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Old 09-15-2010, 07:41 AM   #1
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Seminal Vesicle sparing RP

I've been reading about studies that indicate that retaining the Seminal Vesicles during an RP allows for the potential to decrease the side effects of RP. This is something that can be done only in low risk, slow growing cancers ( I meet the requirements that would be imposed for this).

Has anyone read about this approach or had any experience with it? The results I've read sound promising - decreased side effects and shorter time in surgery. I'm interested in learning more about it.

 
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Old 09-29-2010, 04:24 PM   #2
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Re: Seminal Vesicle sparing RP

Hi,

By this time you may have already learned all you want to learn about RPs that spare the seminal vesicles, but you can check all the research that's been published about it by using this search string at www.pubmed.gov (without the quotation marks):
" prostate cancer AND seminal vesicle sparing radical prostatectomy "

PubMed is a site we can use on this board because it is sponsored by the Government.

I just ran the search for curiosity and got 68 hits. I used the Limits feature to limit the search to studies involving humans and that had abstracts, which slightly narrowed the list to 63. By typing on the title of the studies that look interesting, you can see a summary of the study and its key findings. Some of the studies have free links to complete copies of the studies.

You might also want to look again at active surveillance as arguably your best strategy. Prostate cancer is essentially two diseases, one potentially dangerous and even lethal (high-risk and intermediate-risk disease), and the other so mild that official medical guideline groups are recommending no treatment, just monitoring to make sure the cancer is not a wolf masquerading in sheeps clothing. As one expert doctor put it, true low-risk prostate cancer is as dangerous as a case of dandruff.

There is a new book out with several chapters that bear on the decision making issue for low-risk men, including a chapter specifically on active surveillance. It's "Invasion of the Prostate Snatchers--No More Unnecessary Biopsies, Radical Treatment Or Loss Of Sexual Potency," by Ralph H. Blum and Mark Scholz, MD. It was published in late August. I've now read about two thirds of it, and it's very good. Dr. Scholz was Dr. Strum's partner before Dr. Strum semi retired. The Primer gave relatively brief attention to active surveillance; that is easy to understand as the first edition was published in 2002, prior to any results from the major AS series were published. The second (and latest) edition was published in 2005, prior to many of the major papers on AS. It's great to have a fresh book, closely relating comments to research, that gives insightful coverage to active surveillance.

Good hunting,

Jim

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Old 09-29-2010, 08:50 PM   #3
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Re: Seminal Vesicle sparing RP

Thanks for your comments Jim. I won't repeat my deliberations in this thread except to say that after speaking with a radiation oncologist, I discounted radiation as a choice for me. Ultimately, I could not reconcile the late term risks of ancillary cancers. I just turned 50. My life expectancy is at least 25 years, hopefully more. And, no one can give me an assurance the radiation will be safe for the long haul. There's probably a low risk, but no one will make any guarantees. There were other reasons that I decided against any form of radiation, but they're not relevant to this thread. At 50, it's the right choice for me. If I were 60 or 65 I would have analyzed radiation differently based on my life expectancy.

I have, however, seriously considered Active Surveillance. I'm close enough to the cut off where my doctors would be OK with it if I chose it and would recommend it if I were 65. I have 3 cores positive of 12 (Gleason 6 less than 5% cancer PSA between 3 and 4 after 3 tests) and technically, the cut off I've read about is less than 3 cores. One doctor told me my cancer is not truly insignificant - that 1 core positive is more like the dandruff metaphor you used. Suffice it to say, I'm not worried that I'm going to die of prostate cancer if it's left untreated for another 10 years. I might, but I think it's highly unlikely.

So, why not AS? Well, if I were 60 I would have a more difficult decision. At 65 or older, there would be very little question in my mind. But, at 50, I feel that chances are I'm only deferring treatment and that at some point I will have to treat this. Plus, I have a young family and a busy lifestyle. I don't have time to fight cancer. And, at my age active surveillance means ACTIVE surveillance.

I would start by having a very invasive biopsy under a general anesthesia. This would determine the true extent of my cancer and whether it was actually more pervasive than the original 12 core biopsy indicated. If I were to receive an all clear on this biopsy, I'd have to begin the diet and lifestyle changes necessary to fight cancer that I know is inside me but that's probably indolent and slow growing. I'm OK with diet and exercise because I do this now. But, the semi annual PSA tests, the biopsies, and the worry are something that I'm not sure I'd be OK with - especially when there is a chance that I won't out run the cancer and that, instead; I'm merely deferring treatment.

This is a hard decision for me. I read about unnecessary surgeries all the time. But, at 50, I'm not willing to rely on the probabilities contained in the studies. After my second PSA, there was only a 20% chance that I'd have a positive biopsy. Those are great odds. I still lost.

The seminal vesicle sparing radical prostatectomy is a way to hopefully diminish side effects even more than the never sparing prostatectomy. Since it's a random study, I've got a 50/50 chance of being selected. And, I'm more comfortable concluding that my cancer is confined to the prostate (and accordingly, the risk of removing only the prostate and nothing else is very low) than I am concluding that I can out run the cancer by following AS.

So, that's the "down and dirty" on my decision making. I'll never know what was right unless the biopsy after my surgery shows more aggressive cancer or, in the alternative, it shows that I didn't have cancer after all. As everyone here knows - this sucks! I wish I had never heard of a Gleason score.

 
Old 09-30-2010, 02:24 PM   #4
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Re: Seminal Vesicle sparing RP

Hi,

It's clear that you are almost comfortable with robotic surgery, but I sense you are still not completely comfortable with it. Because of that, and because you may be making decisions based on some misimpressions, I'll add some comments. You wrote in part:


Quote:
Originally Posted by Mr.M View Post
Thanks for your comments Jim. I won't repeat my deliberations in this thread except to say that after speaking with a radiation oncologist, I discounted radiation as a choice for me. Ultimately, I could not reconcile the late term risks of ancillary cancers. I just turned 50. My life expectancy is at least 25 years, hopefully more. And, no one can give me an assurance the radiation will be safe for the long haul.
That risk is quite small, but many of us are comfortable with some risks and not others. I understand where you are.

Quote:
There's probably a low risk, but no one will make any guarantees. There were other reasons that I decided against any form of radiation, but they're not relevant to this thread. At 50, it's the right choice for me. If I were 60 or 65 I would have analyzed radiation differently based on my life expectancy.
As for cure rates long term, radiation is really looking good as quite long-term studies continue to be published. Moreover, most of the patients who are going to recur do it within five years; that makes the success curve fall off slightly in the early years and then flat line (a good thing) - neglibible additional falling off. While no guarantee of continued success, it is a very encouraging indicator that that vast majority of low-risk patients who are successful at the five year point have been cured forever. With surgery, while the continued fall-off is not steep, it continues indefinitely as the years pass.

Quote:
I have, however, seriously considered Active Surveillance. I'm close enough to the cut off where my doctors would be OK with it if I chose it and would recommend it if I were 65.
Here's where I want to make sure you are not being influenced by a misimpression (or possibly by a sales pitch that is not based on your best interests). Just a few years ago, most of the major active surveillance programs (which happen to be among the leading prostate cancer surgery centers as well, though the overlap is not 100%) were not comfortable with younger men on AS, the Toronto program being an exception (any age), and the Erasmus Medical Center program being comfortable with men as young as 55. How that has changed! Dr. Peter Carrol, a prominent PC surgeon from the UCSF, called a conference of 200 world experts in AS in 2007. They reached a consensus on eligibility criteria, and they also reached a consensus that age should not be a consideration, opening AS as an option to a far greater number of men.

If you reached a conclusion that you were too old for AS on your own, that's understandable. It's tough to navigate the world of PC information, and I did not know about the 2007 conference either until a week ago. I'll bet there are many doctors who still do not know about the changed viewpoint of experts toward age for properly eligible patients. It's also possible that your surgeon did know, but is reluctant to go with the change for whatever reasons.

The bottom line: age should not count in ruling AS out!


Quote:
I have 3 cores positive of 12 (Gleason 6 less than 5% cancer PSA between 3 and 4 after 3 tests) and technically, the cut off I've read about is less than 3 cores. One doctor told me my cancer is not truly insignificant - that 1 core positive is more like the dandruff metaphor you used.
I suspect the doctor is thinking based on obsolete information from the days of 6 and even 10 core biopsies. The "more than one core" thinking was based on the 6 cores era, and it just did not fit with the emergence of 10 and especially 12 core biopsies early after the turn of the century. The 2007 conference reached a consensus that AS was okay with up to a third of biopsies positive, which of course means 3 of 12, which you meet. (Of course, if you have a 20 core biopsy and 6 are positive, I think anyone would look hard at that.) It's possible you are getting a pitch to sell you on surgery, one that leans on some now obsolete information. If you don't like being near the threshold, that's understandable; just so you know what the new thresholds are.

Quote:
Suffice it to say, I'm not worried that I'm going to die of prostate cancer if it's left untreated for another 10 years. I might, but I think it's highly unlikely.
I've been aware for a while now that virtually 100% of low-risk patients are alive at the five year mark. I've just learned that that's also true for intermediate-risk patients. Ninety five percent of even us high-risk guys are alive at the ten year mark.

Quote:
So, why not AS? Well, if I were 60 I would have a more difficult decision. At 65 or older, there would be very little question in my mind. But, at 50, I feel that chances are I'm only deferring treatment and that at some point I will have to treat this.
When you put together all the men now on AS in the major programs that are reporting and updating results, the numbers are large, well over a thousand, and include many younger men. Overall, it's looking like the older eligibility criteria are producing a long-term success rate of about 70%, with those going on to treatment having virtually the same success as those initiating it early without going on AS. Most of those needing to leave AS do so after monitoring results around the second and third full year points, which means they have enjoyed a full quality of life for those extra years without the extra burden of care that typically attends prostate cancer treatment, in addition to the recovery period. With the aid of modern technology, we are fully capable of catching and do catch many incidental prostate cancers that are highly likely to never require treatment, even at young ages.

Quote:
Plus, I have a young family and a busy lifestyle. I don't have time to fight cancer. And, at my age active surveillance means ACTIVE surveillance.
If it were me doing active surveillance, assuming my current level of motivation (my life is at stake!), I would pursue a demanding kind of active surveillance involving many lifestyle changes, as I have done to support my intermittent androgen deprivation therapy, thereby minimizing side effects. Essentially, that would (and has involved) a lot of nutritional changes, strength exercise added to the aerobic exercise I was already doing, and some stress reduction (limited perhaps by work and family demands, as it was and still partly is for me). I would also start the mild medications finasteride (or Avodart) and a generic statin.

However, I can say for almost a certainty that many of the men in those AS studies have not done much more than be monitored per the AS rules of the programs they are under. I say that because I'm been amazed at the unsound eating habits and lack of exercise that is evident at prostate cancer patient conferences I've attended.

So that leaves the burden of monitoring. Usually the monitoring is pretty simple: DREs, PSAs and a biopsy at years two and three, with biopsies every few years thereafter depending on the results. Sometimes some imaging is also done. (If it were me, I would have a color Doppler ultrasound done by an expert every few years, but few do that, I think). The new book "Invasion of the Prostate Snatchers" spells out the author's extra diligent AS monitoring program for his patients on page 68:

Baseline spectrographic endorectal MRI and color Doppler ultrsound
PSA every 3 months
PCA-3 at baseline and every 6-12 months
Rectal exam every 6 months
Color Doppler ultrsound semiannually
Spectrographic endorectal MRI annually.

It's worth considering that the documented AS success rates have been based on less demanding eligibility and monitoring practices. Success would surely be even higher if more demanding eligibility practices had been used!

It's also worth considering the relative burdens of surgery recovery, side-effects, and post-surgery monitoring versus AS monitoring, even allowing for a proportion of patients who need to go on to treatment. It's not as if surgery was a cakewalk. Obviously, if the patient is successful on AS long-term, the burden, for the average patient, will be far lower than for surgery and its aftermath. Ultimately, while sound information helps, these are calculations that can only be made by each of us personally.



Quote:
I would start by having a very invasive biopsy under a general anesthesia. This would determine the true extent of my cancer and whether it was actually more pervasive than the original 12 core biopsy indicated.
In a sense that would be the ideal way to get the most information about the cancer. However, the leading doctors I am following are not recommending that, though they respect that it is the ideal method if you only consider nailing down the cancer. However, in view of patient tolerance of the procedure, potential side effects and complications, cost, convenience and especially the effectiveness of alternatives, they are not recommending such saturation biopsies. Instead, they are going with color Doppler ultrasound, perhaps adding endorectal MRI with spectroscopy, and perhaps adding PCA3. They feel a lot of confidence that their patients will do better than even the fine results of the major AS programs with these extra measures.


Quote:
If I were to receive an all clear on this biopsy, I'd have to begin the diet and lifestyle changes necessary to fight cancer that I know is inside me but that's probably indolent and slow growing. I'm OK with diet and exercise because I do this now.

That's good, and these tactics are important because they are what are needed for giving us the best shot against other much more serious threats, such as heart disease, stroke and diabetes.

Quote:
But, the semi annual PSA tests, the biopsies, and the worry are something that I'm not sure I'd be OK with - especially when there is a chance that I won't out run the cancer and that, instead; I'm merely deferring treatment.
Consider that the PSA tests would not be much different as a burden from what you would have anyway to monitor for recurrence after surgery. That said, some of the other wise steps would be a greater burden than post-RP monitoring, but, as noted above, you would not be potentially wearing diapers for months or worried about ED or how to work a penile injection system or vacuum device.

As for the worry about the cancer, men of this generation are still bearing the burdens of past beliefs about prostate cancer, and that is, unfortunately, something that is slow to change. The reality is that low-risk cases are typically as serios as dandruff, or, the analogy I prefer, a healthy appendix. Think of it: most of us are living with healthy appendixes; yet, even though they can kill us in just days if they are not timely treated and burst, we are comfortable with the risk. We know that we can take the proper steps to give us a near 100% chance of success. The same is true with low-risk prostate cancer, but it is hard for us to see that. It will be a lot easier for our children.


Quote:
This is a hard decision for me. I read about unnecessary surgeries all the time. But, at 50, I'm not willing to rely on the probabilities contained in the studies. After my second PSA, there was only a 20% chance that I'd have a positive biopsy. Those are great odds. I still lost.
Dr. Peter Scardino is a famed surgeon for prostate cancer who practiced at Baylor University and now practices at Memorial Sloan Kettering in New York. Despite his great talent, only 62% of his patients achieved what was termed the "trifecta" of cure, continence and potency. From one standpoint, that is nearly two thirds success, and impressive. From another, it could be viewed as a roulette with one of three chambers loaded. Those odds would be great if the surgery is necessary; the problem is that we now know with great confidence that about two thirds of such low-risk surgeries are not necessary. These are the odds you need to work your way through before getting on that gurney. (By the way, Dr. Scardino's patients were a younger group than typical, averaging age 58. (Invasion, p. 122))

Quote:
The seminal vesicle sparing radical prostatectomy is a way to hopefully diminish side effects even more than the never sparing prostatectomy. Since it's a random study, I've got a 50/50 chance of being selected. And, I'm more comfortable concluding that my cancer is confined to the prostate (and accordingly, the risk of removing only the prostate and nothing else is very low) than I am concluding that I can out run the cancer by following AS.
I'll raise a final point as your "devil's advocate." By waiting a few years on AS, patients get the huge advantage of being able to enjoy advances made in therapy, case management, supportive measures, etc. during their time on AS. If you chose to wait, you would be able to see the results of the very study you are now thinking of entering! I've been awed by the great advances made since I was diagnosed back in 1999; so much is improving every year! On the other hand, by going ahead, you would be making a substantial contribution to medical science, and that would be something to be proud of.

Quote:
So, that's the "down and dirty" on my decision making. I'll never know what was right unless the biopsy after my surgery shows more aggressive cancer or, in the alternative, it shows that I didn't have cancer after all. As everyone here knows - this sucks! I wish I had never heard of a Gleason score.
Amen!

If you choose surgery, may you achieve the trifecta and join the 62%! May you be one of the especially fortunate guys who recover in all respects within a few months!

Good luck with whatever course you ultimately choose!

Take care,

Jim

Last edited by Administrator; 12-15-2010 at 09:44 AM.

 
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