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  • Radical Prostatectomy OR Plant Based Diet?

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    Old 12-26-2019, 09:21 AM   #16
    DjinTonic
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    Re: Screening

    With regard to screening (and other areas of PCa and healthcare in general) I have concluded that there are two views that can lead to different decisions.

    The first is Public Policy and Standard of Care, or the view from above, which might look at the cost (not only financial) of widening screening: how many men need to be added to to save one life through earlier detection. (BTW I believe this stat neglects things like the number of men who live miserably for years from mPCA before dying from something else. )

    There is also what I call the Patient-centric View: if I and/or my doc is knowledgeable about avoiding overtreatment, why not screen earlier? Perhaps I'm the 1 in X cases whose high-grade PCa is caught very early; or I'll find out I'm G6 and just start my AS earlier. No harm is done. Why not be "selfish" (i.e., prudent) when deciding about one's own care? I see no reason, even with no personal or family risk factors, to wait until age X to have a first PSA test even though your doc may wait if you don't speak up.


    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 12-27-2019, 06:17 AM   #17
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    Re: Radical Prostatectomy OR Plant Based Diet?

    I agree. Diagnosis and treatment are two distinct choices. My preference is to have early diagnosis and the choice to treat is then before me. Late diagnosis limits or eliminates choice in effective treatment.

    Those who advocate for less and later screening justify it by dismissing the patient's ability to manage the process. It is outdated medical arrogance that exists to glorify the doctor and demean the patient, not to put too sharp a point on it.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    1-15-21 PSA less than 0.02; zero club 4.5 yrs

     
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    Old 12-27-2019, 08:52 AM   #18
    Michael F
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hi stephenwilliam! I stand in Djintonic's camp. Dietary modification to healthy intake is important for all individuals. I wish I had started at age 1!

    Experts have associated good dietary practices with a degree of "preventiveness." However, it is highly unlikely that dietary changes can reverse established PCa. Once the DNA changes have occurred, the repair mechanisms become either overwhelmed or in some cases, blocked.

    Fortunately, most PCas tend to progress slowly. You have time to get 2nd opinions from expert MDs who specialize in treating PCa and learn about the many treatment options. I did not see your age. Unless you are very young, Radiation Therapy (RT) should be looked into. There are several types of RT. Ultimately, you want the treatment option that best addresses your specific disease status and psyche.

    Changing to a plant based diet is a very good decision. Simultaneously, it is equally important to loose unnecessary weight and get on a regular exercise regimen (if not already doing so).

    A very good book to purchase is: Patrick Walsh, MD: Guide to Surviving Prostate Cancer 4th edition

    Keep asking questions and demand correct answers.

    Good luck on your Journey to Cure!

    MF

     
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    stephenwilliam (12-30-2019)
    Old 12-28-2019, 05:18 AM   #19
    IADT3since2000
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hi stephenwilliam,

    I read this in another post and fully agree with it: "BTW, I have yet to read any study that shows that surgery can match the non-recurrence results being reported by the two advanced types of radiation, SBRT and protons. Not even close." I would add another type of advanced radiation, Intensity Modulated Radiation Therapy with Image Guidance" (IMRT IGRT), which is what I had in one of several versions, mine known as TomoTherapy. For a long time advocates of proton therapy could claim a lower side-effect burden, in fact extraordinarily low, but for years now image guided IMRT with extended (~8 weeks) or short (SBRT) schedules have also notched extraordinarily low side effect rates. Be sure you take a look at rates for side effects, both short-term and several years out (say 5 - 6 for radiation, 2 - 3 years for surgery) to inform your current preference for surgery. Surgery can be a good choice for some patients based on circumstances, and some patients, perhaps you, just have faith in it that means that is the choice they "own." "Ownership" is important because most of us will have some side effects, often very mild and perhaps barely noticeable, from whatever treatment we have, and what is known as "treatment regret" will probably be avoided or minimized if our treatment is the one we chose rather than one we were pressured into or walked into ignorantly.

    Good luck.

    Last edited by IADT3since2000; 12-28-2019 at 05:20 AM. Reason: Minor addition right after posting.

     
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    Old 12-28-2019, 06:18 AM   #20
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    Re: Radical Prostatectomy OR Plant Based Diet?

    The choice of surgery or radiation as an initial treatment is one best made based on assessment of the individual's profile including all the factors of age, fitness, life expectancy and the status of the disease.

    Emotion is an obstacle to overcome in being objective. Choosing one over the other based in fear of one over another, the common myths of side effects, personal choice bias, professional bias, short term studies of 5 and 10 years on rapidly changing technologies and perceived treatment convenience is a disservice to the patient.

    In general, outcomes are similar. Individually, patients and the specific conditions of their cancer may be better candidates for one vs another. This is best assessed by a team including surgeon and radiologist.

    Here is a general study. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723424
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    1-15-21 PSA less than 0.02; zero club 4.5 yrs

     
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    stephenwilliam (12-30-2019)
    Old 12-29-2019, 04:52 AM   #21
    IADT3since2000
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hi again stephenwilliam,

    It may help to look at a study in depth, beyond the surface findings.

    The critical problems with this study, “Individual and Population Comparisons of Surgery and Radiotherapy Outcomes in Prostate Cancer Using Bayesian Multistate Models,”
    at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723424, available for free online, for a doctor or patient trying to make a decision today, is that it is quite obsolete (though interesting and useful historically and for the modelling technique).


    Patients were treated between 1996 and 2013. The first ten years of that 17 year period, 2,783 of the 4,544 patients were treated (61%, nearly two thirds), were prior to the routine use of modern image guided radiation. Moreover, for the first half dozen years or so, radiation doses were typically too low to help many advanced patients, which is no longer the case. Additionally, in those years healthier patients were often treated surgically while less healthy, older patients tended to get radiation, factors which definitely affect survival; for example, in this study radiation patients had a baseline (pre-treatment) PSA that was close to double the baseline PSA value of surgery patients, and the Charlson comorbidity index, an indicator of overall health, was far higher for radiation patients. Furthermore, back in the early years Androgen Deprivation Therapy was not always given from men with intermediate and high-risk patients getting radiation; ADT is now standard of care for those patients.

    Another huge factor influencing results is that a heavy proportion of low-risk patients is included; for instance, 2,038 of 4,544 (50%) had Gleason 5 or 6 scores; most of them would probably be managed with active surveillance today. Indeed the study notes that 1,399 patients (31% of total) had low-risk disease. This clouds results, as both radiation and surgery are going to have high odds of success in this group. The authors did look at this adjustment, and they felt that their adjusted conclusions were similar. I have my doubts, but I had trouble understanding what they did to adjust and interpret.

    We really need to look at just intermediate- and high-risk patients to determine whether there is a substantial difference between surgery and radiation, and, as noted above, we need to look at modern radiation that is supported by ADT, adequately dosed and image guided. Back in the period of most of this study, surgery WAS legitimately regarded as the gold standard; radiation, simply, was inadequate for many patients. This is why I took the gamble on waiting since 2000, while on ADT, for radiation to improve, hoping my cancer would not go out of control before that happened; I took my shot with radiation plus ADT in 2013. Surgery is no longer the gold standard versus radiation, as numerous studies have indicated, though it does appear to be a better choice in certain circumstances, even for higher-risk patients, and it does cure a substantial percentage of intermediate- and high-risk patients, just not nearly as many as radiation, from studies I have looked at. Both surgery and radiation results are better in the latter years of treatment in this study, but surgery was maturing earlier, mainly due to the continuing spread of pioneering advances by Dr. Patrick Walsh, MD.

    My own conclusion, drawing on my background that is unusually strong in statistics and experimental design, is that this study is such an apples to oranges, no, make that oranges to watermelons, comparison that it is of no use at all to patients and doctors today who are considering radiation versus surgery. The authors state that they made adjustments to equalize pools of patients, but I don’t see that the concerns I raised have been effectively addressed.

    In fact, because the radiation patients did about as well despite having much more serious prostate cancer, being older, being much less healthy, and many being treated with radiation that is not as good as what we have today, you could view this study as favoring radiation.

    I hope this helps.

    Jim

     
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    stephenwilliam (12-30-2019)
    Old 12-29-2019, 06:19 AM   #22
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    Re: Radical Prostatectomy OR Plant Based Diet?

    The debate is over. Radiation with ADT is the superior treatment path for prostate cancer.

    Good to know since it is my next level of treatment choice if my surgery fails to cure my cancer.

    As an aside to readers, this is an important example of the temptation of personal choice bias. Always read the poster's signatures to see what it may be. Doesn't necessarily mean it is, but an important filtering tool to managing assessment of the information and opinions shared here.

    Back to the original question, changing my diet and supplementing it lowered my PSA but it did not cure my cancer. My explanation is it reduced inflammation and lowered the PSA of healthier prostate cells. It had no impact on the cancer cells. They continued to grow.

    A caveat to the above statement is one about BHP. PSA can rise in time due to aging and not just cancer growth. As prostate cells age they begin to lose their built in DNA time clock for cell replacement. The healthy process has cells dying and generating at the same rate. As we age older cells start dying at a slower rate while new cells are generating at the normal rate. This causes the prostate to become enlarged. More cells produce more PSA. Hence the sliding scale for normal PSA as we age.

    Distinguishing from this and cancer is the value of monitoring your PSA without manipulation. Anything at or over 4.0 is a warning flag for any man. You can Google a sliding scale for normal PSA adjusted for age and ethnicity. If it continues ro rise and gain velocity then cancer is highly likely for the change.

    If it is determined treatment is inevitable then earlier is better. Waiting for a newer better treatment to be invented is playing chicken with cancer. Particularly when all of our diagnostic tools are limited, incomplete, and often inaccurate.

    Attempting to predict the optimum last best moment for treatment is playing a game of pin the tail on the donkey.

    If AS is undertaken it requires diligent monitoring and multiple biopsies and a understanding and agreement on what the measures will be that trigger treatment.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    1-15-21 PSA less than 0.02; zero club 4.5 yrs

     
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    Old 12-29-2019, 06:51 AM   #23
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    Re: Radical Prostatectomy OR Plant Based Diet?

    The newer the RT modality, the shorter the followup time we have to measure results. Thus RT studies for, e.g., SBRT, have necessarily used BCR rates to judge success. However, some recent studies have pointed out that overall survival and PCa-free survival are better endpoints. While most BCR is treated, the majority of BCR does not progress to clinical recurrence. At least in theory, one RT modality may have a better BCR rate, but a worse OS rate than another.

    A recent study that looked at 87,875 high-risk PCa patients (https://scholarlycommons.henryford.com/urology_mtgabstracts/59/) concluded:
    "Conclusions In patients with clinically high-risk PCa, primary RP is associated with an overall mortality-free survival benefit compared to primary RT+ADT, regardless of baseline characteristics."
    In addition, while RT papers like to add the results are "long-term" for, say, 8-15 year studies, a man having treatment at age, say, 50 is not being unreasonable asking what will happen when he is 70.

    I try to never promote surgery over RT -- each guy needs to come to his own decision. But surgery shouldn't be given short shrift. From what I see, the results of a RP depend quite a lot on whether you can achieve a pT2 result with no positive margins. The chances of needing salvage therapy go way down across all G scores. If you can avoid RT and ADT entirely, it is not a small thing.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    stephenwilliam (12-30-2019)
    Old 12-29-2019, 11:33 AM   #24
    IADT3since2000
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hi again,

    I have looked at the study mentioned earlier about 87,875 high-risk PCa patients (https://scholarlycommons.henryford.com/urology_mtgabstracts/59/). It is in the form of an abstract presented at a conference that has not yet gone through the peer review for publication in a research journal. One of the authors, M. Mennon, is very likely the very well-known prostate cancer surgeon Dr. Manny Mennon, MD.

    If this is a sound study relevant to our modern era, it would be important evidence that surgery is a better choice for high-risk men when compared to radiation, which is quite contrary to other studies I have seen; that said, the study is from a respectable source and deserves consideration. My impression at this point is that we need to know a lot more than is available in the abstract, but here is my review based on what we know at this point.

    The key question is whether the patients getting radiation in the study were treated with modern radiation; that is very important as modern radiation (plus supportive technology) has proven far superior to older radiation, which was definitely inferior to surgery for most patients. So the question is, is this study comparing surgery to a poor form of radiation or a good form? In essence, it is now known that external beam radiation that is not SBRT, which would have been very unlikely to have been used in this study, needs to be in the dose range of 78-81 Gy or higher, a dose range that needs IMRT (not the old “conventional” or 3-D conformal radiation) with image guidance plus long-term ADT (of at least 18 months for high-risk patients). (I’ll also ignore brachytherapy and proton beam for this discussion for simplicity.) Such higher-dose radiation was not widely available until the 2000-2009 decade, with increasing availability as years passed. For example, in early 2000 I was not offered IMRT or the higher dose range by my Johns Hopkins radiation oncologist. But another very important technology is imaging to target the prostate and avoid other organs throughout the course of radiation, and such advanced imaging was becoming substantially available only in the latter part of the decade, from around 2007 and onward. Therefore, the key question for us is how many radiation patients were included in the study who were treated before 2007, and even before the early 2000s? If a substantial number of patients getting a poor form of radiation were included in the study, that would destroy the validity of the conclusions. (I know this timeline very well because I was closely watching technology advance in hopes that it would give me a good chance with my own high-risk case, which it did.)

    The short answer is that we don’t know how many got a poor form of radiation in this study. My suspicion is that a high proportion did. That is based the fact that even most high-risk patients are going to survive to the fifteen year point, provided they do not have metastases; it is unlikely that this group had metastases because until recently few such patients were treated with surgery or radiation. Therefore, to get the kind of “high-confidence” mortality figures that appear in the study, patients probably needed to be treated between 15 and 20 years ago. It is now 2019, and that would suggest that the vast bulk of these patients were treated with a form of radiation now regarded as poor.

    We also need to see data on the ages, cancer status, and health status of patients in the surgery and radiation groups to determine whether the study authors are giving us an apples-to-apples comparison or are stacking the deck.

    However, this is a thought provoking study and worth keeping in mind, and I am glad that it has come to the Board’s attention. I hope the authors publish a complete paper this coming year.

    Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low at <0.01; apparently cured.. Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs.

    Last edited by IADT3since2000; 12-29-2019 at 01:25 PM. Reason: Added Italics.

     
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    Old 12-29-2019, 12:47 PM   #25
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    Re: Radical Prostatectomy OR Plant Based Diet?

    While RP techniques continue to have minor improvements, surgery results are more or less a fixed target and have to be compared to what are pretty much moving targets. As RT modalities change, it's hard to compare apples to apples and still have studies with long-term results and statistical power. I'll imagine the study abstracted will have conglomerate RT data; maybe it will have results broken down by RT modality. Just as we get good medium-term data, a new radiation modality usually comes along. Who knows -- perhaps theranostics -- combined targeted diagnosis and treatment will be crowned Prom Queen (?)

    From what I'm seeing, SBRT is still settling on the optimal fractionation schedule. And, of course, we'd all like to see gold-standard, randomized prospective comparative studies, which are hard to pull off. My point was that with the new, you have to wait for long-term results. There is nothing wrong with men choosing the newer, very promising RTs, but there are some unknowns.

    We should be thankful for the good choices men have today. As we know, the difficulty of choosing is left to patient because we do not have a single SOC. Perhaps one will emerge soon for each risk category.

    I would love to see a study of what physicians with PCa are choosing for their treatments broken down by specialty!

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Nodule negative for PCa. Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX, G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.020 (3 yr. 7 mo.)

     
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    Old 12-29-2019, 06:34 PM   #26
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hi ALL...

    I want to thank everyone for their compassion and objectivity on this thread. All of you, along with my Surgeon and Family Doctor, have helped me make an informed decision.

    I would like you all to know that I have read and listened and read the links and research you have all posted and took what I felt applied best to me to both my Family Doctor and my Surgeon and they agreed that my choice to shift to a plant based diet would help me after I have Robotic Surgery.

    By the way, for those of you who asked, I am 64 years old and in what my Doctors say - Excellent Physical Condition - I spend 90 minutes or more a day at the gym and have for many years. My resting heart rate is in the low fifties... and I am grateful to all of you for taking the time to offer your experience and opinions.

    I wish you all health.

    Stephen.
    Collingwood, Ontario.

     
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    Old 12-29-2019, 09:03 PM   #27
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    Re: Radical Prostatectomy OR Plant Based Diet?

    One of my issues with the cited study stating an OS advantage to surgery with high risk patients is that their use of the term “radiation” does not indicate that it includes the combination boost protocol that is now standard practice. A boost therapy, by LDR-BT, HDR-BT, or SBRT, would usually be added to increase the efficiency of the RT plan. If the patients in this study did not have this protocol, which is recent within the past 15 years, then it’s conclusions will be less relevant for men making treatment decisions in 2020.

     
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    Old 12-30-2019, 01:11 AM   #28
    HighlanderCFH
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    Re: Radical Prostatectomy OR Plant Based Diet?

    We're a bit off topic from the plant based focus of this thread, but I'll give my 2 cents about the RT v RP debate.

    Radical prostatectomy and the various types of radiation produce about the same cure rates.

    When talking with a newly diagnosed, and very confused, prostate cancer patient, I encourage him to investigate ALL traditional forms of treatment.

    I advise him to consult with a top notch uro/surgeon to learn the pros and cons of surgery. I also advise him to meet with a top notch radiation oncologist and learn the pros and cons of the various forms of radiation.

    After doing all of his homework, a new patient can then make the treatment decision that makes him feel most comfortable and confident.

    Last edited by HighlanderCFH; 12-30-2019 at 01:12 AM.

     
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    Old 12-31-2019, 06:39 PM   #29
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    Re: Radical Prostatectomy OR Plant Based Diet?

    Hello StephenWilliam;
    While I don't believe a plant based diet will eliminate prostate cancer, I do believe it will help slow down the growth rate of existing cancer. I was diagnosed with G7 (3+4) PCa a few years ago at the same time that I was experimenting with a plant-based diet to control my diabetes type 2. From the time of my initial diagnosis until my robotic surgery, my PSA didn't rise that fast or become that aggressive and I attribute my plant-based diet to that even though there's no way to tell for sure. I have been experimenting with different types of diets as a way to control my diabetes and now that I just retired, am thinking of returning to a plant-based diet (perhaps permanently this time). From all I've read, a plant-based diet provides better outcomes for practically all diseases than a meat-based diet. That isn't saying that it cures but I believe it helps greatly. Like others have said, it isn't a substitute for surgery but I believe that eating plant-based before, and during surgery and/or radiation will also help decrease side effects.

    Tim

     
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