If you have a very small tumor and you meet the requirements of Active Surviellance you may not have to get treated at all. "The Invasion of the Prostate Snatchers" by Mark blum and Dr Mark Scholz has a lot of information an AS and the latest protocols to monitor it.
A small tumor is treatable with the CyberKnife. You Gleason Score and PSA are the important indicators. The CyberKnife is a great choice for localized PCa. For conditions with increased risk of PCa spread the CyberKnife is used as a boost.
Don't know what you mean by "tiny" but if you mean it's only in a small number of cores, low % of core, gleason 6 or less, low PSA, unpalpable, you may be a good candidate for "active surveillance." In the following study they put it forth as a suitable option even for men under 70.
If it's confined to one lobe and you want to do something about it now, HIFU or cryoablation may be worth investigating.
If your life cycle is expected to complete in less than 10 years. AS may be a reasonable option.
All modalities have improved cure with lower stage of disease. If you are healthy and expect to be here in 10 years choose a modality that offers high chance of cure and low risk from the treatment and low risk of long term side effects. Look at the data form all modalities. Today's radio therapy will have a very high chance of cure and low risk of lasting side effects. I personally like hypo fractionation (HDR Brachyterapy, CyberKnife, SBRT in the hands of a very skilled Rad Oncologist) for cure. For low risk of side effects from the therapy delivery process and long term risk I like the CyberKnife. Other advanced radio therapy may offer excellent results with advanced imaging to define the target volume and new equipment and procedures to minimize the high dose to the rectum and bladder. Look at the data for HIFU and Cryo, no advantage of cure or reduced risk in my opinion and understanding of the published data.
Be a well informed consumer and you will do very well.
I think the point of Active Surveillance is this: why do something NOW and incur possible urinary, rectal, and erectile dysfunction if you can enjoy the next several years of your life symptom-free and do something later without any extra risk?
Prostate cancer often grows so slowly that one may still be at an early stage and have equal probability of eradicating it many years later. Also there are several medications such as finasteride and possibly statins and others that may at least further delay growth if not stop it altogether. And the longer we are able to wait, the longer we have to assess the success of other treatment modalities.
Here, for example, is a study comparing prostate cancer progression among men who had RP within 6 months of diagnosis vs men who chose Active Surveillance and waited a median of 18 months (range 7 to 76 months). The result was no difference in Gleason grade, non-organ confined disease or positive margins.
Last edited by Tall Allen; 09-02-2010 at 10:55 AM.
It is unfortunate that the vast majority of studies fail to adequately define the population and conditions. The abstract is not meaningful, in my opinion. It would be my guess your UCLA Radon Dr. would agree.
What is the patient age?
What is the patient ethnic heritage?
Gleason score of = or < 7 is a large fishing net. A Gleason score of 3-4 is different from 4-3 even though the total is 7.
PSA ranges typically < 10 or 10-20.
Men 55 years old with a Gleason score of 4-3 are at higher risk than a man of 75 with a Gleason score of 3-4. These two men are like comparing apples and oranges.
Were the tissue slides read by the same person?
Was the grading criteria the same for all men?
What is importan?
The Gleason score is one subjective indicator of prostate cancer risk. There are other factors to improve risk assessment such as PSA prostate size, tumor evaluation by DRE and color doppler ultrasound.
The rate of recurrence is the only meaingful measure vs adverse events from the treatment and loner term side effects.
It will take at least three years of PSA date, post surgery, to determine the impact of AS. And this data will only be meaningfull if the starting population is randomized with the same distribution of age, ethnic heritage, Gleason (3-3, 3-4, or 4-3) and same number of men in both groups.
What is documented in hundreds of studies is that cure rate from any modality of Gleason 6 with a PSA < will have a higher cure rate than a Gleason score of 4-3=7 and PSA range of 10-20.
Prostate cancer is a very complex disease with no indicators that will confirm if the cancer is indolent or aggressive or when an indolent cancer will turn aggressive.
If surgery is the only treatment option AS seems more a question or risk management.
However AS is of very little benefit to the patient, if the CyberKnife is the treatment. CK outstanding cure at three years from several centers with low risk of side effects. If other modalities can deliver a prescribed dose plan equivalent(including real time tracking) to the CyberKnife; science would suggest the same patient outcome assuming all conditions(total dose, dose fall-off slope, margin, etc) were the same. IGRT-IMRT in the hands of good doctors will result in very high cure rates and low risk of complications. In my opinion if you expect to live ten years treatment advanced radio therapy is a benefit, however the HealthCare/MEDICARE cost mat be higher. Recurrence is an expensive proposition for the patient and HealthCare/MEDICARE providers. We are a shortsighted society and end up paying in the end.
Good Luck to All!
Last edited by viperfred; 09-02-2010 at 12:10 PM.
We all like to poke holes in research that questions our pre-conceived notions. I don't know whether the control and treatment groups were perfectly matched on all parameters. I doubt it -- perfect matching on all the parameters you suggest seems impossible for any research study. If interested, one can read the full study in the peer-reviewed BJUI to find out.
AS is not a treatment modality I personally am using, but for this gentleman who has a "very tiny tumor," it might be worth considering. All treatments, even CyberKnife, carry the risk of acute and/or long term complications. My doctor, whom you seem to respect, has told me that long term complications are about the same, given an equally skilled surgeon or Radiation Oncologist. Living without those complications for even a few extra years may be a consideration for some of us. We all have to decide based on the amount of risk we are willing to take vs the risk of complications we are willing to endure.
CMS and private insures’ have started to use a phrase ” Evidence Based Health Care” as their guide lines for coverage. There is one big problem there is no “Evidence” gathered in randomized trials with controls to support a scientific conclusion. There was a MEDCAC meeting April 21, 2010 at CMS headquarters in Baltimore, MD for the treatment of prostate cancer with all forms of Radio Therapy. On a scale of 1
(low) to 5; the “Evidence” for each modality was rated as a 1. No modality has “Evidence” of superiority. My impression from this meeting is that Medicine is as much art as science and there is a lot of room for improving studies.
There are risk for every modality and there are risk for doing nothing. The risk of side effects from the CyberKnife, that require medical intervention, are very low. All advanced radiotherapy is improving patient outcome. However the “Evidence” takes years to develop.
For optimal care men must understand their specific condition and the risk and rewards for action or inaction. I hope men take the time to be informed consumers. That is the best we can do.