oncologist with
IMRT equipment.

--dt

Hi Jack...From the looks of it you've probably caught the cancer early
on.  It has also probably been in your body for 10 or more years
already.  So, if you need to take a few more months to learn about
this disease in order to make the best decision for your treatment,
it's probably the right thing to do.  Take a few deep breaths and
remember that this is disease that many more men die with than die
from.

I noticed your stats included a T1a staging.  That means your PCa was
found during a TURP.  TURPs usually find tumors located in the
transition zone (the prostate can be subdivided into 5 zones or
regions) and transition zone tumors are typically slower growing than
those found during needle biopsy.  So all in all, your stats are about
as good as it gets for PCa.  Again this means you have the time to
educate yourself and make an informed decision.

A key question you need to ask is, "How long do men in your family
typically live; how long do you expect to live?"  If the answer is 20
more years, that will steer you to one set of treatment options.  If
the answer is considerably less, then other options, including
watchful waiting (WW) come into consideration.  Actually WW is a bit
of a misnomer and many men are renaming it "active management" or
soething similar implying that some action is being taken.  Today most
watchful waiters do things like exercise and diet / lifestyle
alteration in order to slow the disease progression down even further.
WW has the advantage of preserving your quality of life, whereas
other treatment options have a variety of morbidities associated with
them (ED, incontinence, radiation burning of neighboring areas,
secondary cancers, etc.).

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/

Since I mentioned WW, here is a website that provides some information
and guidelines on the subject

http://urology.jhu.edu/diseases/prostate/management.html

A few final comments.  PCa is difficult to grade (e.g. Gleason score)
due to its tenuous, multifocal nature (it's typically not just one
solid tumor). Since treatment selection is often dependent upon the
staging (WW might make sense if you're a GS=6, maybe not if you're a
GS=7, and so on for the other modalities as well), it is usually
recommended that you have your slides reread by an "expert."  There
are a dozen or so experts around the US and they are listed at the
"Prostate-Help" website.

Your cardiac and other condition also need to be factored in to your
decision.  Your doctors can best advise here, but it may make the
surgical option less likely.

IMRT has been around for a while, so there are centers of excellence
that pratice this technique well and comparitive statistics on
treatment success.  But to my knowledge there are no radiation
techniques that provide, as you put it, "Precise radiation of cancer
while sparing everything else."  That is the goal and they may come
close to this objective, but all of the morbidities I mentioned above
can occur with any form of radiation therapy, because they can't spare
everything else.  If your rad onc tells you he can hit just the
cancer, find a new rad onc.  Best wishes and good health!..Ron
RRP 02/13/03

I was 67 with a Gleason 7 and otherwise in good health.  My urologist
suggested either surgery or external radiation.   I chose surgery, but
had I been your age at the time, I would have chosen external radiation.

It is my impression from having studied the matter in some detail, that
modern methods of radiation are just as successful as surgery for up to
ten years.  Beyond that, the data isn't in yet.   If the cancer recurs
after ten years, there is a good chance it won't become a real problem
for some years after that and also hormonal therapy is available when it
does.  I figured that would get me far enough---only one of my relatives
made it past 80.   For men over 70, the chances of being permanently
impotent are somewhat lower with radiation than with surgery.

I haven't yet had IMRT, but am planning to get it very soon, together with
one or another form of brachytherapy (implanted radiation).

I was first diagnosed by a urologist/surgeon who thought surgery was
clearly the best option.  Then I saw some radiation oncologists who believed
that radiation was better for me (though my stats are worse than yours in
all departments.)  Five out of six doctors I have spoken to all thought the
long term outcome for radiation alone is the same as for surgery.  Only
the surgeon thought otherwise.

It is my layman's understanding that IMRT is about the least invasive of all
of the therapies except, possibly, hormone treatment with no radiation or
surgery.  If I were you, especially at your age and with so many other
health problems, I would seriously consider it.

Another factor is your confidence in the particular doctor(s) who will
perform
the procedures.  It's a nebulous thing and it's easy to be wrong about, but
sometimes you get a good feeling about one practitioner and a not so good
feeling about another.  It seems to me that's another thing worth
considering.

Hi Jack,

MSK has a tool to evaluate your treatment options in a "scientific
non-emotional manner." You can download the nanogram here:

http://www.mskcc.org/mskcc/shared/forms/nomograms/applications/prostate.zip

I ran the program using your stats: IMRT 81 Gy or 86.4Gy yields 5 year
progression free probability of 91%, IMRT with adjuvant hormones is
93%, RP is 81%. MSK does not recommend Brachytherapy for people who
have had TURP, they only do it for T1c, T2a & T2b.

I would encourage you and others to run this nanogram for themselves.
The program is based on the scientific literature and since MSK does
both RP and RT presumably they don't have a vested interest either
way.

You have great stats and will do well, no matter what.

Good Luck

Regards,

Sam

P.S. If you want a second opinion on your pathology, Jonathan Epstein
of John Hopkins is the foremost authority for cancers of the prostate.
The procedure for getting his opinion can be found at the below link:

http://urology.jhu.edu/faculty/epstein/index.html