I know I have prostate cancer but still feel that based on my diagnosis surgery is somewhat elective. My family, friends and oncologist want me to keep my scheduled surgery date at the end of February. I've been evaluating the pros and cons of surgery since November and cannot come up with a clear decision. It would be great to be cancer free, but I'm much more concerned about the general risks of surgery plus the specific risks of this surgery - incontinence and impotence - than the cancer.
I interviewed many doctors when I was initially diagnosed and settled on an amazing doc, Dr. Agus at USC. I've met my prospective robotic surgeon Dr. Gill also of USC and feel great about having him do the surgery if I go that route. I'd appreciate any feedback that you may have to offer. Thanks!
Minor Mitral valve prolapse
No ED issues
12/2007 PSA 0.5
3/2009 PSA 0.6
8/19/2010 PSA 0.8 pre biopsy, DRE abnormality
8/30/2010 Biopsy - T1c/T2a, Gleason 3+3=6, Adenocarcinoma 2 (right base) of 14 cores 1.0 and 3.0 mm approx 50% of volume, elected active surveillance.
9/2010 CT scans all neg
10/7/2010 PSA 2.0 post biopsy
2/17/2011 PSA 1.1
11/11/2011 Biopsy T1c/T2a, Gleason 3+3=6, 4 positive of 14 cores - R Lat Mid 5% .06mm, R Mid 30% 4.5mm, R Apex 20% 3.0mm 1 of 2 cores, R Base 30% 4.5mm
12/20/2011 PSA 1.8 post biopsy
Last edited by LookAtOptions; 01-14-2012 at 06:43 PM.
It would help if you tell us more about your case - your age, PSA history, stage, Gleason score, # positive cores, total cores, % cancerous, prostate size, any experience of BPH, prostatitis, ED, and other issues that may affect outcomes (e.g., cardiovascular, diabetes, obesity, colitis, smoking, etc.). Did you get a second opinion on your pathology report from a prostate specialist lab? Have you talked to specialists in active surveillance? Which radiation treatments have you talked to specialists about (e.g., HDR brachytherapy, LDR brachytherapy, proton therapy, CyberKnife, IGRT/IMRT)?
I posted a rather long post (see my prev post) about my husband's DaVincci procedure that he had January 5th. Saw his surgeon yesterday and things are good...cancer was contained to the prostate, lymph nodes were clear...so far very little incontinence.
Active Surveillance is still a possibility for you, since in both biopsies you've had no cores greater than 50%, your PSA has not risen in the last year, and your Gleason score remains at 6. Running your numbers through the MSK nomogram, it shows a very high probability that it is still organ confined and a low probability of extracapsular extension. Why are you considering radical treatment now?
Because your cancer seems entirely confined to the right side, it opens up the possibility of unilobular surgery or ablation -- getting rid of the right side and preserving the rest of the prostate. I have a friend who just had this done at Cedars-Sinai, and many similar cases have been treated by Dr Bahn in Ventura.
If you want to pursue radical treatment (getting it all out), you owe it to yourself to explore radiation too. I found Dr. Demanes at UCLA particularly helpful at explaining all the radiotherapy options, even though I didn't wind up using the technique he invented - HDR brachy monotherapy. Loma Linda is known for proton therapy. CyberKnife, or a version of it, is done both at UCLA by Dr King (the man who first used it for PC) and Dr Fuller in San Diego. I don't know of any LDR brachy centers of excellence in the LA area, although Dr Demanes might.
Another avenue you can pursue is hormone therapy. Dr Liebowitz in Century City advocates a course of triple blockade hormone therapy as a cure for low risk PC. I should state that this is highly controversal. Dr. Scholz in Marina del Rey is also an eminent PC physician in the area who might open up new vistas for you.
Drs Liebowitz and Bahn and possibly Dr Scholz do not accept insurance. Most plans will not cover proton therapy.
Based on your numbers, you certainly have time to explore these options before making an informed decision. I am not discounting surgery at all, if your surgeon has done over a thousand such surgeries. As a young man with low risk disease, you are lucky to have many good options open to you. They mostly differ in the risk of side effects of treatment - urinary, rectal, and ED.
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My oncologist recommended active surveillance at the end of 2010. When the second biopsy came back with four vs two positive cores he suggested surgery. His reasoning, in summary, was that due to my age I go with the treatment that has provided the best cure percentage, 91%.
I did meet with the surgeon and he has done several thousands of these surgeries.
I met with Dr. Scholz a year ago, not an option for me.
I think I do need to slow it down a little and check out all the possibilities.
I agree with your conclusion. Keep in mind that biopsies are just samples. For example, you had at most 50% of a single core with cancer in the first biopsy, but at most 30% of a single core with cancer in the second biopsy. It's highly unlikely that the amount of cancer went down. Conversely, the four cores that were cancerous this time may actually have been there last time, if they had been sampled from exactly the same place. It's entirely possible that nothing has really changed.
The generally accepted Epstein criteria for Active Surveillance are: Gleason score 6 or less, PSA 10 or less, T1c-T2a, and for younger patients (age < 60 years), one third or fewer of cores positive, and no more than 50% involvement of any one core. You still have only 28.6% of cores positive, so on all those criteria, you fall within these widely accepted criteria.
While it's true that surgical outcomes are better while younger, every year of symptom-free living while younger is a good thing too. Surgically speaking, you still have several years in which you will be considered younger and can expect equally good outcomes. If the % chance of getting it all before it can escape the prostate were the only consideration, we would all have our prostates removed prophylactically.
The decision to treat is a very personal choice, and everyone comes at it differently. I'm glad if you're feeling less rushed, at least, to make an immediate decision.
I should add that Dr. Klotz, the father of AS, believes that to avoid overtreatment for men who have been on AS, there should be the additional criteria of PSA doubling time becomes less than 3 years, PSA velocity greater than +2.0/year, or grade progresses to Gleason 4+3 or higher. Fortunately, you don't fall into any of these either.
Hello, my numbers were a little differant than yours but all the same lots of decisions to be made. I was and still am 44, diagnosed September 2011 with a Gleason of 4+4, psa 6.5, T1c. Biopsy showed 1of 12 cores positive. I met with a radiologist, did alot of research, talked to several people that had pc and how they came to their treatment decisions. You have to be 100% comfortable with your decisions. Things couldn't have gone smoother and 2 months after surgery I feel great with still a little leaking when lifting, sneezing.... I've found that if I go sooner than later it also helps. No ED pills yet and things are working good, not like before but very close. My doctor said start the ED pills in 8 weeks (that's tomorrow) 1 pill a day, guessing that's gonna get me back to 100% or close. Final pathology showed no positive margins and a Gleason of 4+3. I go back in a month for a psa check. Friend of mine also 44 with a psa of 3.5 and Gleason of 6 T1c had surgery with positive margins but psa has come back 0's 2 times. His Gleason score went up to a 7 after surgery. Good luck with your decision, it's hard, surgery made since to me and I have no regrets, just glad it was caught before it spread!
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Abc40 thank so much for your reply. Glad to hear your surgery went so well. As of today i have cancelled my surgery and will go back in for a biopsy in august. In the meantime i am planning to gather more info and get a second and third opinion. I did meet with a radiologist who indicated that the staging is T1c not T2a. I dont understand how that could change.
Your radiologist is correct -- confined to one lobe, less than 50% involvement of the lobe, PSA<10, Gleason 6 meets the criteria for stage T1c. It doesn't really matter -- in either case you are considered low risk and all treatment options as well as Active Surveillance are open to you.
Check out Proton Beam Therapy. I was treated at Loma Linda after a failed RP. Do an internet search on Proton Support Groups and then search out all the other groups at the listed Proton Therapy Centers and sign up for the newsletters to find a wealth of information. Surgery often leads to incontinence and impotence problems for many patients. I think that side effect rates are downplayed for surgery and the few men that I have met who had robotic surgery all suffered serious side effects.
Proton has an extremely high cure rate with generally little in the way of side effects. Research Proton before making any treatment decisions.
I had a very similar case as yours and chose to do HIFU in Sept.2011, even though I am still only 5 months post op I would recomend you look in to it, it is by far the least evasive procedure, I only missed 2 days of work and played golf 6 days afterwards. Its a non issues of a procedure and you are home the next day. Steve
I am 63 and in good health. I was Gleason 7 (3+4) with 4.7 PSA which had been trending up. The biopsy came back with 1 sample of 20 showing cancerous cells. I had robotic surgery 1 month ago. If you have the option and decide to go with surgery, I would definitely recommend going that route. It was abt a 3 hour procedure. I was in my room at 5 Wed and walking around Thursday morning. Discharged Thursday abt 1. I had a cathether which was removed a week later. The doc said it was all enclosed in prostate and he expected no further treatment would be necessary.
I was very much doom and gloom before the surgery. None of the treatments are very appealing and the after effects on quality of life can be dramatic. The 3 main issues are bowel, continence and sexual function. Surgery seemed to lessen bowel issues and there was something appealing abt getting the cancer out. That swayed my decision for surgery.
When they removed the catheter, I had complete bladder control. No bowel issues and (pardon me) but the sexual part is working ok as well (although different!). I know I am not the normal case. But it does show there can be good results. I have had 2 friends who did not know of the cancer. One delayed treatment for a year and a half after it was found and by then it had spread and he died. The other friend is now at the end because his had spread before he knew abt it.
Everyone I talked to emphasized geting rid of the cancer, getting cured. Then you can deal with the treatment effects.
I found out on Nov 30, 2011 that I had cancer. My doc told me on Feb 1, 2012 that he got it all. That is the best case you can imagine!!!!
I am convinced that timing, with stage of cancer of course, and skill of surgeon are the keys. The urology group I went to had performed over 5000 robotic surgeries. My surgeon had performed over 1800. I asked abt their "effect" rates and they were significantly better than the national published rates. Their group had radiologists and they went over all options. I am schedule for a follow up in March.
Best of luck to you. It is not an easy decision and a very personal one in each individual case! I would be happy to discuss further if you want. Having friends discuss their cases was a real help to me.