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Old 06-23-2009, 04:40 AM   #31
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

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Originally Posted by sbear1102 View Post
Thanks again for your responses. I will be going with my husband to second opinion this Friday and will bring up some of these points. I'll keep you posted on how things go. (Husband had another PSA drawn today).
Good Morning sbear,

During ny interviews with surgeons and radiologists, I asked the following questions;

1. What are the pros and cons of radiation, open abdominal, laproscopic and robotic surgery?
2. If we choose radiation, and there are cancer cells left, can surgery then performed?
3. I we choose surgery, and cancer is seen in the surrounding lymph nodes, can radiation be performed?

I will never try to persuade a person to choose one procedure over another, as this is indeed a personl decision that only involes the patient and partner. However, in my particular case, my wife and I decided for robotic surgery over all other options, because in our minds it posed the smallest risk with the greatest rewards.

Go into this with a clear and open mind and a list of questions.

Regards,

Joe

 
Old 06-23-2009, 06:38 AM   #32
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

Hi Joe,

I too was recently dx and am going through the procedure of learning my options. I am most fearful of loosing my erctile function.

How were your results ? How long ago?

 
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Old 06-23-2009, 07:21 AM   #33
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

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Originally Posted by Eventod View Post
Hi Joe,

I too was recently dx and am going through the procedure of learning my options. I am most fearful of loosing my erctile function.

How were your results ? How long ago?
Eventod,

Having had surgery on the 16th of this month, I am not an authority in the recovery process. With that being said, I did my research on HIFU, radiation, open abdominal, laproscopic and DaVinci robotic surgery. After I colled all of my data, I sat with specialists in each field to get a "sanity check" re: my findings. I did not like the risks involved with any option other than DaVinci. Although each procedure has its benefits and risks, my wife and I thought that Davinci posed the least risk. It removes the entire prostate intact and a top notch surgeon can preserve the nerve bundles related to erectile function. I am 56 years old, had Hodgkins disease twice and a bone marrow My surgeon said I could live quite a long time if I chose to do nothing. My wife and I made a concious decision to have the prostate removed before the cancer metastised to other organs or the lymph system, because once there, the options window closes quickly.

Best of luck!

Joe

 
Old 07-09-2009, 10:33 AM   #34
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

Quote:
Originally Posted by sbear1102 View Post
Thanks again for your responses. I will be going with my husband to second opinion this Friday and will bring up some of these points. I'll keep you posted on how things go. (Husband had another PSA drawn today).
Hi Sbear,

How was the 2nd opinion?

Regards,

Joe

 
Old 07-09-2009, 07:58 PM   #35
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

icancervive, the 2nd opinion went well. The surgeon spent over an hour answering our questions. He would perform the robotic surgery - if my husband chooses him. We met with another surgeon today, he only does open surgery. The literature he gave us does not speak favorably about robotic surgery. My husband still thinks he'll go with the robotic, but he does have one more doctor to see before he decides- a radiologist. The doctor we saw today ordered an MRI of the prostate with coil. He feels this to be more accurate than a CT scan of the pelvis/abdomen which is what the surgeon who performs robotic surgery ordered. They both ordered bone scans and the robotic surgeon ordered a creatine lab, not sure why. My husband may have his surgery (if this is what he decides) either this month or next month. He wants to visit the radiologist just to get a different perspective. After that, he really would just like to begin treatment. All the ordered diagnostic tests will be done within the next week. Something I found interesting is that the surgeon who does open surgery would biopsy surrounding lymph nodes and send a frozen section to the pathologist prior to performing the surgery. If more than 5 came back positive, surgery would not be started. The surgeon who does the robotic prostatectomy would biopsy the surrounding lymph nodes, but would not wait for the results, but rather start surgery. Is this typical with robotic surgery? Hope all is well with you.

 
Old 07-09-2009, 08:16 PM   #36
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

I forgot to mention one other important piece of information. The surgeon my husband saw today did a DRE. He said he felt "some firmness" in the base. (my husband's PCP and urologist said it felt normal). My husband said it's easy to feel something when you have the pathology report. But, I'm now thinking about the extent of his cancer. Does firmness take it to another level? They are all saying they "think" they caught it in the early stage, being that his Gleason is a 6 which the robotic surgeon's pathology lab agrees with (unfortunately, we didn't get the slides to the doctor we saw today soon enough). He also only had 6 cores biopsied, of which 4 were 5-30% positive, moderately differentiated cells. They all feel it is localized, but I'm worried Any comments?

 
Old 07-11-2009, 05:23 AM   #37
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

Quote:
Originally Posted by sbear1102 View Post
I forgot to mention one other important piece of information. The surgeon my husband saw today did a DRE. He said he felt "some firmness" in the base. (my husband's PCP and urologist said it felt normal). My husband said it's easy to feel something when you have the pathology report. But, I'm now thinking about the extent of his cancer. Does firmness take it to another level? They are all saying they "think" they caught it in the early stage, being that his Gleason is a 6 which the robotic surgeon's pathology lab agrees with (unfortunately, we didn't get the slides to the doctor we saw today soon enough). He also only had 6 cores biopsied, of which 4 were 5-30% positive, moderately differentiated cells. They all feel it is localized, but I'm worried Any comments?
Sbear,

I have come to the conclusion that surgeons and radiologists are a lot like car salespeople... my model is better than the next dealers.

It appears as though you and your husband have done enough research to determine what's right for the two of you. Trust your research, and trust each other.

In regards to removing lymph nodes, submitting them to a pathologist and then decide whether to continue with the surgery, make no sense to me. Unless, IF it spread to the lymph system, follow-up or salvage radiation may have to be performed. During my robotic surgery, my surgeon removed the prostate, seminal vesicles, surrounding lymph nodes and margins. After everything was removed, it was then sent to TWO patholgists for final determination of status (Gleason rating, SVI, Margin cleanliness and % of total concentration). For me it was much easier to accept the fact that my prostate cancer was on a lab table somewhere, and not in my pelvic bed.

Good Luck,

Joe

 
Old 07-11-2009, 11:44 AM   #38
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

Quote:
Originally Posted by sbear1102 View Post
The surgeon my husband saw today did a DRE. He said he felt "some firmness" in the base. (my husband's PCP and urologist said it felt normal). My husband said it's easy to feel something when you have the pathology report.

Hi sbear,

Having gathered several opinions, you better understand first-hand the subjective nature of the DRE...It is well known that if different doctors carry out a DRE on the same patient (even on the same day, one immediately after the other), they may come to different decisions about what they think they feel. Your husband's comment is well-taken...the last one to perform the DRE knew that cancer had already been found by the biopsy.

Regarding PLND pelvic lymph node dissection (also recall my comments on this from earlier posting), I've found a relatively consistent general rule of thumb that reads "...only men with a moderate or high risk of pelvic lymph node metastases need to undergo pelvic lymph node dissection. This includes men with PSA values in excess of 15 ng/ml or high-grade cancers." (Your husband is neither.) That being said, you will find some doctors who are naturally more conservative than others. For example, a more conservative doctor might include the PLND as surgical protocol for low risk patients, while others may not. My understanding for low risk patients is that it largely comes down to doctor preferences/doctor philosophy.

My understanding is that there is also a historical component, and the rule of thumb written above was not always the case. In the last several decades (i.e., the PSA-era), the incidence of pelvic lymph node metastases has decreased, specifically because more low risk cases are being found as a result of wide-spread PSA testing. A doctor my age trained 20-some years ago would have been taught by surgeons who regularly found advanced cases in the pre-PSA-era and always performed PLND as a matter of course. Many doctors form their personal philosophy based largely on their own mentor's philosophies, and those can be hard to change.

(Also reference back to posting #4 in this thread where Jim pointed out AUA guidelines for lymph node sampling...not recommended for low risk cases.)

In a low risk case, I believe that this is another situation where there is really no "right" or "wrong"...we PC patients face many of these situations. My recommendation is to find the best possible surgeon (if you decide on surgery), and let him do his thing.

best wishes...

Last edited by kcon; 07-11-2009 at 12:55 PM. Reason: added reference back to posting #4

 
Old 07-11-2009, 07:42 PM   #39
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

I hear you. At this point, my husband is in the process of having all the scans done. Once he gets through this, he will probably have surgery. I'll keep you posted on how things go. Thanks for your support

 
Old 07-12-2009, 05:06 PM   #40
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

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Originally Posted by sbear1102 View Post
.... At this point, my husband is in the process of having all the scans done. Once he gets through this, he will probably have surgery....
Hi sbear,

Your continuing story of wrestling with tests, doctor choices and other decisions reminds me of what I went through back in 1999/2000, and I'm sure it brings back those memories to many of us.

What you have told us has raised a concern in my mind: the doctor intends three tests that the AUA recommends avoiding! As kcon noted, the doctor's plan to do lymph node analysis is counter to a "rule of thumb" and to the recent recommendations of the American Urological Association for cases with characteristics like your husbands; and, doing a CT scan and bone scan in such a case is also counter to those recommendations. The reasons, in essence, are that the lymph node check and those scans are rarely useful in such cases.

The source document, published in April 2009 by the AUA and available to the public, is entitled "PSA Best Practices Statement." The recommendation about lymph node dissection is on page 36 - "for clinically localized prostate cancer may not be necessary if the PSA is less than 10.0 ng/mL and the Gleason score is less than or equal to 6." The recommendation implies a likelihood of nodal mets of just 3% to 5% in such cases based on several large studies. The recommendation regarding bone scans is on page 34: "Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is equal to or less than 20.0 ng/mL." Not only is bone involvement highly unlikely in such cases, but it takes about 10% of bone involvement with cancer before the bone scan highlights the area, so even if there is a small metastasis, it is unlikely to be detected. The recommendation regarding CT scans is on page 35: "Computed tomography [CT scanning] or magnetic resonance imaging scans may be considered for the staging of men with high-isk clinically localized prostate cancer when the PSA is greater than 20.0 ng/mL or when locally advanced or when the Gleason score is greater than or equal to 8."

It could be that the doctors ordering the scans just have not yet been able to read the new guidelines. On the other hand, the studies on which they are based have been public for years. For example, my 2002 edition of "A Primer on Prostate Cancer - The Empowered Patient's Guide," strongly recommends not doing CT and bone scans in low risk patients based on published medical research.

These observations do not mean that the doctor is performing below par, but they do raise that possibility. It's also possible that he is simply practicing defensive medicine to conform to what he believes other doctors in your area are doing.

However, based on these areas of doubt about the doctor, if your husband chooses surgery, it would be wise to look extra closely at the doctor's record. How many robotic surgeries has he performed? Studies have shown that there is a "learning curve" for robotic prostatectomy, and it appears that several hundred surgeries is needed for full proficiency. I've heard 300 quoted by one presumed expert. You could ask the doctor for references so that you could talk to patients that he treated about a year earlier. A local Us Too or Man-To-Man or other prostate cancer support group might also provide knowledge about the doctor's reputation among patients.

An endo-rectal MRI with spectroscopy appears to be a useful scan, though the evidence is not yet conclusive. (That also is per the AUA, p. 35-36, though the AUA says that "MRI scanning using a body coil is also not a useful staging procedure in the vast majority of patients with newly diagnosed prostate cancer, ...." From your post, it is not clear which of these two scans the doctor wants to have done.

Before having the scans, your husband might want to ask if there are special circumstances that call for the scans despite the recent AUA guidelines. This is a question that needs care in the asking to avoid antagonizing the doctor. One way would be to say something like: "I've learned that the AUA is recommending that these scans generally not be done in cases like mine; I'm concerned whether there are special circumstances that are prompting the scans. Can you tell me about that, and would there be much risk if I skipped the scans?" If your husband does have the scans, at least you can relax with the knowledge that the overwhelming likelihood is that results from the scans would be negative, and the scans themselves, while somewhat bothersome with preparation and such, are not that big a deal.

In your post #35 on the thread you said the doctor stated that the literature was not favorable to robotic surgery. That is very contrary to my impression as a savvy layman, with the very important condition that the doctor doing the surgery is fully competent. I believe it is true that robotic surgery has not been around long enough to have a long track record, but it certainly has at least a medium length track record.

Regarding the stage - whether Stage 1 or Stage 2 based on the DRE, it might be worth getting an independent opinion from a doctor respected for his DREs but not aware of the biopsy results. The stage is an important piece of information, but it's encouraging that at least one doctor judged the cancer to be Stage 1.

It's not easy sorting all this out, but many of us have enjoyed better results by making the effort.

Take care and good luck to you both,

Jim

 
Old 07-14-2009, 09:47 AM   #41
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

Well, my husband had his bone and CT scan of the abdomen/pelvis with and without contrast yesterday. They gave him a disc with the images. I have no idea what I'm looking at. I did call the hospital to see if a written report is available- and it is. He can pick it up today.. I'm trying to be positive. I am wondering what the purpose of providing him a CD with the images without any report. (trying to figure out if what the image shows is this or that). Have you all gone through this? Is it better to wait for the report- wait until we meet with the surgeon who ordered them? We need to know, and will, just not sure about receiving a report without having a doctor there. The tech who did the bone scan gave him a heads-up, indicating it looked normal, but the CT scan techs just did the procedure and said nothing.

 
Old 07-14-2009, 10:43 PM   #42
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

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Originally Posted by sbear1102 View Post
Have you all gone through this?
Yes, but not the same sequence as you. It seems goofy that they first gave you the disk, followed by the report, followed by your doctor's meeting. Mine was exactly the opposite order. I met with the doc. He gave me a one sentence summary** that nothing was detected, and he handed me a report before the meeting ended (which he advised--appropriately--I would want to keep for my records). I picked up a copy of the disk later, but certainly I couldn't tell anything from me looking at the scans themselves.

Hopefully, you have an appointment soon with the doc to review. In my meeting, like I said, it was a quick review of the scan results, then an hour to talk about the full range of possible treatment options. There were some findings on my report, but nothing having to do with PC, and nothing which required action, but it helped to have the doc give his summary first...then I read and researched an understanding of each reported line item in detail.

**Actually, the first thing he asked me was "Who punched you in the mouth?" In the days immediately after diagnosis, but prior to scans, I was so stressed out that I "killed" one of my teeth. Apparently, I started grinding my teeth from the stress--something my dentist said is common--and ended up having 'emergency' root canal about 3 days before the scans were scheduled. My jaw was 'lit-up' on the scans...but obviously not a bone mets issue. I'm almost able to look back & laugh now, but clearly wasn't funny at the time.

Last edited by kcon; 07-14-2009 at 10:44 PM.

 
Old 07-15-2009, 05:56 AM   #43
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

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Originally Posted by sbear1102 View Post
Well, my husband had his bone and CT scan of the abdomen/pelvis with and without contrast yesterday. They gave him a disc with the images. I have no idea what I'm looking at. I did call the hospital to see if a written report is available- and it is. He can pick it up today.. I'm trying to be positive. I am wondering what the purpose of providing him a CD with the images without any report. (trying to figure out if what the image shows is this or that). Have you all gone through this? Is it better to wait for the report- wait until we meet with the surgeon who ordered them? We need to know, and will, just not sure about receiving a report without having a doctor there. The tech who did the bone scan gave him a heads-up, indicating it looked normal, but the CT scan techs just did the procedure and said nothing.
In my particular case, I went for the CT scan and bone scan on the same day. Because my doctor was associated with the hospital, the results were on the main server, so I didn't have to get a disc or film. Withing a day or so after the scans, I had the appointment with my original urologist where we discussed my options. Once, my wife and I decided on the course of action (DaVinci), I found the best available surgeon which happened to be at St. Joseph's Hospital in Atlanta.

 
Old 07-15-2009, 12:36 PM   #44
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

I put a call in to the ordering physician but haven't heard back from him yet. My husband picked up the report yesterday. There were some findings on the CT Scan...not sure whether they are significant. Hopefully we will get a call from him soon......

 
Old 07-24-2009, 10:24 AM   #45
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Re: My Husband, 43 yrs. old was just dx with prostate ca, gleason score of 6

My husband, 48, was dx with prostrate cancer in May. Talk to as many people as you can and get 2nd and 3rd opinions from doctors if possible. Each time we talked to someone we picked up one more piece of information that led to our final decision. The first doctor (urologist) told us the options but made no recommendation. He sent us to a doctor who specializes in radiation therapy and of course this doctor was pushing for radiation treatment.

Husband's stepmother's daughter recommended us to a urologist at Missouri Baptist Hospital who works in the cancer center. This doctor spent a lot of time with us, recorded the session and recommended that we pursue a "cure" rather than a "fix" due to husbands age. This doctor does no surgery or radiation treatment so we felt very comfortable with his recommendations. He ultimately gave us a recommendation for the best doctor/surgeon in the St. Louis area that uses the 'da Vinci" for prostrate removal. The reasons we went with prostrate removal are:

We were looking for a "cure" not a "fix".

Radiation will cause the blood vessels to become brittle. If you pursue radiation as the treatment of choice and the cancer recurs later down the road then getting the prostrate removed is no longer an option. There are only a handful of doctors in the USA that can/will remove the prostrate after radiation treatment due to the damage caused by the radiation. A second session of radiation will cause more damage and so on. Recovering from the side effects will probably take longer each time. Your husband is very young and his chances of recurrance are probably high.

Prostrate removal using the "da Vinci" leaves the nerves intact. Husbands chances of a normal sex life are greater after recovery.

My husband's first statement after learning that he had prostrate cancer was, "No doctor is going to cut on me!" Guess what?! My husband had surgery on Monday, July 20th, was sitting in his room at the hospital 2 hours later as if nothing happened and was discharged the next morning. He went home with a catheter and his follow up appointment in Tuesday (catheter will be removed). He has pain from the surgery, leakage from the incision for the drain in the surgery site and had to figure out how to drain the "urine bag". He still feels that our decision was a good one.

Take care and the best of luck. Let me know if you have any questions.

 
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