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    Old 05-06-2021, 05:43 AM   #1
    TNGuy1940
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    Treatment Opinions

    Hello. I am hoping to get opinions on how to treat (cure) my Grade 2 prostate cancer.

    Background: 57 year old, went for physical and my PSA was 4.1. DRE showed small nodule. Next week it was 5.5. Went to oncologist who confirmed small nodule and had a needle biopsy which confirmed Grade 2 cancer with Gleason score 7 (3+4). T2a. 3 of 12 cores with only one Grade 2 (right mid lateral).

    He sent me to discuss with radiation doctors who recommended SBRT (Tru-beam or Cyberknife but they want to do Tru-beam).

    Next and MRI showed that the cancer was confined to the prostate. I was ready to do radiation, but my oncologist said there is no backup plan other than HT, where with RP radiation is your backup plan.

    Further research tells me that cyro-therapy is a valid backup plan to radiation so I'm swinging back to RT.

    Now I am choosing between RP and radiation. I am 90% certain I want radiation but it's more of a feeling and honestly convenience with supposed lower side effects. I am concerned about urinary incontinence with RP and recovery time (I live alone). Just trying to decide what side effects I want to risk.

    I've heavily scanned these boards and it seems like most go with RP. I didn't see anyone with my exact problem so I hope some of you can share what your choice would be and why.

     
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    Old 05-06-2021, 10:22 AM   #2
    Terry G
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    Re: Treatment Opinions

    TNGuy, Welcome to this forum we’re glad you found us. Often following a cancer diagnosis we are in a bit of panic and that’s a very poor time to make potentially life changes decisions. I’m assuming your reference to “oncologist” is your urologist? If that’s the case he’s not telling you the whole story. With either a failed surgery or a failed RT the backup plan is pretty much the same and can include more radiation and or ADT.

    I think it’s best to focus on a cure and plan for success with consideration given to side effects. Every treatment includes side effects and it’s important to know and understand them. SBRT is typically a five radiation procedure (fractions) and can be given with different equipment makers. It can go by other names as well. Some beam radiation is delivered over twenty or more fractions and is actually delivered in lower individual doses (EBRT, IGRT). Other radiation choices include Brachytherapy including both low and high dose There are a lot of variations in RT and for the new guy a little confusing. We’ve all been the new guy, understand and can walk you through it. Possibly you can provide your location and that might lead to more specific recommendations. The important thing right now is to become better informed and lead to the best treatment choice for you.
    __________________
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    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
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    Old 05-06-2021, 10:30 AM   #3
    Prostatefree
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    Re: Treatment Opinions

    Perfect. Very treatable with radiation or surgery.

    I'm good with my choice. I would consider radiation much more seriously now after having an RP. But, the RP has been successful and I've been spared the radiation and ADT to use another day if I have to. So far not necessary, knock on wood. And yes, the wood is back.
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    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 05-06-2021, 11:47 AM   #4
    IADT3since2000
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    Re: Treatment Opinions

    Hi TNGuy and welcome!

    I'll add to the responses to your concern below:

    Quote:
    Originally Posted by TNGuy1940 View Post
    .... I was ready to do radiation, but my oncologist said there is no backup plan other than HT, where with RP radiation is your backup plan.

    Further research tells me that cyro-therapy is a valid backup plan to radiation so I'm swinging back to RT....
    I too am thinking that "oncologist" was a urologist (surgeon); many surgeons say that as a selling point, but it is misleading. The fact is that modern radiation is going to be at least as effective at wiping out cancer in the prostate and immediate environment (seminal vesicles) as surgery, so if radiation did not do the job, surgery would not have done it either. Also, recurrence is quite unlikely with well done radiation or surgery for such a case. Finally, there are follow-up treatments in reserve after radiation, including cryo, but more likely spot radiation or surgery to any metastatic sites, as well as systemic treatments such as androgen deprivation therapy (ADT, aka HT - hormonal therapy) and possibly a limited course of chemotherapy, with the need for that being small.

    The side effect profile for radiation is remarkably low. However, if used after surgery, there is often an unfavorable synergy that amplifies the side effects likely to be experienced. To me, it makes sense to use your best shot first.

    Did either of the doctors recommend having the biopsy reviewed by an expert if not done initially by an expert? That is important, as biopsies are fairly often either upgraded or downgraded when seen by an expert. Downgrading might open up the option of "active surveillance," while upgrading might indicate a need for more aggressive therapy, likely more aggressive radiation and ADT.

    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 05-06-2021, 01:15 PM   #5
    TNGuy1940
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    Re: Treatment Opinions

    Replying to Terry and Jim,

    Sorry, yes urologist. He did a great job with my biopsy so he made me stop and reconsider radiation "You're so young." He put some worry in me that it would age me and that the 'backup plan' of salvage surgery and/or HT was not optimal. But the cure is the goal.

    I do not know if my biopsy was reviewed/done by an expert. It was done by 'Associated Pathologists (PathGroup)' in Nashville.

    Oddly, my 'nodule' was not seen on the MRI which confirmed the adenocarcinoma was localized.

    I am receiving good care at Tri-Star in the Nashville area. SBRT would be at Centennial downtown and they recommend 5 treatments lasting 1.5 weeks. They have both Cyberknife and the new Tru-beam. The radiation oncologist has over 50 operations with Tru-beam and he has brought the technology to Tri-Star Nashville from Dallas.

    Thank you very much for your replies.

     
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    Old 05-06-2021, 07:50 PM   #6
    IADT3since2000
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    Re: Treatment Opinions

    Yes, that "You're so young" gambit is one we often hear from urologists, but they have no support from research to back up a claim that being younger makes surgery superior. Radiation definitely does NOT age you! Your urologist is definitely touching the usual bases in his sales pitch, but that does not make him a bad doctor.

    Jim

     
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    Old 05-07-2021, 03:17 AM   #7
    HighlanderCFH
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    Re: Treatment Opinions

    I would consider that SBRT -- if I understand it properly -- only targets the tumor and not the surrounding tissue. The thing I would caution is that, by treating only the identified tumors, it is always possible that the biopsy missed other tumors that would get a "free pass" from the SBRT.

    I would consider traditional radiation in which the entire gland is irradiated to ensure that the whole thing -- including any other tumors -- is covered.

    I would also consider RP for a couple reasons. Number one is that the entire gland can be examined post-op and the patient knows exactly what was in the prostate. A second reason would be that radiation is a good backup plan in case of recurrence -- whereas salvage surgery is almost always NOT an option if the radiation fails.

    The side effects of both major treatment types are identical -- except that they happen immediately after surgery and happen a year or two later with radiation.

    With all of that said, the cure rates between radiation and surgery are virtually identical. The big trick is to have a very highly experienced surgeon, or radiation oncologist, who has performed many hundreds of such procedures.

    Best thing is to interview very experienced surgeons and radiation oncologists and learn for yourself all of the pros & cons of these treatment options.

    In any event, it appears that you have a very curable case and I wish you the very best with whichever option you choose.

    Good luck!
    Chuck

     
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    Old 05-07-2021, 05:30 AM   #8
    IADT3since2000
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    Re: Treatment Opinions

    Coverage of the Prostate by SBRT

    Hi Chuck. You wrote the following in raising this question:

    Quote:
    Originally Posted by HighlanderCFH View Post
    I would consider that SBRT -- if I understand it properly -- only targets the tumor and not the surrounding tissue. The thing I would caution is that, by treating only the identified tumors, it is always possible that the biopsy missed other tumors that would get a "free pass" from the SBRT.

    I would consider traditional radiation in which the entire gland is irradiated to ensure that the whole thing -- including any other tumors -- is covered.
    My impression, a bit shaky, is that SBRT delivered with CyberKnife and similar systems does cover the entire prostate and can also be aimed nearby or to cover the entire pelvis, but I am not sure and have never heard this addressed or read about it to confirm my impression. To me the term SBRT (an awkward acronym for words that do not convey the concept well, StereoTactic Body Radio Therapy), has become a bit fuzzy. My impression is that it was originally closely associated with the highly precise CyberKnife delivery system as well as a dosing approach that involved higher dose per session delivered in just five sessions. While there were a number of pioneers in SBRT for prostate cancer, Dr. Christopher King, MD, then at Stanford, as I recall it, was the preeminent leader, so his papers might answer this question. Now, emphasis in use of SBRT seems to be more on using just a few radiation sessions with their higher dosing per session but a range of delivery systems, including IMRT (but at higher doses in just a few sessions, with the technical term for that being hypofractionation). (And not even five doses is sacred; the eminent radiation oncologist Mack Roach, MD, at UCSF sometimes uses just four sessions, with somewhat higher dosing per session than in the five session program.)

    One important piece of evidence that entire coverage of the prostate is provided by SBRT is the very high non-recurrence rates achieved, as documented in numerous published medical research papers. I don't see how that could be achieved if SBRT only targeted visible tumors, as, if that were the case, other tumors would be missed as you point out, and those would cause recurrences fairly quickly.

    Some highly targeting delivery systems, such as proton beam, have at times been coupled with dosing by systems with a more shotgun approach that are still precise enough to avoid or minimize collateral damage to organs at risk.

    So that's my impression. I would like to get an authoritative answer. Tall Allen, who used to participate on this forum, is really knowledgeable about SBRT and a great communicator. Maybe we can find him or get an answer some other way.

    All that said, if I were a patient, I would not be concerned because of the well-documented extraordinarily high rates of non-recurrence after treatment by SBRT.

    Curiously yours,

    ….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 05-07-2021, 08:01 AM   #9
    Terry G
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    Re: Treatment Opinions

    SBRT (Cyberknife, Precise, etc.) does treat the prostate and surrounding tissues very precisely. The amount of radiation is also varied to spare critical structures. It’s a team effort with a urologist placing gold markers and more recently SpaceOAR. The radiation is delivered in fewer fractions (typically five) and higher dose volume making it more convenient than IGRT. It compresses 45 treatments into 5. Data has shown in HDBRT that the higher dose rate is more effective killing the cancer and that’s the reason SBRT is so effective. Comparing it to the older beam radiation is kind of like comparing carpet bombing against smart bombs. The RO can have his ‘plan’ reviewed by other specialists in the field unlike a surgeons who work only in real time so the number of cases worked on becomes a little less important.

    Every treatment has side effect risks; but, the risks with SBRT appear minimal. I participate in a couple of forums and can find no one who regrets this choice. I believe that if RO’s diagnosed PCa that very few guys would go to urologist/surgeons. I realize my bias is associated with my good experience; but, from everything I’ve read my experience is typical. There are good reasons for surgery; but, a lot of guys would be spared some life changing side effects by investigating radiation options.
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
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    Old 05-07-2021, 09:35 AM   #10
    jorlo
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    Re: Treatment Opinions

    I have heard this notion about radiation as a backup plan for failed surgery for years. It always raises two questions:
    1. What, exactly, do they radiate once the prostate is gone?
    2. Whatever it is that they are radiating, wouldn't radiation have gotten it if that was the initial treatment?

     
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    Old 05-07-2021, 09:52 AM   #11
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    Re: Treatment Opinions

    Quote:
    Originally Posted by jorlo View Post
    I have heard this notion about radiation as a backup plan for failed surgery for years. It always raises two questions:
    1. What, exactly, do they radiate once the prostate is gone?
    2. Whatever it is that they are radiating, wouldn't radiation have gotten it if that was the initial treatment?
    Prostate cancer (PCa) can leave the prostate in two ways: (1) by local spread into adjacent structures, such as the fat around the prostate, the seminal vesicles, the bladder neck, etc.) and (2) metastatic spread at a distance, but especially pelvic lymph nodes. Also, sometimes a piece of prostate tissue or seminal vesicle is left behind after surgery. Only a sampling of lymph nodes is done at surgery (usually the higher the Gleason score at biopsy, the more nodes are taken). If, say, only one node is positive, the question is: was that the only positive node? Radiation can be done (1) relatively soon after RP if the results from the path examination of the prostate were not very good (adjuvant RT) or the PSA remains high after surgery, or (2) one can wait to see if and when the PSA rises again before doing RT (salvage RT).

    When primary treatment fails (RP or RT) the prostate can be irradiated (or reirradiated). The radiation field can be narrow (mainly the prostate bed -- where the prostate used to be), or wider (whole-pelvis). The tradeoff is that wider means including more lymph nodes but more radiation.

    When as the primary treatment takes time to work -- it does not work instantly. Studies have shown that some men who choose radiation still had viable PCa when a prostate biopsy was done 2 years after radiation. Recurrence can be local for these men as well. One of the ways of treating men with recurrence after primary RT is with another round of RT.

    Djin
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    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.
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    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
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    Dry; ED OK with sildenafil
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    Old 05-07-2021, 10:29 AM   #12
    Prostatefree
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    Re: Treatment Opinions

    Surgery recovery seems to be easier the younger you are, assuming good health.

    This isn't an easy decision and is not alway clear cut. I have a prejudice against radiation, in general. It is toxic to healthy (all) tissue. This has nothing to do with precision. Anything it radiates will pay a price. What's the big concern for accuracy if it's safe? (Rhetorical)

    Radiation kills or stuns cancer cells because they have fundamental flaws to their DNA redundacy. Radiation can not be directed to hit only cancer cells. It hits everything it's pointed towards. It can not hit a cancer cell and then miss the healthy cell next to it any more than a knife.

    Healthy cells can take the hit and recover, but they do a pay a price. Will you live long enough to need it? If a healthy cell has nine lives and a cancer cell has one we can see how radiation works. But, the healthy cell may have lost one or two lives as a result of being radiated. Maybe you will need them if you live long enough or maybe not.

    This board is decidedly pro radiation, and for good reason. However, I'm glad I'm "cured" and never had radiation. I'm certain I'd think the same about radiation if it "cured" my cancer. Tough choice. They both have their pros and cons and the idea one is better than the other is a misservice to the complexity of healthcare, imo.

    Those who chose radiation thinking the side effects will be less than surgery are not likely to hang out sharing a different story. My brother had surgery and follow up radiation. His experience was the surgery was a preferred expereince to radiation and ADT. He had colon side effects because the cancer was against the colon and the colon got a heavy dose. Remember, wherever the cancer is is where the treatment goes, knife or radiation.

    You know what works best against treatable cancers? Early detection! Hands down.

    And, can an MRI really produce a report that the cancer is confined? I don't think so, but you hear it here almost every week. What it can produce is a report it didn't detect any cancer. And it's a good thing, but they are not the same.
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    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 05-07-2021, 05:49 PM   #13
    Eonore
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    Re: Treatment Opinions

    Like Prostatefree, I am not biased either way in terms of treatment. In my case, the choice for removal was clear due to my severe urinary problems due to BPH. However, having been through both surgery and radiation with hormone therapy, I would choose radiation every time, in terms of side effects. That’s just me though. The giant size of my prostate (240 grams) required a long and difficult surgery, with corresponding side effects. My feelings might be very different if I had a more normal sized organ. That is why there is no one size fits all solution. Good luck with whatever choice you make.

    Eric

     
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    Old 05-07-2021, 10:32 PM   #14
    guitarhillbilly
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    Re: Treatment Opinions

    As someone who had 42 IMRT treatments and Still on ADT [Lupron] I have more complaints about the ADT than the IMRT. The radiation side effects were gone within 8 weeks after completion and that was one year ago that I completed IMRT. I had the SpaceOAR Gel injection prior to IMRT. Dealing with ADT side effects that are moderately annoying. In my case I'm glad that I chose EBRT over RP.
    Keep in mind that you could wind up exposing yourself to 2 different traumas in your pelvic region if you choose surgery. The RP and then later some type of EBRT.
    Any choice you make has the potential for long term side effects.
    It is not for me to tell you what to choose but do your homework before making the choice.
    __________________
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    Old 05-08-2021, 03:44 AM   #15
    HighlanderCFH
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    Re: Treatment Opinions

    Good post. Thank you, Jim.

     
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