Originally Posted by jawhik
I understand that prostate surgery is a dangerous procedure for a man over 70 with a health issue like my dad.
But, since it is less invasive, is a robotic prostatectomy as dangerous as an open prostatectomy for an older person with health problems?
I agree with shs50 (Bob) and kcon that surgery in whatever form is a questionable option at best for your dad, as I mentioned in another thread.
I'm a big advocate of active surveillance for truly low risk men and even for men with intermediate risk who are older or who have other health conditions, but it's a tougher call to choose that for your dad.
That's because he clearly has an aggressive case of prostate cancer, though it appears it has been caught fairly early. Gleason 7 prostate cancer for a 73 year old man with cardiac problems and other case characteristics on the low-risk side would probably be eligible for active surveillance in some of the major programs, such as the one overseen by Dr. Laurence Klotz in Toronto. But several points warrant concern:
- First, that Gleaon 9 cancer, which is usually quite aggressive, accounts for a substantial percentage of that one core at 40%;
- Second, the Gleason 7 cancer, which is usually moderately aggressive, accounts for virtually all of one core at 88%;
- Third, while Gleason 6 cancer is not very aggressive as a rule, finding it adds up to three locations where the biopsy hit cancer.
Have you found the exact reading of the latest PSA and the dates of the last two? It could make a difference whether the velocity was greater than 2.0 per year. It could also be useful to get another PSA test as another check on recent velocity, though interpreting two tests close together is often a bit cloudy as PSA varies for each of us on a day-to-day basis; it's not a great percentage, but 20% variation, for example, is not unheard of.
Your dad might want to get some additional staging, probably a CT scan first. That is quite unlikely to show cancer, but in its April 2009 guideline document, the AUA (American Urological Association) judged it warranted for a patient with Gleason scores above 7 even if the PSA is not high. (The AUA recommended avoiding "routine" use of a bone scan unless the PSA was 20 or higher, but your dad's case is not exactly routine, so a bone scan might also be useful.) If he wants to invest extra effort, a Combidex scan in the Netherlands would give an excellent view of any spread to lymph nodes, but the strains of the trip itself might make that of questionable value. An endo-rectal MRI with spectroscopy (at an expert center) could be valuable (preferable to a regular MRI - again per AUA guidelines), but it requires about an hour lying on the MRI platform with a rectal probe - not comfortable so I've heard!
Here's a list of some therapies that might be fairly low on the intrusiveness/risk scale but potentially helpful with the cancer:
- external beam radiation. (This includes the CyberKnife (with SBRT - basically meaning delivery in just five doses - about an hour long for the patient each time) that Bob mentioned, but that is still an investigational, non-standard therapy at this point, though widely available. If your dad does go for that choice, research strongly suggests the doses should be delivered with a day of rest in between. The key issue is that the likelihood of "late rectal toxicity" is not yet known; disturbingly high percentage of early patients in the major trial - those treated on five consecutive days, 38%, developed problematic late rectal complications.
It's encouraging that all later patients, treated with a day of rest in between doses, were doing well around the third year of follow-up.
That's good, but we would really like to get another couple of years before concluding that this approach is a good bet, at least if done by a center of excellence.)
- brachytherapy (radioactive seeds).
- cryosurgery (freezing). Cryo is referred to as surgery, but it is quite different and might be a good option for your dad.
- a mild form of hormonal blockade. The mildest form would be just one of the sister drugs finasteride (formerly Proscar) or Avodart. That would probably help a bit with the cancer, but would likely not add enough control. The next choice on the power scale would be a combination of the drug Casodex with finasteride or with Avodart. Dr. Mark Scholz, a leading expert with hormonal therapy, says that such a combination gives roughly 80% of the benefit of heavier duty approaches with roughly just 20% of the side effect burden. That might be all your dad needs. Hormonal blockade that includes the heaviest duty type drug, known technically as LHRH-agonists (such as Lupron, Zoladex, Viadur, Eligard, etc.) would probably not be a good choice as they have a significant risk of leading to higher cholesterol, unless countered with a statin drug, and other heart complications in patients with cardiac issues. Those issues don't rule out the use of the LHRH-agonist type drug, but they do make its use more complicated, requiring more attention and management, as well as the added risk.
Part of the choice for your dad is the seriousness of his heart issues. If they are under excellent control, that opens up options, and vice versa.
In any event, using lifestyle tactics would be wise. They include nutrition/diet/supplements, exercise (especially strength exercise), and stress reduction. A program could be tailored to your dad's ability at this stage. Here's a thread that provides an overview and leads (might have mentioned on the other thread): "Nutrition & lifestyle tactics - books, resources and a quick summary," started 3/6/2008. (A patient working on adopting these tactics does not have to do everything, but the more he can do, the better his odds. Research indicates these tactics can make quite a difference in achieving better outcomes.
Take care and good luck to you and your dad,