I am 51 years old, in good health and have just been diagnosed with PC. Dr. said it is in Stage 1 T1. My PSA was 5.3, retest was 3.9 with a Gleason Score (3+3) 6. Bone scan and CT showed no other cancer. Being only 51 am I a canidate for Active Surveillance? Or should I consider other forms of treatment? I am also considering Tomo Therapy(IMRT). I am interested in hearing anyones thoughts or comments.
Yes you are a candidate for Active Surveillance. NCCN guidelines define "Low Risk" as T1-2a, Gleason score ≤6, and PSA <10. They recommend Active Surveillance as one alternative for all Low Risk men. Other institutions may add qualifications on the number of positive cores, the % cancer in them and PSA density. I think that if you're comfortable with quarterly PSA tests, semi-annual DREs, and occasional re-biopsies, it's a great option. You can also find online an MSK nomogram that will show you the odds of extracapsular penetration for your specific biopsy results.
I just learned that a new pencil beam proton center opened in NJ. It is still a very new treatment with only two year published results (from Florida), and I'm not sure I'd want to be the first on my block to be treated at the new center, but it's worth watching. I think it's conceptually a vast improvement over the old proton treatments. I had CyberKnife treatment (5 treatments) which just published its very impressive five year results. HDR Brachytherapy monotherapy (2 inpatient treatments) has excellent eight year results. And LDR Brachy (seeds - 1 inpatient treatment) as practiced at MSK across the river from you has had equally impressive results. Tomotherapy is just a brand name for a kind of IGRT/IMRT and requires 40+ treatments.
Focal therapy may also be an option for you if your biopsy showed insignificant amounts of cancer.
Allen, Thank you for your reply. I think I will follow Active Surveillance until I can research the different treatments. One reason I am concerned about AS is that I am only 51. Being on the younger side is their a chance my cancer is more aggressive? If I was 70 it would be an easier decision. I spoke to my Urolegist about Cyberknife and he did not recommend it. He said it is new and not enough past history on it's results. Also the radiation levels are very high. He recommended the Tomo Therapy(IMRT). If anyone is currently pursueing Active Surveillance I would like to hear from you and your story.
You can do AS if it is monitored by a doctor that is familiar with AS, As you said at 70 it would be a no brainer, but at 50 it gets a little trickier. If I were embarking on an AS program I would get a Color Doppler Ultrasound or an MRIS with a 3 telsa. These scans will identify the size and location of the tumor so you can make a better decision and can also be used as a baseline to identify any future progression. There is a good probability that you will have to be treated somewhere in the future and all studies indicate delayed treatment has the same results as immediate treatment in low risk cases.
Read "Invasion of the Prostate Snatchers" for a good protocol on how to monitor AS.
If you do choose treatment consider Brachytherapy instead of beam radiation as it is 1 hour vs 45 procedures and delivers a higher dose to the prostate without affecting other tissues, resulting in lower side effects and better cancer control.
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Tomotherapy was started for prostate cancer in 2003, the year after CyberKnife was started for prostate cancer -- they have both been around for about the same amount of time. The five year results for CyberKnife have just been published and they are excellent.
The reason CyberKnife is superior in terms of cure rates and lower side effects is because the radiation is more intense (about 35 Gy delivered in 5 sessions) but less than half as much in total compared to tomotherapy or other IGRT/IMRT (about 80 Gy delivered in 40 sessions). However, the "biologically effective dose (BED)" is much higher with CyberKnife. The reason for this was because they found that prostate cancer is peculiar in that the cell kill rate is higher with more intense blasts of radiation, while healthy rectal and bladder tissue is better able to repair itself from a few intense blasts than from sustained low doses. They learned this from the success of HDR brachytherapy (temporary implants) which showed a similar advantage.
You have already learned what many prostate cancer patients eventually have to -- all doctors only recommend treatments they know or have a financial interest in. I interviewed three urologists and two radiation oncologists before I made up my mind. Urologists tend to be specially ignorant about radiation techniques. Even Radiation Oncologist tend to recommend only the technique they are most expert in.
I don't know what it takes for you to get into NYC from where you are, but Dr. Zelefsky at Memorial, Sloan, Kettering (MSK) is one of the top radiation oncologists in the country, and Dr. Alan Katz in Flushing, NY has done more CyberKnife treatments than anyone -- both worth taking to. You didn't mention surgery, and I'm usually not a big proponent, but Dr. Ash Tewari has a new kind of torsionless neurovascular bundle/penile oxygenation technique for which he reports 93% return to their baseline sexual function and extremely low rates of incontinence. I think it's worth hearing his opinion as well. I can't recommend any of them personally, but only know of them through their published research.
Active Surveillance is not just for old folks anymore. In the event that all you have is an indolent tumor, you may never have to experience the side effects of treatment, and all treatments have side effects. There is no danger to you in monitoring it, and if you find that it is progressing 10 years from now, you will still have all the same options open to you that you have now, plus you will have all the new treatment options developed between now and then. MSK is an NCCN medical center and has an excellent active surveillance program -- ask Dr. Zelefsky about that too.
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