Dear Norman

I have much empathy for your situation.  The prospects of total or some
degree of  impotence and incontinence resulting from treatment of
prostate cancer are certainly an assult on one's manhood.   I know
this is late in the game because you have scheduled surgery for
December 7th.  I sense in your e-mail that you are still on the fence
and have a feeling of despair with respect to electing radical prostate
surgery. The majority of men with prostate cancer are led to believe
that surgery is the best chance of achieving a cure, depending on the
stage of your cancer.  Perhaps that is true in you case--I am not a
doctor.

I have been faced with a similar treatment decision after i was
diagnosed with prostate cancer in recently.  I am in my late 60's,
still healthy and somewhat youthful!  Diagnosis: PSA 7.1; Gleason 6
(3+3) less than 5% in one of three cores and Gleason 7  3+4 about 10%
in three of five cores;  29 core samples taken; negative bone and MRI
scans; stage T1c.

I am considering robotic surgery as well as proton (radiation) therapy.
I have basically ruled out any other form of treatment. Based on
extensive research and discussion with others, I believe the proton
therapy is an alternative consideration for treatment, which is much
safer, with fewer potential side effects, than IMRT photon (x-ray)
therapy.  If IMRT x-ray was the only available type of radiation
therapy available,  then I would opt only for surgery.

Inasmuch as there is no guarantee of a cure with any prostate cancer
treatment, one has to weigh (1) the potential side effects of each
treatment with the related quality of life that you can expect after
that treatment and (2) your assessment of whether the potential
treatment you select will hopefully give the same chance of  a cure or
extend your life for long period of time. If you have not gotten a 2nd
opinion on your prostate cancer situation, especially because of the
your high PSA, which seems to be a mystery in comparison to your biopsy
and normal size prostate, I strongly advise you to do so before you go
forward with your radical prostate surgery. You would also be wise to
find an excellent medical oncologist who specializes in prostate cancer
who can objectively advise you as to your best potential treatment
options (surgery or some form of radiation).

Your message, because it focused principally on penis shrinkage from
prostate surgery, did not give enough information to fully understand
your decision making process.  I have the following questions and/or
observations:

--Do you have medical coverage for treatment in the United States for
either robotic surgery or some other form of treatment?

--Did you get a 2nd opinion with respect to your prostate biopsy.  This
is very important.

--Did you consult with any doctors other than the doctor who is
scheduled to perform your surgery?  2nd opinions are very important,
including a radiation oncologist.

--I had almost 30 core samples taken for my biopsy which gives me a lot
of confidence as to the stage of my cancer.  I question whether 8
samples is enough, especially with your high PSA.  Usually a high PSA
is an indication of more advanced cancer than your biopsy showed.
Surprisingly, you have a normal size prostate.  The fact that you were
unable to have any doctor explain these inconsistencies should concern
you.  Were you given antibiotics for a period of time to rule out an
infection of the prostate which can raise the PSA level (but not
necessarily as high as yours).  Also, sex is not advised within 2-3
days before a PSA test as it can also raise the level of your PSA.

The key to surgery is having one of the best surgeons perform it to
reduce the risk and magnitude of impotence and incontinency.  Are you
confident that your surgeon is one of the best?  Examples of the best
radical prostectomy surgeons are Dr. Peter Scardino at Soan-Kettering
in New York City and Dr. John Walsh at John Hopkins in Baltimore.
Today, they can perform nerve-sparing surgery if the cancer has not
spread to these vital nerves.  They can also transplant the sural nerve
from your foot in case one or both of the erectal nerves have to be
substantially removed. The transplant, however, does not guarantee
potency.

Prostate surgery being performed robotically today will soon be
approaching 50% of total prostate surgery.  It seems to be the wave of
the future.  The side effects are substantially reduced and the
recovery period is much shorter than with radical prostate surgery.  In
younger men, including you at 59, there is a better chance of
overcoming impotency and gaining total continence with robotic surgery.
Dr. Ash Tewari, at New York-Presbyterian (Cornell) in New York City,
is considered one of the top robotic surgeons as is Dr. Menon at the
Henry Ford Clinic in Detroit.  Dr. Tewari worked with Dr. Menon  before
he transferred to New York-Presbyterian. I would advise you to consider
contacting one of these surgeons if there is any possibility that you
have insurance coverage for robotic surgery and can travel to either
New York City or Detroit.  Many prostate cancer patients travel a long
distance to find the best doctors to treat their prostate cancer.

Your concern about reduction in penis size is understandable for all
prostate cancer patients, big or small. The key here, after surgery
(radical or robotic), is the need to be on pills (viagara, etc.) and
most likely a penis pump.  It is of upmost importance to exercise the
penis after surgery to regain blood flow and potency as soon as
possible, and also to reduce the possibility of shrinkage.  So think in
a positive manner about this.  Living a much longer life is far more
important than the size of your penis.  In intercourse, quality is far
more important than penis size!  Most of the stimulation to the vagina
needed to bring a woman to orgasm is at the entry point!

There is a big debate today as to whether radical or robotic prostate
surgery is any more effective in potentially achieving a cure than
radiation treatment.  A great deal depends on the stage of cancer you
are at. There are potential negative side effects with radiation
therapy (i.e., urinary, rectal and impotence) as there are with surgery
(impotence and incontinence).  With radiation therapy, some of the side
effects do not occur until months or years down the road, although the
urinary and rectal side effects seem to be relatively low at the top
radiation centers. Also, with radiation therapy, it takes upwards of 30
months before your PSA will reach a low point of  0.5 compared with
surgery when it is expected to reach 0.2 soon thereafter (both of which
PSA readings are considered an indication that there is no cancer at
present, although there is never a guarantee that the cancer will not
recur years later).

There are two types of radiation therapy:  photon (x-ray) therapy which
is the most prevalent today and proton therapy which is beginning to
emerge.  Proton therapy is considered much safer than photon therapy
because there is less potential damage to good tissue surrounding the
prostate.  With proton therapy, unlike x-ray therapy, the radiation
isn't at the top dose when it enters the body and leaves the
body-the top dose is directed right to the cancerous areas of the
prostate.  The first proton center to open in 1990 was at Loma Linda
University in Loma Linda, CA (their long-range statistics on cancer
recurrence are quite comparable to the results from surgery, depending
on the stage of prostate cancer you were at prior to treatment).  The
second proton therapy center was opened in Boston (Massachusetts
General Hospital) in 2000.  Dr. Anthony Zietman is considered a
top-rated and well respected doctor there in charge of proton therapy
for prostate cancer.

In the meantime, two new centers have opened in Texas (Anderson Cancer
Center) and Florida (University of Florida) this year.  The reason for
the slowness of this therapy to grow in the U.S.  is that each proton
center costs approximately $125 million.  In the years ahead,
additional proton therapy centers are expected to open, including one
in Philadelphia.  The fact that more centers are being opened,
considering the huge cost, is an indication that proton radiation may
well be the preferred method of radiation treatment for cancer in the
future.  Some may well argue that the present IMRT (x-ray radiation) is
equivalent to proton radiation, but I am very skeptical of this based
on my research.  I am very fearful of x-ray radiation, but very open to
proton radiation. I have read that if impotence problems occur with any
form of radiation treatment, it is much easier to treat them with pills
such as viagra, than after surgery if permanent impotence occurs.

With respect to hormone therapy, I would avoid it at all costs and as a
last resort considering the horrible side effects of such treatment.
Hormone therapy usually leads to very low sexual libido and most likely
impotence during treatment or possibly thereafter.  Intermittent or
short-range hormone therapy, where possible, is considered better than
continued long-range hormone therapy.  Temporary hormone therapy is
often given to men to reduce their enlarged prostates (which you do not
have) when electing some form of radiation treatment.  It is also given
to men with higher Gleason scores (especially over 7) and with a high
PSA; in any event, a 2nd opinion should always be obtained before
undergoing hormone treatment of any type.

At first, I seriously considered robotic surgery.  My first concern was
total or some stage of incontinency and my 2nd concern was the
likelihood, at my age, that I might be totally impotent for the rest of
my life.  I do not like the thought of having brachetherapy (seeds)
implanted in my prostate which is sometimes followed by IMRT therapy.
Even Dr. Scardino, does not look favorably on implanted radioactive
seeds in his book.  The only other therapy that I am considering,
before deciding if I really want to chance surgery and the potential
negative side effects at my age, is proton therapy. I feel that it is
much safer than IMRT (photon x-ray therapy), will potentially give me
an equal chance of a cure compared with surgery, and potentially give
me little or no negative side effects compared to surgery.  I expect to
make a final decision in the near future.  My decision making is based
on my age (many years older than you), my diagnosis (which is not
exactly equivalent to your diagnosis), extensive research and
consultation with both surgical and radiation doctors.

Please consider my thoughts above even though your surgery is only a
week away.  If, after reading my message, you still feel that radical
surgery is your best and only choice, then go for it!   If you have any
questions or want more information, please post them on this website
and I will respond promptly.

Best of luck to you Norman.  Be strong and think positively!  You have
many years ahead of you and they may well turn out to be much better
than you are anticipating.  A large portion of men with prostate cancer
live a happy healthy life for a long time after treatment!  As they
say, most prostate cancer patients will die of something other than
their cancer!

Jim

P.S. I was very impressed with the intelligent comments and advice
given by those who responded to your original message.