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Old 03-05-2010, 09:56 AM   #1
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CT and Bone Scans

I've received two opinions from two respected specialists in the Sacramento area. They (I'll call them Sam and Craig) both agree on the meaning of the bipopsy test scores, the aggressiveness of the my cancer, and that surgery is the best option for me. Both individuals seem highly compentent and, I might mention, over-worked.

Their advice differs in two significant ways:
1. Sam believes that the pathology report of the removed prostate is enough to determine whether to do a CT and/or Bone Scan. He recommends waiting until after the surgery so that we do not perform un-necessary tests.

Craig believes that my cancer appears aggressive enough that I should have a CT and Bone Scan prior to surgery to determine if surgery is even useful - In other words, if the cancer is in other locations of the body then removing the prostate is a useless exercise. At that point the recommendation would be radiation and hormone therapy to slow down the cancer rather than remove it.

2. Sam believes he should try to do everything possible to spare the nerves during surgery. However, if during surgery, he determines that there is cancer in the nerve bundles on either side of the prostate, he will not be able spare those nerves.

Craig says he will likely not spare the nerves on the side of the prostate where the cancer has been located. He wants to make sure that he has gotten all the microscopic cells that may reside in the nerve bundles.

Does anyone have any thoughts about these two different opinions between Sam and Craig?
Thanks
-Lido

Last edited by Lido; 03-05-2010 at 09:58 AM.

 
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Old 03-05-2010, 11:51 AM   #2
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Re: CT and Bone Scans

Over treatment is statistically rampant in PCa cases, but not in this case: Craig is the straight-shooter and gets my vote.

 
Old 03-05-2010, 01:25 PM   #3
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Re: CT and Bone Scans

Hard to say on the CT without more info. What was your Gleason score and psa? How many cores were taken, how many were positive, what percent cancer in each core? Probably more CTs are done than are necessary. But it depends on your stats.

If you do a bone scan, many (probably most) suggest DEXA scan. Most prostate cancer experts, however, will suggest Qct instead.

In terms of whether to spare nerves or not, most docs - in most surgery cases - will not make that decision until they get in there and see how things look. But it is possible that a doc might have a view on the likelihood of being able to spare nerves based on tumor location.

Make sure whatever surgeon you select has done many of them, and does them often.

Best wishes,

 
Old 03-05-2010, 02:09 PM   #4
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Re: CT and Bone Scans

Go with Craig - no ifs and no buts! I had IMRT radiation, and I recommend radiation over surgery to avoid incontinence and complete impotence. And if you have the surgery, and some stray cancer cells are detected later, you will have to have a full radiation treatment to kill them. The pelvic and bone CT scan should be given before any procedure to exclude spread of cancer before treatment begins. I suggest you avoid surgery, and the terrible side effects would have been a waste for you , and a money-maker for the urologist surgeon. If I were you, I would dismiss Sam as a charlatan! Seriously. P.S. You will have sexual dysfunction with radiation too - about a year after radiation, but not as bad as with surgery.

Last edited by Aguy44; 03-05-2010 at 02:15 PM.

 
Old 03-05-2010, 03:07 PM   #5
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Re: CT and Bone Scans

Thanks for the responses. Just to provide a bit more information that I should have provided:
My Age: 56
My Gleason score: 8
My PSA 6.3 (Velocity over 2.0 for last year and for the previous year)
Volume at 29% based on 12 core samples
My Brother and Father both had Prostate Cancer.
Thanks again
-Lido

 
Old 03-05-2010, 04:22 PM   #6
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Re: CT and Bone Scans

Welcome to the board hopefully you will find information and support here. It sounds like both of your opinions have come from surgeons.


edited

You may not have acquired a lot of understanding of your diagnosis yet. A couple of books that helped me are Dr Strum’s A Primer on Prostate Cancer and Dr Myers Beating Prostate Cancer (Diet and Hormone Therapy).

Your Gleason is 8. The higher the Gleason the more aggressive the cancer. You might want to ask for a second reading of the biopsy from a center that specializes in reading prostate cancer biopsies.

I would also ask for an opinion from a radiation oncologist. It will no doubt be different from those of the surgeons you have talked to. I am not sure where you are located or your insurance situation but I would think a bone scan and cat scan would make sense no matter which way you go.

Get the most experienced Dr you can at the best center you can. There is no substitute for experience especially with higher Gleasons

Last edited by Administrator; 03-07-2010 at 04:22 PM. Reason: inappropriate comment

 
Old 03-05-2010, 04:58 PM   #7
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Re: CT and Bone Scans

Thanks for your thoughts. I actually have two reports on the biopsy - one from a local lab and one from a lab in New York. Both labs reported a gleason score of 8. The second lab had additional calculations about the likelihood of the cancer returning within 8 years after the surgery - My likelihood of returning cancer is 45% for the period mentioned. I've also reviewed Partin tables and have a sense of what it all means to me.

You are correct that both opinions I received were from doctors who are Urology Oncologists who perform about 200 laporascopic robotic surgeries per year. Both individuals have over 20 years experience in Urology Oncology.

My main concern is whether to request a CT and/or Bone scan prior to any treatment chosen. Everything about this disease seems to be surrounded in controversy including the PSA which, in my case, turned out to expose a problem otherwise hidden. I know that some folks are dead set against surgery and some are dead set against radiation. Hopefully whatever choice I make will be the right one for my circumstances.

Thanks again.
-Lido

 
Old 03-06-2010, 09:22 AM   #8
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Re: CT and Bone Scans

I appreciate the responses on the differences between the two opinions I received. It's clear I will need to visit with my GP again to discuss this matter.

 
Old 03-06-2010, 04:30 PM   #9
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Re: CT and Bone Scans

Hi Lido,

I too would like to welcome you to the board with your case that poses some extra challenges. I feel an extra portion of empathy with you as my case also has been challenging, and I was also diagnosed at age 56, and two direct relatives had PC, both dying from it (my father and paternal grandfather). I've read through your post #9 today at 12:22 PM. I'll insert some thoughts in green in an excerpt of your post just before your last post..


Quote:
Originally Posted by Lido View Post
Thanks for your thoughts. I actually have two reports on the biopsy - one from a local lab and one from a lab in New York. Both labs reported a gleason score of 8. The second lab had additional calculations about the likelihood of the cancer returning within 8 years after the surgery - My likelihood of returning cancer is 45% for the period mentioned. I've also reviewed Partin tables and have a sense of what it all means to me.

Was the lab associated with Memorial Sloan Kettering in New York City? MSK is one of the premier sites for dealing with prostate cancer in the world. If MSK is the source of the projection, most of us who are prostate cancer veterans would consider that a reliable projection.

You are correct that both opinions I received were from doctors who are Urology Oncologists who perform about 200 laporascopic robotic surgeries per year. Both individuals have over 20 years experience in Urology Oncology.

The biases of surgeons and radiation docs have already been noted. Dr. Craig seems more open to the possibility of radiation as the best course, but more on that below.

My main concern is whether to request a CT and/or Bone scan prior to any treatment chosen. Everything about this disease seems to be surrounded in controversy including the PSA which, in my case, turned out to expose a problem otherwise hidden.

Actually, you are in luck there. Controversy is receding in a number of areas as research continues to be published. In April 2009, just last year, the American Urological Association (basically represents surgeons among the doctors treating prostate cancer) published its "Prostate-Specific Antigen Best Practice Statement." Ten doctors were on the panel, including Dr. Peter Carroll, MD, a highly respected surgeon, as the chairperson, from UCSF not far from you. The recommendations were later reviewed and endorsed by a larger group.

On pages 33 through 35 they make their recommendations about bone and CT scanning. Based on their review of published research on the effectiveness of bone scanning, they say "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." The reason is that useful results are just so rare in those circumstances. A bone scan does not prove you do not have bone mets, as usually at least 10% of involvement at a bone site is required before the bone scan will light up (actually, darken), indicating a possible metastasis. With a PSA of just 6.3, it's not likely a scan for you would hit the sweet spot: greater than 10% involvement, but likely not much more due to the low PSA. Your Gleason 8 might warrant a little more concern, but the outcome would still likely be negative. Bone scans are often negative even at much higher PSA levels. My scan was negative even though my baseline PSA was 113.6 (all cores positive, most 100% cancer, GS 4+3=7 back in December 2000). I'll give the nod to Dr. Sam on this one as it appears he is keeping up with the latest guidance. If you want, you can get a copy of the guidance document and check out the studies on which the recommendation was based. I'm impressed that Dr. Peter Carroll and other leading experts think bone scans are usually not necessary unless the case characteristics are distinctly high risk.

However, a "bone density scan", recommended by medved in his post #3, is a different matter. Decreased bone density is epidemic among prostate cancer patients, and I like his recommendation of a qCT scan, or even a DEXA scan. (My DEXA was positive, and I'm now using bisphosphonate drug therapy, first Fosamax but now Boniva, plus calcium and quality vitamin D3 supplements as countermeasures. It's working.)

On the other hand, the AUA guidance document would give a "go" for the CT scan due to your Gleason Score. Here's their recommendation: "Computed tomography or magnetic resonance imaging scans may be considered for the staging of men with high-risk 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 equalt ot 8." It's likely the result will be negative, but according to the experts, it's worth checking. Let's give the nod to Dr. Craig here.

But neither doctor is going strictly by the AUA guidance. That doesn't say they are wrong, as their is room for interpretation. But at least you now know some of the context.

By the way, some of the world's leading expertise in MRI with spectroscopy for evaluation of prostate cancer, and endo rectal MRI examination, is not far from you, again at the UCSF. There are some other options. One is a color Doppler ultrasound, with one of the world's leading experts, Dr. Duke Bahn, in Ventura near LA. Another is known as Combidex, a special way of scanning the lymph nodes, but that requires a trip to Belgium.

A word to Straightguy and to you: that 29% volume figure is probably a sound number that helps the doctors assess your case. About Gleason Scores, the top score is 10, so an 8 is definitely in the high risk zone. There are no 12, 15 or higher Gleasons.


I know that some folks are dead set against surgery and some are dead set against radiation. Hopefully whatever choice I make will be the right one for my circumstances.

Thanks again.
-Lido
Surgery works fine for some cases, radiation works best for others, cryo is great for some, and any of the three would work for some of us. In addition, some of us higher risk guys go straight to hormonal blockade, like me; by the way, incontinence is not an issue with that approach, and both a decrease in libido and in erectile function are temporary for most of us on intermittent therapy, especially with countermeasures.

One more point to mention, research shows that radiation appears to be as good at curing cancer as surgery, though surgeons are sometimes reluctant to see or admit that. Radiation is not just for control of the cancer without cure. Also, some of the world's best radiation expertise for prostate cancer is not far from you at Stanford, among other California locations.

Please keep asking questions. Being empowered is vital when you are facing a challenging case.

Take care,

Jim

 
Old 03-07-2010, 09:12 AM   #10
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Re: CT and Bone Scans

Jim,
You have provided a wealth of solid information and a lot to consider. I will find the paper you reference and will study it. Thank you very much for the time you spent in considering my questions.
-Lido

 
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