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  • Any options besides surgery for PC with Enlarged Prostate

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    Old 03-20-2021, 06:56 PM   #1
    MikeInPhila
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    Unhappy Any options besides surgery for PC with Enlarged Prostate

    Hi All,

    While I have been dealing with BPH for several years, that was kept under control with meds. Unfortunately, I do have a large prostate at 97cc

    More recently I was diagnosed with PC, pirads 4 on MRI then biopsy showing 3+4 and 3+3, PSA is 8.4

    In my mind, RP is the option of last choice. Too many permanent AE's even under the most skilled surgeons. 40% chance of a trifecta. Being an active 58 year old, the thought of wearing depends for the next 20+ years is my personal nightmare.

    I was looking at newer treatments like Tulsa. While side effects seem low, for full gland ablation, the efficacy and recurrence data is not encouraging.

    My understanding is that brachy is mostly indicated for smaller prostates. That leaves SBRT / Cyberknife / Proton. However, I may be wrong here, it does not appear that those therapies do anything to reduce the prostate size. Surgery for BPH followed by radiation therapy for PC does not seem to make a lot of sense to me as it seems you then have worst of both worlds.

    Am I essentially screwed. Is RP my only option other than letting nature take its course over time?

     
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    Old 03-21-2021, 06:14 AM   #2
    guitarhillbilly
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Quote:
    Originally Posted by MikeInPhila View Post
    Hi All,

    While I have been dealing with BPH for several years, that was kept under control with meds. Unfortunately, I do have a large prostate at 97cc

    More recently I was diagnosed with PC, pirads 4 on MRI then biopsy showing 3+4 and 3+3, PSA is 8.4

    In my mind, RP is the option of last choice. Too many permanent AE's even under the most skilled surgeons. 40% chance of a trifecta. Being an active 58 year old, the thought of wearing depends for the next 20+ years is my personal nightmare.

    I was looking at newer treatments like Tulsa. While side effects seem low, for full gland ablation, the efficacy and recurrence data is not encouraging.

    My understanding is that brachy is mostly indicated for smaller prostates. That leaves SBRT / Cyberknife / Proton. However, I may be wrong here, it does not appear that those therapies do anything to reduce the prostate size. Surgery for BPH followed by radiation therapy for PC does not seem to make a lot of sense to me as it seems you then have worst of both worlds.

    Am I essentially screwed. Is RP my only option other than letting nature take its course over time?
    You also MAY have another option possibly. Radiation EBRT [IMRT-IGRT] and ADT to deal with the Cancer then HoLEP to deal with the large prostate. Not sure which order.

    HoLEP:
    https://my.clevelandclinic.org/health/treatments/17917-holmium-laser-enucleation-of-the-prostate-holep

    Radiation:

    Quote:
    What Happens to the Prostate after Radiation?

    The entire prostate gland is radiated when we treat the cancer. The prostate normally produces some of the fluid in the ejaculation. Radiation therapy has the side effect of damaging the glands in the prostate, so a lot less fluid is produced. The ejaculation may be dry or nearly dry. In addition, you will probably be sterile (unable to father more children) after radiation, but this is not 100% guaranteed and should not be relied upon as a form of birth control. You can still usually have erections because the nerves and blood vessels that go to the penis are not as damaged as the prostate gland.

    The prostate gland will end up having a lot of scar tissue. It will shrink in size to about half its original weight within a couple years after finishing radiation. The urethra (urine passage) passes through the canter of the prostate gland like the hole of a doughnut. Sometimes this passage can widen, other times it can shrink after radiation. In summary, the prostate gland is heavily damaged from radiation and does not work normally afterwards."
    __________________
    T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
    1-5 aggressive score : 4
    12 cores= 4 positive
    NBS = Negative
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    Age at Diagnosis= 60-65 age group
    Completed 42 IMRT Sessions
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    Old 03-21-2021, 02:41 PM   #3
    DaveinMaryland
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    Re: Any options besides surgery for PC with Enlarged Prostate

    The AE's with surgery are mostly temporary. Unless you are a VERY rare exception, continence comes back within 3 to 6 months. The catheter is not as bad as it seems. It's a bit inconvenient, but if you take care of it as you are instructed, it is not painful. And in odd actuality, after it is removed you kind of miss it because you haven't had to go pee for awhile. I was told to remove mine myself after 10 days. They gave me instructions and it was a nothing event. You will needs pads for a few weeks, then shields for a couple months. The only leakage that occurs after that is if you do something that strains or compresses the abdominals. By straining I mean heavy lifting or strong compression of the abdominal area. Most men get their ability to get an erection months to 2 years post surgery.

    I was very active and in good shape for age 63 when I had my surgery. I recovered quickly from the surgery. I had an open RP and felt fine in 2 weeks but had to remind myself there was still healing going on in my abdomen so as to no overdo it.

    I don't know what the 3rd leg of the trifecta may be - bowel issues? Virtually non existent.

    I don't know where you got that 40% chance of the trifecta, but that is way out of line.

    For most men, in a few months it was nothing but a minor inconvenience plus your BPH issues will be gone.
    __________________
    Dx at age 63 March 2017
    Prostate Cancer 3+4 Open RP May 2017
    PSA detectable May 2018, single digit .1 2 digit .06
    August 2018 2 digit .07
    November 2018 2 digit .10
    6 month Lupron Shot Dec 2018
    Salvage Radiation Jan - Mar 2019
    Testing every 6 months, undetectable since then.

     
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    Old 03-21-2021, 04:40 PM   #4
    Southsider170
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Actually, the vast majority of men who have radical prostatectomy recover their continence within a matter of months. For some, yes, it can take a bit longer, but even then there are surgical remedies for that, like an artificial urinary sphincter.

    The points of positivity in your case are your youth, a mere lad in his 50's, as well as only moderately risky PC with a 3+4 Gleason and a PSA under 10.

    Further, if you choose to go to a big academic medical center- you are in eastern PA- you will likely have a very experienced surgeon which will increase your chances of a good result even more.

    Think positive thoughts , Mike. Expect success.

     
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    Old 03-21-2021, 09:42 PM   #5
    GuyBMeredith
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Do you have reference for comments that external beam radiation is not suitable for large prostates? Many or most of us have enlarged prostates when we are treated. I went in to the urologist for urinary problems caused by an enlarged prostate and was diagnosed with cancer. ADT was recommended to help reduce the size of the prostate for radiation and also to make the cancer more vulnerable to radiation.

    However, my prostate was under 50 cc.

    You may want to look up the statistics of recovery after surgery. Expectations on recovery from ED are often too optimistic and you may want to check on stats on continence. Everyone is different, every surgery is different due to anatomy, location of cancer, skill of surgeon and so on.

    I chose radiation, but I was 74 and decided that I would prefer to have a guarantee I could enjoy sex for at least a few more years. Continence probably a better bet. But radiation can affect these as well further down the line and again at your tender age you will want to check on stats for recovery.

     
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    Old 03-22-2021, 05:37 AM   #6
    DaveinMaryland
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    Re: Any options besides surgery for PC with Enlarged Prostate

    I'm going on 4 years post surgery and 2 years post salvage radiation, so I've had both along with ADT for 6 months with the radiation. I am doing fine and have had no long term and few short term after effects. I had ED prior to the PCa so I can't personally comment on erection recovery, but everything else is fine.

    Make the choice you are comfortable with and find doctors you are comfortable with and have confidence in. I had a very good team from my PC doctor to the urologist, surgeon, and RO.
    __________________
    Dx at age 63 March 2017
    Prostate Cancer 3+4 Open RP May 2017
    PSA detectable May 2018, single digit .1 2 digit .06
    August 2018 2 digit .07
    November 2018 2 digit .10
    6 month Lupron Shot Dec 2018
    Salvage Radiation Jan - Mar 2019
    Testing every 6 months, undetectable since then.

     
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    Old 03-23-2021, 10:31 AM   #7
    MikeInPhila
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Dave,

    I see you are in MD. Did you go to Hopkins?

    My next step is to get a consult with either Hopkins, Penn or FoxChase. While those are all centers of excellence, determining who to meet with is a puzzle. Even at the best institutions, not all surgeons, oncologists, etc. are created equally. Unfortunately, medical outcomes at the physician level appear to be a closely guarded trade secret. I do not want to travel to a place like Hopkins only to be randomly assigned to the goat whose schedule happens to have the greatest availability.

    Any recommendations for centers or individuals at those centers is greatly appreciated.

     
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    Old 03-23-2021, 12:24 PM   #8
    GuyBMeredith
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Look for videos by Dr. Mark Scholz for an open and honest explanation of all forms of treatment, their side effects, quality of life issues and suitability for different kinds of prostate cancer. His information is more current than much of the on line information.

     
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    Old 03-23-2021, 12:34 PM   #9
    Prostatefree
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Surgery worked for me. No incontinence and no ED. You may have a different experience.

    Surgery works better the younger you are and the earlier the detection. I'm surprised you are not already having incontinence and ED with the size of your prostate. A large prostate pressing against the nerve bundles for any length of time can lead to temporary and permanent erectile damage.

    Why are you waiting so long to do anything?

    I don't wear diapers. Most men who do learn to be happy to be alive and most regret failing early detection and treatment.

    Treatment usually isn't the source of unhappy outcomes unless a less than expert practitioner is involved. In most cases, it's failure to act with either early screening or accepting the treatment option that best fits your profile.

    Playing chicken with cancer is high risk. This isn't a designer disease where you get to shop for the designer treatment that fits your idea of the disease.

     
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    Old 03-23-2021, 03:54 PM   #10
    DaveinMaryland
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Quote:
    Originally Posted by MikeInPhila View Post
    Dave,

    I see you are in MD. Did you go to Hopkins?

    Any recommendations for centers or individuals at those centers is greatly appreciated.

    My primary URO referred me to Hopkins for a surgical consult and recommended 2 surgeons. (Hopkins actually called me then) and to the U of MD for a radiation consult (which was in the same building as my URO). Hopkins is where I had the surgery done and the U of MD radiation center in my home town of Columbia is where I had my salvage radiation done the the RO recommended by my URO.

    My surgery was done by Dr. Partin (he of the Partin tables and has done over 5500 PCa surgeries - both open and robotic). My URO also referred me to Dr. Moswick at Hopkins. I just went with who was available the soonest between the 2.

    So I guess my situation was different than many. My diagnosing URO did the biopsy but referred me to others for actual treatment.
    __________________
    Dx at age 63 March 2017
    Prostate Cancer 3+4 Open RP May 2017
    PSA detectable May 2018, single digit .1 2 digit .06
    August 2018 2 digit .07
    November 2018 2 digit .10
    6 month Lupron Shot Dec 2018
    Salvage Radiation Jan - Mar 2019
    Testing every 6 months, undetectable since then.

     
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    Old 03-26-2021, 12:54 PM   #11
    SubDenis
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    Re: Any options besides surgery for PC with Enlarged Prostate

    I think High DOse brachytherpy can be done on larger prostates. "Previous guidelines suggested that the gland volume should be smaller than 60 cm3 however with greater experience and high quality transrectal ultrasound imaging this is no longer an absolute stipulation and larger volumes may be implanted [32]." This is from https://www.sciencedirect.com/science/article/pii/S0167814013002004

    I wish you well. Denis
    __________________
    65YO healthy man, PSA 5/17 4.6, MPMRI, 5/17 lesion. 13 core biopsy 3 positive 3+3 All cores less than 30% 8/17 - second opinion Yale (3+4) in one core, < 5%, decipher test shows intermediate risks. HDR BT completed 2/6/18. 5/3/18 3 month Post HDR BT PSA 1.3, 6 mo PSA 1.2. 1-year PSA 1.0, testosterone 475, 18 month PSA 0.4 Testosterone 524, 24 month PSA 0.4, 32 month PSA 0.4 Testosterone 391, 40 months PSA 0.3, Testosterone 630.

     
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    Old 03-27-2021, 05:33 AM   #12
    IADT3since2000
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Hi Mike,

    Denis mentioned an important development, and his point should be combined with the point that large prostates can be reduced in size prior to brachytherapy. Typically, using a number of drugs, with Proscar/finasteride and Avodart/dutasteride being prominent among them, the prostate is typically reduced by about 1/3. Depending on the circumstances, that is often enough to open the door for brachytherapy, especially by an expert.

    Proscar and Avodart also have a number of other desirable properties for prostate cancer patients, though neither has been approved for prostate cancer. In addition to reducing the size of the prostate, which makes both the PSA level and trend (properly interpreted) more effective as a sentry for prostate cancer and also makes biopsy probes more efficient in detecting cancer (smaller target for the same number of probes), these drugs sharply reduce the conversion of testosterone into dihydrotestosterone (DHT), which is a far more potent fuel for prostate cancer cells. Also, these drugs reduce blood flow to the prostate somewhat.

    One way you can get some insight into radiation oncologists who are prominent in prostate cancer is by going to PubMed, www.pubmed.gov, a service of our National Library of Medicine under NIH, and searching for the institution and the therapy in which you are interested, or, broadly, radiation; then see who the authors are and their roles in the study. For example, I just searched for - prostate cancer AND radiation AND Fox Chase Cancer Center - and got a list of 378 papers (and also a message stating "Your search was processed without automatic term mapping because it retrieved zero results."). Then click on the authors list and check the affiliations; I did that for the first two listed and saw affiliations with Fox Chase. (In the mid-Atlantic states, Fox Chase has been regarded as one of several outstanding radiation centers for at least two decades.) As radiation has improved so dramatically over the past decade, you can also apply a publication date filter. I just did that for 5 years and reduced the list to 70 articles. It takes some work, but you can get a sense for who is doing leading edge work at an institution. Many excellent doctors do not publish at all, but the doctors who do publish tend to be respected leaders in the field. Some doctors had fears that these drugs promoted high grade cancer, but those fears have been put to rest by research. (What happens is that these drugs make high grade cancers easier to find by biopsies.)

    Good luck,

    .Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. 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 12/2/2020). (Current T 93 12/2/2020.) 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. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 05-13-2021, 08:20 AM   #13
    MikeInPhila
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    Re: Any options besides surgery for PC with Enlarged Prostate

    I met with both surgeon and radiation oncologist at Fox Chase. They were both pleasant, knowledgeable and really spent a lot of time discussing options.

    Surgeon thinks I would be good candidate for surgery. I am still apprehensive about the surgical route. I have seen so many people share their regrets in comparison to those who have chosen radiaton. I am likely exaggerating the risks but I fear becoming an incontinent, suicidal hermit with ED and a stubby, malformed penis.

    I had high hopes for SBRT, either with Spaceoar or MRI guided. Then the enlarged prostate again comes into play.

    So, radiologist feels that:

    Brachy is not a good option. The enlarged prostate makes placement of the seeds a challenge.

    In terms of treating the cancer, likelihood of recurrence, radiation on par with surgery.

    Spaceoar. Probably not a good option due to size of prostate.

    EBRT becomes the remaining option. However, the have concerns about urinary complications with SBRT. Again, comes down to prostate size and history. That leaves traditional 8 week daily treatment. Guided conformal using Calypso markers. He seems to think this is less risky in my situation than SBRT however he still feels that there could be short and / or longer term risk of complication. Short term can likely be dealt with, longer term more if an unknown. He did not seem to think there is significant risk of urethral stricture or rectal fisures.

    When my spouse inevitably asked the what would you do question he did not give a definitive answer (which I do respect). However, even I could read between the lines and sense that he thinks I am probably a better candidate for surgery than for radiation.

    It's one thing when the urologist/surgeon is telling you that surgery is your best option, quite another when RadOnc is essentially saying the same.

    I met with another radiologist at a center where they use Viewray guided. He seemed more positive about radiaton but also recommended for 9 week fractionated versus sbrt. The problem there is that short term AEs appear around week 2-3. You then face 6 more weeks of daily treatment feeling worse after each. Long term AEs seem about the same.

    Someone knowledgeable recommended a nearby cyberknife specialist. I am torn. At what point does doing your due diligence cross the line into shopping until you get the answer you want? Even if he says I am a great SBRT candidate, I can't just ignore what the other two RadOncs had to say.

    Yup, it feels like my options are closing in around me leaving only the one I fear most.

     
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    Old 05-13-2021, 08:27 AM   #14
    DjinTonic
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    Re: Any options besides surgery for PC with Enlarged Prostate

    I had a very successful TURP for BPH. Several years later my PCa was diagnosed, and I had a very successful RP for that. I would have paid a pretty penny to have gotten the PCa diagnosis earlier and solved both problems with a single operation!

    I have seen no studies on the effect of primary RT for PCa on BPH symptoms. None. Why is that?

    IMO, the presence of BPH is a factor that weighs in favor of surgery as primary treatment choice. Of course, that doesn't mean that a man won't prefer and choose a different treatment modality for any number of reasons/preferences.

    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.)...0.023 (4 yr. 6 mo.)

     
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    Old 05-13-2021, 10:32 AM   #15
    MikeInPhila
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    Re: Any options besides surgery for PC with Enlarged Prostate

    Quote:
    Originally Posted by DjinTonic View Post
    I had a very successful TURP for BPH. Several years later my PCa was diagnosed, and I had a very successful RP for that. I would have paid a pretty penny to have gotten the PCa diagnosis earlier and solved both problems with a single operation!

    I have seen no studies on the effect of primary RT for PCa on BPH symptoms. None. Why is that?

    IMO, the presence of BPH is a factor that weighs in favor of surgery as primary treatment choice. Of course, that doesn't mean that a man won't prefer and choose a different treatment modality for any number of reasons/preferences.

    Djin
    Thanks for the response. Would you mind sharing what your recovery was like? When you say successful outcome, how would you compare your urinary, sexual function before and after. I have one friend who feels his surgery was a success yet acknowledges that, "he will pee his pants every time he stands up for the rest of his life".

     
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