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KPJ1 11-28-2020 07:40 AM

Surgical removal vs. EBRT
I am 67, good health, my PSA has always been about 1.2 and this year is 1.4. My Dr. felt a hard spot with DRE, and sent me to urologist. I had MRI (pirads 4) and a fusion biopsy (Gleason 3+4=7), a bone scan and CT scan with no indication of spreading. Urologist is suggesting surgical removal, but says EBRT (40 treatments over 8 weeks) is another option. I am interested in hearing from those who have already made the surgery vs. EBRT decision, and any regrets you may have had with your decision. Especially interested in hearing of any after-effects from EBRT, and the downsides of EBRT.

Terry G 11-28-2020 09:53 AM

Re: Surgical removal vs. EBRT
Hi KP and welcome to the forum. At this point in the journey the first thing to do is get informed, understand your options and not make a quick decision that you may regret later. The number of treatment choices can be a bit overwhelming at first and as you share information here they usually become clearer with help from the folks that have already been in the place you are right now. Your PSA looks pretty low and does not suggest either a lot of cancer or an oversized prostate. I’ll assume your urinary function is pretty normal. What kind of biopsy did you have, how many cores were positive and what was the Gleason score of each core? Did you have any other relative testing such as scans?

For most guys any of several radiation treatments or removal will likely provide a cure. Each treatment comes with side effects. It’s important to understand the differences and weigh which are most important to you. For me I had a low risk cancer and chose active treatment over active surveillance. I choose a form of beam radiation that involved only five treatments (SBRT). And since SBRT was relatively new I sought out a center of excellence that routinely treated PC. Absolutely no regrets. I researched my options for four months and made an informed decision. For some guys my decision would not be what was best for them. Your just at the beginning I encourage you to learn as much as possible and make an informed decision. Urologists are surgeons first and most know very little about radiation and likewise you should not go to a RA for surgery advice. Good luck and keep posting.

ASAdvocate 11-28-2020 10:05 AM

Re: Surgical removal vs. EBRT
Newly diagnosed men are choosing active surveillance, surgery, and radiation in equal numbers, There is no gold standard. Some men with G(3+4) do active surveillance, but that has more risk than for Gleason(3+3).

There are several radiation protocols. The two advanced types, SBRT/Cyberknife and proton beam therapy, are reporting non-recurrence results that no other treatment can match. Take your time, explore your options, and be comfortable with your choice.

KPJ1 11-28-2020 10:06 AM

Re: Surgical removal vs. EBRT
Thanks Terry G for your quick response. I just edited my original post to add some testing info. My notes say 3 areas of the fusion biopsy were positive with 20 to 30% cancer in 6 areas. I didn't get a printout of the detailed results, I will try and get that. The urologist sort of led me towards the surgery option, but the more I learn about EBRT I think that may also be an acceptable option with equal cure rates. I'm most interested to hear from anyone who had the EBRT and then regretted their decision.

IADT3since2000 11-28-2020 11:29 AM

Re: Surgical removal vs. EBRT
Hi KPJU1 and welcome to the Board!

I have done very well with radiation plus ADT in 2013, now apparently cured of a once life-threatening case, and with a very low burden of side effects (minor bowel urgency at highly predictable times; under good control).

Both surgery and radiation would have a very high probability of cure for you, which means that the key consideration becomes side effects. A couple of decades ago surgery was clearly superior to radiation in both effectiveness against the cancer and a generally lower burden of side effects. However, radiation, and its associated, supportive technologies (mainly imaging and ADT), has steadily improved, and now there is a fair amount of evidence that it is superior to surgery, for most types of cases/circumstances, in both effectiveness and in having a substantially lower risk of burdensome side effects. Radiation got its act together about 2007, when advances in imaging enabled coupling with higher dosing of radiation that could then be more precisely targeted, increasing potency against the cancer and decreasing side effects.

An excellent book for orienting new patients is "The Key to Prostate Cancer," 2018, Dr. Mark Scholz, a medical oncologist dedicated to prostate cancer, plus 29 others.

- - - - - - - - - - - - - - - - - - - - - - - -
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 and stable at <0.01; apparently cured (Current PSA as of 9/4/2020). (Current T 128 9/4/20.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education. [/SIZE]

Terry G 11-28-2020 11:45 AM

Re: Surgical removal vs. EBRT
SBRT is a subset of EBRT. Most beam radiation today is delivered with guidance often in the form of small gold markers placed in the prostate prior to treatment. They have found that PC is more sensitive to higher radiation amounts given in few doses. That’s the big advantage for SBRT. Standard EBRT may require 40 to 50 treatments over the course of typically seven or eight weeks. It can be a very effective treatment for most low and intermediate risk guys. Most guys treated with either form report minimal long term side effects. On the short term most radiation guys report some mild urinary burning that resolves in a week or two following treatment. In my case I was able to maintain an active life style including sex. You can also expect a significant reduction in ejaculate but orgasms and desire remains as they were prior to treatment.

Active Surveillance can be a great way to either delay invasive treatment and their accompanying side effects or possibly never require treatment. The key here is to stress the active monitoring part. Each year the treatment options for PC advance and it might be a significant advantage to watch and monitor closely rather then elect treatment today. It’s important to explore all the options.

GuyBMeredith 11-29-2020 11:27 AM

Re: Surgical removal vs. EBRT
At age 73 I was diagnosed pretty much as you, but had a 3.1 PSA.

Check Jim's notes on surgery vs radiation. Look down the list of issues post surgery and post radiation: impotence, incontinence, bowel issues and so on. Maintaining sexual function was at the top of my list right next to survival.

With robotic surgery there would be 5 incisions, at least "temporary" impotence and incontinence, and possible bowel issues. "Temporary" is vague and depends on factors like age (I am now 75) and health.

With radiation there are possible urinary urgency and bowel issues during the treatment. With the suggested addition of hormone treatment with radiation there are menopausal symptoms. There "might" be ED problems in a few years from radiation.

I chose guaranteed sexual function over a maybe since the efficacy of the two methods is the same. The 28 weekday sessions of IMRT were done at the Salem Cancer Institute with the Varian Truebeam. Before treatment, a CT scan is done to map out the cancer and best angles of attack. Once treatment begins, the Truebeam does a CT scan to adjust for position at each session and then delivers dosage.

Check on the net for several videos demonstrating the machine.

IMRT was completed in July and hormone treatment (lupron) supposedly began "withdraw" the first of September. I experienced the bladder urgency during treatment which led to a couple of surprises and while on hormone treatment experienced total loss of physical libido (a good portion of sex is in the mind), over the top emotions and hot flashes. I continued sexual activity while on hormone treatment (chemically induced temporary castration) to ensure sexual health after treatment.

As of three months after end of treatment I can say that the only results are memories of treatment and sensitive nipples. Everything is back to "normal" and I am now on a schedule of PSA checks every thremonths to monitor success. Testosterone checks are also being run with the PSA checks for my curiosity.

I am very satisfied with the results so far.

Prostatefree 11-30-2020 08:43 AM

Re: Surgical removal vs. EBRT
A few things to note. You have a significant volume of cancer and a low PSA. It is somewhat unusal and may have some statistical significance. My question to the doctors would be is there a chance of a more aggressive cancer present and undetected with such a large volume and low PSA. There is a subset of men who present with low PSA and smaller more aggressive cancers. Are you taking any medications that alter your PSA?

Considering your volume and the presence of G-4 I suggest treatment and not AS. I have had successful surgery and am happy with the outcome. However, learning what I have learned on these websites I'd look long and hard for a successful radiation treament solution before choosing surgery. Your older age indicates less concern for the long term side effects of radiation.

They all have side effects. Succcess with surgery depends on the extent of the cancer and the skill of the surgeon. Both are difficult to predict. Radiation is more forgiving in both those aspects. Location of the cancer is a critical aspect of side effects from radiation.

You can send your samples to another lab to get a second opinion on the Gleason score. Epstein's lab at Johns Hopkins is an often used expert for this. The 4 is the concern and it may provide some comfort with a confirming opinion it is present or questionable in a second opinion. It can also go the other way.

My biopsy indicated a large volume of G3+3, but pathology after the surgey revealed G3+4. So, there is always the concern it can be worse than the diagnostic tests reveal. They are all fallible. I'm surprised at the CT and bone scans. What about your case indicated a higher risk and the need for them? They are usually reserved for more serious cases than what your biopsy suggests.

A fusion biopsy before a more traditional biopsy is also another sign of an upgrade in care. Do you have a higher risk profile for a reason we do not see in your post?

Insanus 11-30-2020 09:46 AM

Re: Surgical removal vs. EBRT
For me surgery had several benefits over radiation. A solid pathology report, no ambiguous PSA values to worry over, radiation treatment as a back stop.

KPJ1 11-30-2020 12:01 PM

Re: Surgical removal vs. EBRT
Prostatefree thank you for your guidance. I have another appointment with the urologist-surgeon tomorrow, when I will ask some more detailed questions. I'll respond further after that. Thanks.

Southsider170 11-30-2020 02:03 PM

Re: Surgical removal vs. EBRT
A couple of things you should take into consideration in your decision.

Prostatectomy is one of the most technically challenging surgeries that are frequently done. You definitely want someone with hundreds if not thousands of these under their belt if you go this way. Someone who has seen it all and nothing will surprise them with they get in there. Removing a water pump on Buick Roadmaster is a lot simpler as Buick made them all the same. But Almighty God didn't make all men the same and the surgeon has to think on his feet. That's why urologist get paid more than mechanics.

As far as radiation, the equipment is really the key. They are refining and coming up with new radiology equipment all the time. Having the new, most accurate equipment can reduce the amount of damage to adjacent tissues, the side effects.

IceStationZebra 11-30-2020 08:01 PM

Re: Surgical removal vs. EBRT
[QUOTE=Insanus;5507109]For me surgery had several benefits over radiation. A solid pathology report, no ambiguous PSA values to worry over, radiation treatment as a back stop.[/QUOTE]


You don't know what cancer is truly there until you get the final pathology report. Keep that in kind that you could have more or worse cancer than what was found. Or, you could have lucked up and found all that is there.

Good luck!

KPJ1 12-01-2020 03:06 PM

Re: Surgical removal vs. EBRT
Thanks to all who have responded to my question. I have obtained the two recommended books Surviving Prostate Cancer (Walsh) and The Key to Prostate Cancer (Scholz) and I will begin reading both which will broaden my understanding of all the treatment options. I had a discussion today with my primary doctor who reassured me that the urologist/surgeon who I am seeing is among the best. I also had another appointment today with the urologist/surgeon (he's been doing robotic prostate surgery for 20 years). He said my EBRT option was actually IMRT. He was open to me getting a second opinion from a highly recommended radiation oncologist. I will see him later next week to learn his recommendation. Meanwhile I will have time to learn more and think about which way to go. I would still appreciate hearing from any others who have experience with surgical removal or IMRT.

KPJ1 12-03-2020 06:07 AM

Re: Surgical removal vs. EBRT
I have been questioning why my PSA has never been above 1.4 over the past 10 years, yet I have a Gleason 7 score. According to the book by Walsh, 25 percent of men who have prostate cancer have a low PSA level. The implication is that PSA is only a good indicator 75% of the time. Additionally, I have been taking one aspirin a day for the past 30 years since my family has a history of strokes. The book says that taking aspirin and other NSAID's will lower PSA levels. That could explain why my PSA reading has always been artificially low.

Steve135 12-03-2020 06:45 AM

Re: Surgical removal vs. EBRT
KPJ1, like all the great post above, its sometimes a very hard choice. In 2015 with my staging and age 56 removal was an easy choice. Today the advances in EBRT have greatly improved. And your age (67) at diagnosis gives you more options. Just do your research and may an informed choice.
steve d

Diag. 56 DOB 2/59 PSA Base 1.5 01/14 2.0 6/15 2.4
Biopsy 6/15 5 Gleason Score 8
RP 10/15 Path 54g 5x4.2x2.8cm 4+3=7 Tumor location quadrants Bilateral
Extra-capsular extensions present,SV no invasion
Vascular invasion none, PNI yes ,Multicentricity multifocal
Margins Not Present inked margins 5 neg.LN stage pT3a,N0
PSA 10/16 <0.1 02/7/17 1st BCR 0.4 02/15/17 0.5
Pet Scan 2/17 Neg PSA 03/17 0.6 Axumin trial 17.4mm tumor rt. SVB Casodex + Trelstar
04/17 SRT (42) to include location of tumor
08/17 PSA 0.1 Last 6 uPSA 0.006 uPSA 2/19 0.030 2nd BCR 5/19 0.235 5/30 0.32 6/19 0.34
7/19 0.06 8/19 0.08 9/19 0.056 10/190 0.08 11/19 0.07 12/19 0.07
7/19 Continue Trelstar, Add Xtandi, Zoledronic Acid
12/19 (3) SBRT Iliac bone liasion post SBRT 1/ 20 0.06 2/20 0.04 3/20 0.02 4/20 <.02 5/20 <0.02 6/20 <.02
7/20 <0.014 8/13 <0.014 9/24 <0.014 10/5 <0.014

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