Surgery or Brachytherapy (seeding)

[patrick1111]

New to the website....Diagnosed 11/07 in Stockton, Ca. Dr. Garbeff performed the biopsy. He took 20 samples and found 30% cancer in one of the samples from the lower right area. Gleason 3 + 4. PSA 2.6, which could be a supressed number because I've been on propecia (finisteride), for hair loss for at least 5 years. The bone scan was negative. The urologist/surgeon in Stockton, Dr. Garbeff, suggested RP and he does it the old fashioned way. My wife and I have always gone to the big city for important medical problems and have had great success in the past. I'm now dealing with UCSF. After speaking with the surgeon, Dr. Konetti, I was ready to have him do RP using the Da Vinci Robotic, which is the only way they do the procedure at UCSF. He asked if we had enough time to stay for an ultrasound which was performed by Dr. Shinohara who just happens to be one of the foremost authorities on brachytherapy. After making an appoinment and speaking to him I was ready to have him perform brachytherapy. My hesitation was that with RP they remove some lymph nodes in the proximity for pathology and with brachytherapy you just have to hope that the cancer hasn't gotten to them yet. Dr. Shinohara said that in his opinion all that I needed was brachytherapy and no external beam radiation. He said that he understood my concern and suggested that I speak to Dr. Speight, radiation oncology, in the basement of UCSF. She works hand-in-hand with Shinohara performing the brachytherapy procedure. She disagreed with Shinohara and said that I should have brachytherapy in a lower dose and then external beam radiation to the prostate and lymph nodes in the proximity of the prostate. I asked her to get together with her partner, Shinohara, and see if they could reach agreement. She said she would not only do that but would present my information to the "tumor board" for evaluation. That should take about 2 weeks, maybe until the first week of February, 2/08. Then possibly a 6 week waiting period before surgery. Is it true that statistics, as far as brachytherapy, can only give about 15 years of reliable data for longevity, because they haven't been doing it for any longer? Still weighing the options but I'm leaning toward just having brachytherapy with no external beam radiation. Any input would be greatly appreciated. Thanks.

[CapBob]

Originally Posted by patrick1111

New to the website....Diagnosed 11/07 in Stockton, Ca. Dr. Garbeff performed the biopsy. He took 20 samples and found 30% cancer in one of the samples from the lower right area. Gleason 3 + 4. PSA 2.6, which could be a supressed number because I've been on propecia (finisteride), for hair loss for at least 5 years. The bone scan was negative. The urologist/surgeon in Stockton, Dr. Garbeff, suggested RP and he does it the old fashioned way. My wife and I have always gone to the big city for important medical problems and have had great success in the past. I'm now dealing with UCSF. After speaking with the surgeon, Dr. Konetti, I was ready to have him do RP using the Da Vinci Robotic, which is the only way they do the procedure at UCSF. He asked if we had enough time to stay for an ultrasound which was performed by Dr. Shinohara who just happens to be one of the foremost authorities on brachytherapy. After making an appoinment and speaking to him I was ready to have him perform brachytherapy. My hesitation was that with RP they remove some lymph nodes in the proximity for pathology and with brachytherapy you just have to hope that the cancer hasn't gotten to them yet. Dr. Shinohara said that in his opinion all that I needed was brachytherapy and no external beam radiation. He said that he understood my concern and suggested that I speak to Dr. Speight, radiation oncology, in the basement of UCSF. She works hand-in-hand with Shinohara performing the brachytherapy procedure. She disagreed with Shinohara and said that I should have brachytherapy in a lower dose and then external beam radiation to the prostate and lymph nodes in the proximity of the prostate. I asked her to get together with her partner, Shinohara, and see if they could reach agreement. She said she would not only do that but would present my information to the "tumor board" for evaluation. That should take about 2 weeks, maybe until the first week of February, 2/08. Then possibly a 6 week waiting period before surgery. Is it true that statistics, as far as brachytherapy, can only give about 15 years of reliable data for longevity, because they haven't been doing it for any longer? Still weighing the options but I'm leaning toward just having brachytherapy with no external beam radiation. Any input would be greatly appreciated. Thanks.

While I can't speak to the brachytherapy as I chose the robotic RP (surgery 12/07) which apparently went well (time will of course tell), I was very impressed in general with Shinohara (who did a great job on my biopsy) and to a lesser extent Konetti who I consulted with before having choosing to have my robotic RP in Concord with Dr. Steven Taylor. The conventional wisdom is that the more robotics under the belt, the better. Konetti, while seemingly very sharp and personable has somewhere around 70 of the robotics under his belt, which is on the lower end of the experience spectrum. In fact, the head of the department there (Carrol?) hasn't done all that many and he's the most experienced on property. As I recall UCSF has only been doing the robotic for about two years now. The doctor I chose has been doing it for over five years and has at least 500 robotics. In my case I was a 5.0 PSA with the biopsy indicating mostly 3+3 and some 3+4. In the surgery he took 17 lymph nodes, the seminal vesicles, the bladders base resection margin and of course the gland itself and sent it all to pathology. The post surgical pathology indicated that the cancer was confined to the gland (all margins being clear), the lymphs and bladder resection and seminal vesicles clear as well...an obvious relief. However, as in some cases I was upgraded to 3+4 with a bit more tumor volume than the biopsy suggested. While from what I've read, the radiation therapy is as effective in stopping the cancer growth there is an element of mystery if you will as to if it spread, other than the follow-on PSA tests that everyone takes. For me, age (45) along with career reasons made surgery my only viable option. A month after catheter removal the incontinence has improved a lot, and I am beginning to tackle the impotence issues. While radiation spares you those little joys (up front at least) thus far on balance I am happier having gone with the surgical option. Unfortunately you can't ever be sure you did the right thing, so just do the best you can do.

[able5]

Originally Posted by patrick1111

New to the website....Diagnosed 11/07 in Stockton, Ca. Dr. Garbeff performed the biopsy. He took 20 samples and found 30% cancer in one of the samples from the lower right area. Gleason 3 + 4. PSA 2.6, which could be a supressed number because I've been on propecia (finisteride), for hair loss for at least 5 years. The bone scan was negative. The urologist/surgeon in Stockton, Dr. Garbeff, suggested RP and he does it the old fashioned way. My wife and I have always gone to the big city for important medical problems and have had great success in the past. I'm now dealing with UCSF. After speaking with the surgeon, Dr. Konetti, I was ready to have him do RP using the Da Vinci Robotic, which is the only way they do the procedure at UCSF. He asked if we had enough time to stay for an ultrasound which was performed by Dr. Shinohara who just happens to be one of the foremost authorities on brachytherapy. After making an appoinment and speaking to him I was ready to have him perform brachytherapy. My hesitation was that with RP they remove some lymph nodes in the proximity for pathology and with brachytherapy you just have to hope that the cancer hasn't gotten to them yet. Dr. Shinohara said that in his opinion all that I needed was brachytherapy and no external beam radiation. He said that he understood my concern and suggested that I speak to Dr. Speight, radiation oncology, in the basement of UCSF. She works hand-in-hand with Shinohara performing the brachytherapy procedure. She disagreed with Shinohara and said that I should have brachytherapy in a lower dose and then external beam radiation to the prostate and lymph nodes in the proximity of the prostate. I asked her to get together with her partner, Shinohara, and see if they could reach agreement. She said she would not only do that but would present my information to the "tumor board" for evaluation. That should take about 2 weeks, maybe until the first week of February, 2/08. Then possibly a 6 week waiting period before surgery. Is it true that statistics, as far as brachytherapy, can only give about 15 years of reliable data for longevity, because they haven't been doing it for any longer? Still weighing the options but I'm leaning toward just having brachytherapy with no external beam radiation. Any input would be greatly appreciated. Thanks.

Maybe I missed it but did you mention your age?

[shs50]

I agree with Captain Bob and others that one of the major drawbacks to Brachtherapy and External Beam (including Proton Beam) for that matter is that the treatments are performed without dissecting any lymph nodes. In the absence of tissue and lymph node pathology one has no way of knowing whether all cancer has been eliminated. The only measure is frequent PSA monitoring which could be viewed as another form of "Watchful Waiting".
This was the main factor in my decision to have surgery in addtion to not wanting to relinquish the chance for a permanent cure vs ablation which might not be permanent.
Also the 10-15 year statistics on Brachytherapy are unclear because the technology has evolved so much in the past 15 years, the expertise and patient selection criteria vary widely as do the methods and materials used. Its a tough choice and I would think that age and health status would also be major decision points.

[IADT3since2000]

I'm interspersing some comments in green. I am a fellow survivor with no enrolled medical education, doing well since diagnosis in December 1999 with a challenging case, and was not eligible for the choices you have. Color me envious!

Originally Posted by patrick1111

New to the website....Diagnosed 11/07 in ... biopsy... took 20 samples and found 30% cancer in one of the samples from the lower right area. Gleason 3 + 4. PSA 2.6, which could be a supressed number because I've been on propecia (finisteride), for hair loss for at least 5 years. The bone scan was negative. ...ultrasound which was performed by Dr. Shinohara who just happens to be one of the foremost authorities on brachytherapy.

Those are good findings except for the Gleason, of course. Propecia is only one fifth as strong as finasteride, but it seems to me too that it is likely to have at least some of the same PSA suppression ability as finasteride. However, since finasteride suppresses PSA by about 50% (counteracting the cancer to an extent at the same time), I doubt Propecia would suppress the PSA by more than 50%. Therefore, it seems reasonable that your PSA without finasteride would not have been higher than about 5. I'm not familiar with the pathologists at UCSF, but I would have to think they are good.

After making an appoinment and speaking to him I was ready to have him perform brachytherapy. My hesitation was that with RP they remove some lymph nodes in the proximity for pathology and with brachytherapy you just have to hope that the cancer hasn't gotten to them yet. Dr. Shinohara said that in his opinion all that I needed was brachytherapy and no external beam radiation.... Dr. Speight, radiation oncology, ... works hand-in-hand with Shinohara performing the brachytherapy procedure. She disagreed with Shinohara and said that I should have brachytherapy in a lower dose and then external beam radiation to the prostate and lymph nodes in the proximity of the prostate...

The Memorial Sloan Kettering Cancer Center (MSKCC)has prostate cancer nomograms that help guage the effectiveness of surgery, external beam radiation, brachytherapy, or a combination based on the case characteristics you input. The nomograms can help sort out the risks and benefits of different approaches, and you can get an idea how much the additional benefit of external beam in addition to brachy would be in view of the characteristics of your case. The nomograms do not ask about current propecia use or allow for an adjustment, so you could double your PSA to make that a "worst case" piece of data. The Prostate Cancer Research Institute's hard copy and online newsletter "PCRI Insights" (no charge) had an article about using the nomogram a couple of years ago by Dr. Mark Scholz. While the nomogram has been updated, the article would still be helpful.

About the value of surgical sampling of nodes: It certainly gives a lot of good information as CaptainBob pointed out. However, even such sampling is well short of 100% assurance, and there is an emerging alternative that appears to be superior, though hardly as convenient. Here's what Dr. Charles Myers, MD, has to say about surgical sampling in his book "Beating Prostate Cancer: Hormonal Therapy & Diet," page 38-39: "... Sometimes the [cancer] cells enter the lymph nodes immediately adjacent to the prostate gland or they pass through to lymph nodes at the back of the pelvis next to the sacrum. The lymph nodes in these two areas are those most commonly involved with prostate cancer. For reasons that are not entirely clear, it's more likely for prostate cancer cells to infiltrate the iliac nodes on the left side of the body, even if the cancer is on the right side of the prostate. If you're at high risk for lymph node spread because of a high Gleason grade, high PSA, or tumor size, many surgeons will biopsy your pelvic nodes before doing a radical prostatectomy. But they never sample nodes next to the sacrum because those are difficult to reach." I suspect that inability to access certain nodes goes for node sampling when the operation is carried through to completion.

There is an expensive scan that is not used for low and low/intermediate risk cases called the fusion ProstaScint scan. It is good at spotting spread to nodes. But because of the low risk unless the case characteristics indicate a more challenging case, insurance will not cover it for lower risk cases.

There is another emerging scan, much less expensive, I think, known by a number of names such as USPIO (Ultra small SuperParamagnetic Iron Oxide high resolution MRI), Combidex and Sinerem, but no US center has demonstrated mastery of it yet, and insurance coverage may be a problem. Dr. Jelle Barentjz, in Nijmegen, the Netherlands, has developed a high reputation for his expertise and scans many US patients. The scan appears to be excellent at identifying and locating lymph node metastases; it appears to be far more effective than surgery for this purpose and in fact to be highly reliable in determining the presence of cancer in nodes. The US FDA has published information on the evidence for using this scan. Unfortunately, that evidence is not clear cut yet. I attended the FDA hearing, and came away discouraged, but the theory sounded highly promising. At least one expert brachytherapy/IMRT doctor, Dr. Michael Dattoli of Sarasota, Florida, plugs the Combidex scan from the Netherlands directly into his treatment planning software and is a real fan. I suspect that Dr. Shinohara may also do that. If you ask and find out, please tell us. And I would really like to know what he thinks of Combidex. UCSF is a one of the world's leading institutions in cancer imaging, and Dr. Shinohara is a part of that. Of course, for you the Netherlands would be quite a trip and probably not cheap, so Combidex might not be an attractive option

would present my information to the "tumor board" for evaluation. That should take about 2 weeks, maybe until the first week of February, 2/08.

You are so fortunate to get this team approach at a leading institution! You gain not just from the consideration of your specific case, but the board approach helps keep the institution's doctors sharp and current with the state of the art.

Then possibly a 6 week waiting period before surgery. Is it true that statistics, as far as brachytherapy, can only give about 15 years of reliable data for longevity, because they haven't been doing it for any longer?

Fifteen years of followup is actually quite good for any therapy, though of course we would like longer data. It used to be that five years of success was truly not enough to match up with surgery. But ten years of success looked pretty good. Now even surgeons coming to our support group tell us that surgery, brachy, and IMRT are pretty much equal in their effectiveness when the difficulty of the case is equal.

Still weighing the options but I'm leaning toward just having brachytherapy with no external beam radiation. Any input would be greatly appreciated. Thanks.

Good luck, take care, and I hope you keep posting,

Jim