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Old 07-06-2008, 04:49 PM   #1
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Diagnostic bone and CT scans: worthwhile?

So many of us undergo both of these scans following a diagnosis of prostate cancer; they are virtually routine.

Today's edition of Parade Magazine included an article titled "The Danger of Too Many Tests," and it prominently featured CT scans, also noting a concern about unnecessary radiation. Of course, most of us get a CT scan following diagnosis.

When the biopsy and other evidence indicates the patient has high-risk prostate cancer (me), those CT and bone scans are a quick and relatively inexpensive check whether there is substantial spread of the cancer into the bones and lymph nodes. But most of us diagnosed these days have low-risk cases.

Here's what is said about the CT scan in the book "A Primer on Prostate Cancer - The Empowered Patient's Guide," Strum and Pogliano, 2005, p. 62: "Unfortunately, a CT scan of the pelvis and of the abdomen is routinely ordered in virtually all newly diagnosed men with PC. However, it is our contention, based on published literature, that this is a serious waste of healthcare dollars while exposing the patient to unnecessary radiation and inconvenience.... For at least 90% of men undergoing baseline staging procedures, a CT scan of the pelvis is not indicated. In 99.9% of all newly diagnosed patients with PC, a CT of the abdomen is definitely not needed...." The Primer advises routine bone scanning if the PSA is over 10, but points out that for newly diagnosed patients with a PSA not exceeding 10, there is an abnormal bone scan in only half a percent of patients. (pp. 60, 61)

It's obvious that the authors of the Primer are in the minority, but what they have written makes sense to me. It's at least worth a little discussion with the doctor. He may be prescribing the scans just because it's defensive medicine protecting him against an ill-founded lawsuit.

Any comments?

By the way, with a baseline PSA of 113.6, a Gleason of 3+4=7, stage 3, all biopsy cores positive and most 100% cancer, my CT and bone scans were both negative. I've run into many high-risk patients with the same results. That said, doing both scans made sense for a case like mine.

Jim

 
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Old 07-08-2008, 12:11 PM   #2
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Re: Diagnostic bone and CT scans: worthwhile?

I just ran across a statement by another doctor along the same line. Dr. Glenn Bubley, MD, a medical oncologist, in his 2005 book, "What Your Doctor May Not Tell You About Prostate Cancer," page 130, states that bonescans, CT scans, MRI and endorectal MRI, are not necessary for low-risk patients.

Jim

 
Old 07-08-2008, 02:09 PM   #3
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by IADT3since2000 View Post
.. just ran across a statement by another doctor along the same line.... that ... MRI and endorectal MRI, are not necessary for low-risk patients.

Jim
Jim- another viewpoint:

When I asked my urologist about getting an MRI, since I initially was headed for robotic surgery, I was told it's not necessary for low-risk patients. Then I ended up getting the test as part of the workup for my proton radiation- my ultimate choice of treatment. That test was somewhat inconclusive, although there were possible signs that the cancer had gone beyond the edge of the capsule. I had some waiting time of not knowing, but then got a more accurate spectroscopic (endorectal) MRI, and the reading of that concluded that I was ok, with no extracapsular penetration.

But my question is this: how does one conclude it's truly low risk when the chances of something like this are ever-present. And if one did have penetration beyond the edge of the capsule, and had surgery, there would have been a high liklihood of positive margins, so radiation might then be the logical step afterwards. So the middleman, surgery, could have been avoided under those conditions. I don't think surgery would have been the choice under those circumstances, but no one would have known until it was too late.

As it was, based on the findings in my tests, coupled with my physical exam, they chose to radiate a little deeper into the margins where the suspicious activity was going on.

So yes, overtesting is not good in itself, but how does one really judge what's necessary? I was a Gleason 7, by the way, when I was told by the urologist I was low risk. (I would have ranked me as intermediate.)

 
Old 07-10-2008, 02:02 PM   #4
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by daff View Post
Jim- another viewpoint:

When I asked my urologist about getting an MRI, since I initially was headed for robotic surgery, I was told it's not necessary for low-risk patients....But my question is this: how does one conclude it's truly low risk when the chances of something like this are ever-present. And if one did have penetration beyond the edge of the capsule, and had surgery, there would have been a high liklihood of positive margins, so radiation might then be the logical step afterwards. So the middleman, surgery, could have been avoided under those conditions. I don't think surgery would have been the choice under those circumstances, but no one would have known until it was too late.
...So yes, overtesting is not good in itself, but how does one really judge what's necessary? I was a Gleason 7, by the way, when I was told by the urologist I was low risk. (I would have ranked me as intermediate.)
Hi daff,

Thanks for relating your experience.

I can easily accept that CT, bone scans and regular MRIs are not needed for low risk patients, but like you, I was surpised by Dr. Bubbley' extending that list to endorectal MRI. He is a well-known doctor, so he isn't giving an off-the-wall opinion. Perhaps there have been major developments since he wrote the text; considering that his book was published in 2005, he probably wrote it in 2004, and several years between then and now is a long time in prostate cancer technology in view of the rapid pace of developments. Perhaps adding spectroscopy to the endorectal MRI makes it a worthwhile approach, and perhaps he would have endorsed that combination approach if asked.

If I had been facing your situation with a Gleason 7, I too would have wanted some additional evidence, and the endorectal MRI with spectroscopy would be one of the logical choices. It seems odd to me too that the doctor described your case as low risk.

Did your earlier doctor raise the possibility of an endorectal MRI with spectroscopy? There are not very many facilities with the combined MRI and spectroscopic combination, so accessability may have been an issue in your earlier doctor's thinking. I know of one facility at UC San Francisco, another at Memorial Sloan Kettering in New York, and possibly one in Florida at the new site offering 3 Tesla MRI (not sure whether that is endorectal with spectroscopy). There may be more now that this technology is coming into its own. Where was your endorectal MRI with spectroscopy done? How was the test? I've heard some patients say it was okay, and at least a couple say it was really uncomfortable because of the endorectal probe and the length of time you are on the table.

On the other hand, I can understand ruling out a regular MRI. Dr. Myers wrote in May 2006 that CT and regular MRI scans were "completely inadequate" because studies show that they reveal only 15 to 30% of known lymph node metastases. That kind of track record would harldy give us the kind of reassurance we want! A CT scan can be useful as a triage type approach for a challenging case with strong likelihood of metastases, and that's why it made sense in my case. It's fairly quick and relatively inexpensive, and it does find large tumors. If you get a positive result, then you may not need more expensive and time consuming scans such as the fusion ProstaScint. (I was glad I needed the ProstaScint! )

I hope a Combidex scan facility is established in the US since that technology is so good at detecting lymph node mets anywhere in the body. As far as I have heard, the only competent facility now is in the Netherlands, though a group in the Boston area was working on it in recent years. Combidex, also known as USPIO and Sinerem, is a high resolution ultrasmall, superparamagnetic, iron oxide contrast agent MRI scan. It has not been approved by the FDA.

Jim

 
Old 07-10-2008, 03:39 PM   #5
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by IADT3since2000 View Post

If I had been facing your situation with a Gleason 7, I too would have wanted some additional evidence, and the endorectal MRI with spectroscopy would be one of the logical choices. It seems odd to me too that the doctor described your case as low risk.

Did your earlier doctor raise the possibility of an endorectal MRI with spectroscopy? .... Where was your endorectal MRI with spectroscopy done? How was the test? ....


Jim
Hi Jim-

As I mentioned, no tests were suggested by my urologists in advance of my
scheduled robotic surgery-- (prior to my discovering proton radiation).

A standard MRI is part of the battery of testing prior to proton radiation at University of Florida Proton Therapy Institute in Jacksonville. I may be wrong, but I think that's because there's usually no problem shown, but if there were, the spectroscopic test is available. With higher risk patients, maybe a Gleason 8 or a high PSA (mine was 4), they'd start off with the spectroscopic test.

The more advanced MRI was not available last year at the facility for proton treatment, a standalone facility next to Shands Hospital-- but I think it's now available. I needed to go to the Mayo Clinic, only about 30 minutes away, in Jacksonville. The test itself was easily tolerated by me, partly because the Mayo Clinic was such a classy, patient-oriented facility and they treated me well and gave me warm blankets and the like...

Had the results of the spectroscopic MRI not turned out in my favor, I most likely would have just continued the course of radiation but likely added hormone shots, like Lupron, when I got home. I know you've had more than your share of that type of treatment, but you've done very well with it all.

 
Old 07-10-2008, 04:20 PM   #6
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Re: Diagnostic bone and CT scans: worthwhile?

Thanks. I'm glad to hear that Jacksonville now has such a facility and that they are patient oriented!

Jim

 
Old 07-14-2008, 07:47 PM   #7
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Re: Diagnostic bone and CT scans: worthwhile?

I just ran across a book by some other experts who also think a CT scan is of little value for most of us to aid in staging the cancer. The authors note that the CT scan is used for planning radiation therapy, a worthwhile use, but also for checking the spread to lymph nodes after diagnosis, which is the use being questioned in this thread. The authors state that "... the technique is not reliable for this purpose (a lymph node dissection is the better approach)." (pages 60-61)

The book was published in 1999, and now the Combidex scan is emerging as a superior way of checking lymph nodes throughout the body. However, that scan is virtually unavailable in the United States as the only center that has been established for the scan is in the Netherlands, from what I've heard.

The book is by Dr. David Bostwick, MD, and others, and it was in the series of books on prostate cancer published every few years by the American Cancer Society. Dr. Bostwick is again the lead author of the latest book in the series, published in 2005.

Jim

 
Old 08-11-2008, 10:46 AM   #8
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Re: Diagnostic bone and CT scans: worthwhile?

Hi IADT.....think I picked up something in one of your earlier posts, suggesting that you are (were?) on active surveillance, and seemed to be one of those relatively few people supporting that option, whereas majority opinion seems to be against it, in favour of positive intervention.

I joined the site just a few days ago and posted an outline of my recent-diagnosis, and was looking for comments for/against surveillance. Anything you can add onto that thread would be much appreciated - sorry, no intent to be a thread-hijacker !

Cheers / David

 
Old 08-20-2008, 05:09 AM   #9
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Re: Diagnostic bone and CT scans: worthwhile?

Reading the artcicle is it saying that 99.9 % of men with a PSA reading of less than 10 are unlikely to have bone spread pciked up by MRI / CT

Low risk being under 10.

Am I correct in thinking that in general, the greater the spread of PC, the higher the PSA reading ?

tony

 
Old 08-20-2008, 01:06 PM   #10
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Re: Diagnostic bone and CT scans: worthwhile?

I haven't read the article but based on my knowledge and experience with prostate cancer for which I was treated successfully seven years ago my understanding is as follows:PSA under 10 is considered early stage, most likely localised and highly treatable with either surgery or radiation with best prospect for being cured. As PSA advances over 10 the risk of spread to surrounding tissue and lymph nodes increases incrementally with increases in PSA. I believe that when PSA exceeds 10 the probability of its penetrating beyond the prostate capsule (ECP)is 50%. The velocity of the PSA increase is a more significant indicator of its rate of progression and its Gleason Grade denotes its degree of aggressiveness.Gleason Grades under 6 are not considered clinically significant or requiring treatment. Gleason Grades 6-7 are classified as moderately aggressive and Grades 8-10 as very aggressive. Hope this clarifies it somewhat.

Last edited by shs50; 08-20-2008 at 01:07 PM.

 
Old 08-20-2008, 01:09 PM   #11
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Re: Diagnostic bone and CT scans: worthwhile?

yes it does and thanks, nicely worded for all to understand

tony

 
Old 09-11-2008, 10:10 AM   #12
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Re: Diagnostic bone and CT scans: worthwhile?

Hi Exflyboy - David,

I'm including responses in green.


Quote:
Originally Posted by Exflyboy View Post
Hi IADT.....think I picked up something in one of your earlier posts, suggesting that you are (were?) on active surveillance,

I do believe that active surveillance is an excellent option for the right kind of low-risk patient, but that has not at all been my course of action. I had a very high risk case. My request for surgery, back when I knew little , was rejected, wisely, by Johns Hopkins. When a ProstaScint scan was unexpectedly negative, opening the possibility of radiation, I was planning on and preparing for that for several months, but I was doing so well on hormonal blockade that I decided that an advanced form of that would be my therapy. I'm now at the end of my second off-therapy period of intermittent triple blockade as I near the nineth year point as a survivor. I'm enjoying the quality of life I had before diagnosis except for the side effects of my current main medication, thalidomide, which I'm about to stop and switch back to blockade. (That's a significant "except" - some mental sluggishness, "orthostatic hypotension," very slight gait impairment in the morning for me.)

and seemed to be one of those relatively few people supporting that option, whereas majority opinion seems to be against it, in favour of positive intervention.

The more patients and doctors I've talked to, the more convinced I am that the vast majority of us have a compelling need to take what we see as strong action after we are diagnosed. Often that action is to have surgery or radiation, and the choice seems to turn out well. However, a substantial portion of us have annoying or more serious side effects from those choices. Until the past several years not much was known about the odds of success for active surveillance, and not much was known about what enhanced the odds of success. Now we have learned a great deal with more sound knowledge being reported each year.

I joined the site just a few days ago and posted an outline of my recent-diagnosis, and was looking for comments for/against surveillance. Anything you can add onto that thread would be much appreciated - sorry, no intent to be a thread-hijacker !

Try searching the archives of this board for "active surveillance". I started a thread about it on January 5, 2008, and there are other posts as well. You can also go to [url]www.pubmed.gov[/url], a website we can mention here since it is a US Government website, and search for " active surveillance AND prostate cancer ". The exciting thing is that most of the major centers in the US that are known for their expertise in treating prostate cancer now have active surveillance programs and are enthusiastic about them. Key members of the research teams include some of our best known prostate cancer surgeons. Here is a brief list of some of the top international centers with some of the leading active surveillance doctors associated with them: U. of Toronto, Sunnybrook - Dr. Laurence Klotz (arguably the world's leading expert); Johns Hopkins - Dr. H. Ballentine Carter; Memorial Sloan Kettering - Dr. Peter Scardino; Erasmus Medical Center (Netherlands) - Dr. Fritz Schroeder (spelling is actually Schroder with an umlaut over the "o"); MD Anderson - Dr. Babaian (spelling?); and U. of California at San Francisco - Dr. Peter Carroll. There are other large programs as well, but these are the ones I know the most about and are probably the most prominent. Disciples from these programs are going to other centers and spreading the technology. You don't have to be at a major center to do active surveillance, though you would get the benefit of their greater experience with it. You could see the key criteria that they use and the monitoring techniques they use and find a doctor that will follow their lead or is up-to-speed himself.

Their results give us two key insights: First, properly selected patients do very well with active surveillance, with more than half being able to stay on surveillance rather than moving to a definitive therapy while the vast majority get at least a couple more years of normal life . Second, on the other hand, even in the low-risk groups in these programs, well over a third, closer to a half, will have cancer aggressive enough to warrant definitive treatment within a few years.

The key objectives in these programs are to avoid overtreatment while catching those cases that are aggressive early enough so that the likelihood of cure is not significantly reduced.


Cheers / David

Hope this helps.

Take care,

Jim

 
Old 09-11-2008, 10:26 AM   #13
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Re: Diagnostic bone and CT scans: worthwhile?

Quote:
Originally Posted by shs50 View Post
...As PSA advances over 10 the risk of spread to surrounding tissue and lymph nodes increases incrementally with increases in PSA. I believe that when PSA exceeds 10 the probability of its penetrating beyond the prostate capsule (ECP)is 50%. The velocity of the PSA increase is a more significant indicator of its rate of progression and its Gleason Grade denotes its degree of aggressiveness....
Hi shs50 and fellow board participants,

That 50% figure is on the high side for many patients, and board participants might like to know that, though I think I understand where you are coming from and the 50% figure is not far off for a lot of us. I just checked the Partin Tables for a PSA over 10 (used the 2001 version - not the latest, but handy, and the results would be very close to the latest version).

Here are some key figures for capsular penetration for a PSA exceeding 10, by Gleason range and stage:

Gleason 2-4: odds range from just 20% chance the capsule has been penetrated for stage T1c to 46% for T2c.

Gleason 5-6: odds range from 33% for stage T1c to 51% for stage T2c.

Gleason 3+4=7: odds range from 43% for stage T1c to 42% for T2c.

Gleason 4+3=7: odds range from 51% for stage T1c to 43% for stage T2c.

Gleason 8-10: odds range from 50% for stage T1c to 41% for stage T2c.

Jim

 
Old 09-17-2008, 10:51 PM   #14
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Re: Diagnostic bone and CT scans: worthwhile?

Jim & Daff,
Thanks for your postings. Your entries are rich with data. It makes a person new to this a bit weary...knowing how much work is required to get that level on understanding. Jim, I have, also, gained some information from you on another topic with which you are assisting (about the issue of organ containment). I had a CT scan and bone scan today. I read only a few low and medium risk patients have positive bone scans. So I will be surprised (and depressed) if that is positive. I am not as optimistic about the CT scan. What does one do if the CT scan is negative? Is it true that a negative report does not rule out that some penetration has taken cancer to seminal vesicles or lymph nodes? Should I ask about other tests (lymph node biopsy? ProstaScint?). The urologist who ordered the prostate biopsy does robotic surgery. I think he may recommend surgery, but has referred me to a radiation oncologist for a second opinion. That sounds premature to me. I would have thought a medical oncologist would have been more appropriate given the limited knowledge (maybe his knowledge is not as limited as that he shared with me).
Daff, I, too, was informed (Friday) that my Gleason score was 7. I had no research at the time, hoping for the expectancy of my urologist, who predicted I had no cancer and the expectancy of the surgeon, who gave me one chance in 4. So I did not know enough to get many specifics. He called the risk "medium" --half way between 5 and 10 (I would think 5 or 6 would be "medium"; my PSA is low, 1.5, but he does not give that much weight. --nor do the Partin Tables weigh a low PSA as heavily as I had hoped I don't know if my 7 is 4+3 or 3+4 (which, I read, enjoys significantly better prognosis). I wasn't told the precise location of the cancer. I don't know if it is near the edge with a greater likelihood of penetration.
I don't know that either of you need to add to information in your postings. The depth of your knowledge exceeds my current capacity to digest more than you have already provided. Tomorrow (9/18) I will see my regular doctor, who happens to be an urologist. I presume he will have some suggestions re treatment after reviewing the reports (biopsy, CT, bone scan). He, feeling a bit bad about not ordering a prostate biopsy, will try hard to guide me to a good outcome. Any ideas to help him along with that effort? Maybe that request is more easily addressed when results of the tests are known. Thanks again for your help.
Dale

 
Old 09-27-2008, 05:56 PM   #15
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Re: Diagnostic bone and CT scans: worthwhile?

Hi Dale,

I fully appreciate the difficulty of orienting yourself as a new patient. I remember very well the period of several weeks that I took in late 1999/early 2000 to study the odds, before choosing surgery, believing then that I knew enough to make a reasonable choice for my challenging case. I soon realized that was far from true, but that realization was partly spurred by being rejected for surgery by Johns Hopkins , a rejection for which I soon became grateful.

I'm posting some comments in green interspersed in an excerpt of your post.


Quote:
Originally Posted by dale2035 View Post
Jim & Daff,
Thanks for your postings. Your entries are rich with data. It makes a person new to this a bit weary...knowing how much work is required to get that level on understanding.

The key is to learn at least what you need to know to deal with your own case. Most of us don't do that - we just go with the general odds or what we hear from someone we know who has had prostate cancer.

Jim, I have, also, gained some information from you on another topic with which you are assisting (about the issue of organ containment). I had a CT scan and bone scan today. I read only a few low and medium risk patients have positive bone scans.

Apparently the percent is very low.

So I will be surprised (and depressed) if that is positive. I am not as optimistic about the CT scan. What does one do if the CT scan is negative? Is it true that a negative report does not rule out that some penetration has taken cancer to seminal vesicles or lymph nodes?

That's correct - a negative CT scan is not that helpful. At least it indicates that you do not have extensive disease that is large enough in the lymph nodes to be detectable.

Should I ask about other tests (lymph node biopsy? ProstaScint?).

A lymph node biopsy is based on a sampling of nodes that are fairly easy to get to. That means you get a fair clue whether the cancer is in the nodes, but the lymph node surgery check often misses cancer that is in nodes that are not sampled.

An endo-rectal MRI with spectroscopy, especially a 3-Tesla (power level) MRI, is a much better scan, as I understand it. I've had a ProstaScint myself, though not the fusion ProstaScint that is now the state of the art. However, while my scan was covered by insurance as I clearly had a high risk case based on the PSA over 100 and the stage, etc., your case may not be coverable. You could check with the doctor. I'm thinking the endo-rectal MRI with spec could be a more practical option. These and other options are very well described in the Strum/Pogliano book "A Primer on Prostate Cancer - The Empowered Patient's Guide. I highly recommend that book. It's a wonderful aid for navigating the ins and outs and options of prostate cancer. There's a new lymph node scan that is highly effective, known variously as Combidex, Sinerem, or USPIO, but unless things have changed this year, it is not yet available in the US.


The urologist who ordered the prostate biopsy does robotic surgery. I think he may recommend surgery, but has referred me to a radiation oncologist for a second opinion.

That sounds premature to me.

Actually, that should be par for the course, and I'm impressed that your doctor did that. This disease is too complex and knowledge is moving too fast for doctors in one field, such as surgery, to be masters of what is going on in another field, such as radiation, even if they can overcome their biases, which is challenging. More than 4,000 medical research papers are published each year on prostate cancer.

I would have thought a medical oncologist would have been more appropriate given the limited knowledge (maybe his knowledge is not as limited as that he shared with me).

I really like the idea of a consultation with a medical oncologist. In my opinion, they have the least bias and the best overview of the disease IF they get much of a flow with prostate cancer patients. It doesn't have to be either a radiation oncologist or a medical oncologist - you can do both! It makes sense to see the medical oncologist last so you can review recommendations from the other doctors.

Daff, I, too, was informed (Friday) that my Gleason score was 7. ... He called the risk "medium" --half way between 5 and 10 (I would think 5 or 6 would be "medium";

You just don't hear much from patients with Gleasons below 5, or even with 5. A 7 is a medium risk indicator, but other indicators like PSA, PSA velocity, stage and other characteristics (such as perineural invasion) also play a role.

my PSA is low, 1.5, but he does not give that much weight. --nor do the Partin Tables weigh a low PSA as heavily as I had hoped I don't know if my 7 is 4+3 or 3+4 (which, I read, enjoys significantly better prognosis).

You have a right to your medical records, and I'm confident your doctor's office would be happy to provide them. That should reveal whether you have a 4+3 or a 3+4. Get copies of all your reports. I'm envious of that wonderfully low PSA. It looks to me as if it makes quite a difference in the Partin Tables, though it obviously does not completely override the stage and Gleason. It is clear that your PSA did not rise by more than 2.0 in the year prior to diagnosis - the newly recognized key risk factor (D'Amico and team), so you have one more thing going for you.

I wasn't told the precise location of the cancer. I don't know if it is near the edge with a greater likelihood of penetration.

That will be at least roughly indicated in your biopsy report. By the way, the Primer has an extensive section with forms you can use to track your key data. Having such data handy is very helpful.


I don't know that either of you need to add to information in your postings. The depth of your knowledge exceeds my current capacity to digest more than you have already provided. Tomorrow (9/18) I will see my regular doctor, who happens to be an urologist. I presume he will have some suggestions re treatment after reviewing the reports (biopsy, CT, bone scan).

Urologists should be knowledgeable about surgery and often are strongly biased in favor of it. My strong impression is that most of them are not well versed in developments outside their own fields unless they specialize in prostate cancer, and sometimes not even then. I'm convinced that most of them know relatively little about the ins and outs of hormonal blockade, and many of them subscribe to unfortunate myths about hormonal therapy which they confidently pass on to their patients.

It's really good to get second opinions and do your own thinking. The Primer has a lot of tips for tailoring the treatment choice to your own circumstances. That tailoring is vital for getting the best shot at the best outcome.

Here's one more book that should be a real help in putting things in perspective: "Surviving Prostate Cancer Without Surgery - The New Gold Standard Treatment That Can Save Your Life and Lifestyle," 2005, Michael J. Dattoli, MD, Jennifer Cash, ARNP, MS, OCN, Don Kaltenbach, survivor. Dr. Dattoli is one of the world leaders in radiation for prostate cancer. He has just had a paper published on his long-term results that is impressive.


.... Thanks again for your help.
Dale
You're welcome and keep at it,

Jim

 
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