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Re: Image Guide External Beam Radio Therapy or Da Vinci?
I wouldn't dismiss a prostatectomy too quickly. Almost no one dies of prostate cancer within 10 years of getting a prostatectomy and then you are still open to salvage radiation treatment. They will almost never do a salvage prostatectomy after radiation due to the fact that previously radiated cells do not heal well.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
As suggested, the more research on different treatments the better.
But to me personally, an important choice would be: Do you let the varying potential side effects make a choice for you, or do you choose the best treatment suited to the biology of your particular case.
In other words, are you trying to negotiate side effects versus cancer?
Re: Image Guide External Beam Radio Therapy or Da Vinci?
That is a good point. My priorities are in this order:
Ideally (10 year+) removal of cancer (PSA consistently less than 0.2 is as good a measure as any)
Preferably with the least side effects!
Incontinence/ED of similiar concern, but no point being super virile and dead!
I cannot see any great logic for surgery and radiation, great if surgery will sort but maybe in my case proton or ProstRcision better although there I would be worried about bowel/bladder or other cancers. Not sure how likely these are given modern advances?
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Just seen original Urologist who downgraded me to a T1c and said the Gleeson 8 was only in 20% of one core so 'there was no indication it had escaped the protrate and surgery is the answer' - oh and yes he is an ex- surgeon! Was overly/too dismissive of proton and ProstCist saying he saw many complications. Second opinion due next week.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Simon,
You have said that you cannot see any reason for surgery and radiation, might as well just do radiation. So I would like to give you a few things to consider.
1) If surgery comes first then almost all the cancer will be removed, or maybe all. Since what may remain is very small the amount of radiation used for your treatment is considerably less than if you were to be radiating the intact prostate gland. 60 - 66 Gy instead of about 80Gy I think.
2) When you have surgery the removed material is examined thoroughly. Thus you get a first hand look at the state of your cancer. You won't get this with radiation.
3) If the surgery shows the cancer to be capsule contained then you will probably need no further treatment, i.e. no radiation at all.
It seems you do have some good information about the particular location of the cancer within your prostate. That location may have a bearing on whether surgery is a better or worse choice, look into that. I don't have any info to share on this.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Simon you are experiencing what a piece in The New England Journal of Medicine in July 1997 had to say about our disease:
‘The many recent changes in therapeutic approaches to localized prostate cancer are exciting and preoccupying but to patients they are bewildering and can seem dangerous. Until the trials now under way have been completed,(they were completed many years ago) we have no firm guidelines for advising our patients about which therapeutic option is best. This means that education is more important than ever, but the art of multidisciplinary counseling is hampered by rivalries that seem more common among prostate-cancer specialists than in other cancer specialties. This must change. ……Close collaboration between surgeons, radiotherapists, and medical oncologists is mandatory for substantially improved control of prostate cancer.’
Although the article made a strong point for change, there is not much evidence that anything major has happened in that connection in the past 13 years. All of which doesn’t help you, so let’s look at a few broad issues that might help you focus on what is important for YOU.
I think the first factor in the light of your stated aim of (10 year+) removal of cancer is to see what data there is about the odds of achieving this. As a first step perhaps you need to consider your life expectancy. I only have US figures to hand, but would expect UK figures to be similar. They show they show the range of life expectancy for a man of 50 to be between 14 and 43 years with a median of 28 years. So the first question is, where does your life expectancy fit in this range? One of my pals in South Africa was diagnosed but had no treatment because his doctor said his heart condition or his lung condition would get him before the PCa. Seven years after diagnosis none of them had……
Assuming you consider yourself as having a median (or longer) life expectancy, then it is pertinent to see what data there is concerning life expectancy for men diagnosed with PCa. Here the waters can be rather muddy because of the lack of relevant data. At the broad brush end of the data, it can be said that the survival rates are high, with a number of studies indicating disease specific mortality rates of less than 5% ten years after diagnosis. But as ever, the devil is in the detail, because most men diagnosed are over the age of 65 and the mortality rates only really start rising steeply for men in their 70s, not to mention the fact that the non-disease specific mortality rates for men in these age groups is also climbing. And Frank is not strictly speaking correct when he says Almost no one dies of prostate cancer within 10 years of getting a prostatectomy….. As a general statement, like the general statement that the mortality rate is less than 5%, this may well be so, but for sub-sets of men, the mortality rate can be higher. There is only one long term study that compares surgery to what is termed ‘conservative management’ and that does show a survival advantage of surgery over a period of 20 years, but not at 10 years.
The only age-related study that I know about was one done by Albertsen PC, Hanley JA, Gleason DF, Barry MJ titled Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer. JAMA 1998 Sep 16;280(11):975-80. The authors came to these conclusions:
• Men with tumors that have a Gleason score of 6 face a 18% to 30% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis
• Men with tumors that have a Gleason scores of 7 face a 42% to 70% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis and
• Men with tumors that have Gleason scores of 8 to 10 face a 60% to 87% chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis.
It must be borne in mind that these were men who were not initially treated with invasive therapies and that the Gleason scores were those which applied before the so-called ‘migration’ of scores which saw an increase in scores.
This Albertsen study is one that points to the importance of early intervention for a GS 8 tumour – and the importance, which I have mentioned previously of ensuring that the grading of the material in the biopsies is as accurate as possible.
Having got some idea of the relative risks, perhaps the next step in deciding on treatment options is to establish the probability of the disease being contained or have spread beyond the gland. The PARTIN TABLES are often used for this purpose. These are not predictive at an individual level but give some ideas of probability. But before looking at your probabilities, you would need to clarify your staging (and your Gleason Score) because there are very different probabilities associated with these figures.
If the revised staging of T1c is correct then the probabilities are shown below – the figures in brackets are the range of probabilities; the main figure is the median of the range
I’d personally lean towards the second set being a more likely set because it appears, from the number of positive needles in your biopsy, that there is a fairly large mass of tumour and some studies have indicated that when a critical mass is achieved, the disease will start to spread.
There is another set of tables – the HAN tables – linked from the link above that indicates probabilities of failure of surgical treatment. If your staging is T2c then the relative probabilities of what is termed a biochemical failure (detectable PSA) are:
3 years after surgery: 18% (6-50)
5 years after surgery: 28% (9-68)
7 years after surgery: 38% (13-81)
10 years after surgery: 46% (16-89)
If there is a low probability of the disease being organ confined surgery is not regarded as the best option, although, as BillG says, there is some value in getting better data. But as it seems you were leaning away from surgery, it may be a good decision for you to concentrate on the options.
ProstRcision® is the trademarked name of the therapy administered by Radiotherapy Centres of Georgia (RCOG) but one which is carried out elsewhere. It consists of a combination of brachytherapy (to deliver the highest safe dose of radiation with the least risk of collateral damage) with EBRT (External Beam Radiation Treatment) to deliver a lower dose to the outer and adjacent parts of the gland and surrounding tissue. This approach has always made sense to me personally and many men who have had this treatment were very satisfied with the outcome. One thing that has always puzzled me is that RCOG has always collected a good deal of material about patients and their outcomes, but have never, to my knowledge published this in any journal where the results are subject to third party scrutiny. For that reason only I have a question mark over some of their claims. In your case you might not be eligible for this treatment (or for any other form of brachytherapy) because of your TURP (Trans Urethral Resection of the Prostate).
If EBRT (External Beam Radiation Treatment) is the main option, then there is a variety of therapies and delivery systems to consider (subject to cost and availability). PBT (Proton Beam Therapy) would be my personal choice, but there are no independent studies demonstrating the superiority of this form of treatment over any other. Like RCOG, the people who have been carrying out the therapy longest – Loma Linda in California, have not, to my knowledge published any independently scrutinized data.
Leaving aside PBT, there are many variants on dosage and delivery all claiming to be better than the opposition but none with independently published and scrutinized long term outcomes. So it is really up to an individual to carry out what investigations he can to establish the track record of individual facilities – talking to nurses who work there is often an excellent way of getting a pretty accurate picture.
Finally – and I hope this has been helpful rather than boring, there is the question of ADT (Androgen Deprivation Therapy) – if and when it should be applied. There are papers that demonstrate that what is termed neo-adjuvant ADT (ADT applied prior to the commencement of radiation therapy) has positive outcomes because it reduces the size and texture of the gland and increases the effectiveness of the radiation therapy. There are other papers that claim that ADT applied after the radiation produces better results because the radiated cells are more susceptible to the continuing effect of the radiation therapy. And of course there are papers that say neither of the above approaches produces any better outcome.
I think personally that a good deal depends on how widespread the disease might be at diagnosis. There is one school of thought that believes that the disease may be what is termed systemic at diagnosis. That is to say that cancer cells might be lying dormant throughout the body at that time. Others refer to micro-metastasis – very small groups of cells that have not fully metastasized. Whatever term is used, the only way to attack cells outside the gland and outside the immediate vicinity of the gland at present is by way of ADT To that end, if there is any good indicator that there has been spread beyond the gland it would seem to be appropriate to consider intermittent ADT as an adjuvant therapy to radiation.
Any decision of this nature, with its long reaching consequences should be discussed with a qualified medical person. We amateurs have a place in helping people towards decisions, to point out what they may not know, but ultimately professional help is required – and that person should be an oncologist, not a specialist in any specific discipline.
Good luck. I’ve waffled long enough – must get on with some updates.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Sorry Terry just to clarify - I am fit and sailed through my last medical (apart from this) so longer term life expectancy rather than short. Only 1 of 12 biopsy cores was positive - the 4+4 20%. They took 1g of material from the front (anterior) left and right because that is where the MRI said the tumour was - and that was 30% 3+3 and on the other side 31% (3+4 60:40). So comparing me to Partin or Han is difficult - I am not sure how relevant they are! How lost am I!
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Well, you've succeeded in confusing me again, Simon.
In a previous post you said:
Therefore I had a minor TURP to get at that (Gleeson 3+4) AND a normal biopsy (Oh joy) 7 out of 12 cores positive most 3+4 but one small one 4+4!
Now you say:
1. Only 1 of 12 biopsy cores was positive - the 4+4 20%. - NOT 7 out of 12 apparently
and
2. 1g of material from the front (anterior) left and right ..... was 30% 3+3 and on the other side 31% (3+4 60:40).
This shows, as far as I understood the issues that 30% of the material in the focussed biopsy samples was positive for PCa.
As explained in the piece on Gleason Scores, the highest Gleason Score in all samples is taken for the purposes of 'scoring' the disease. Therefore you have a GS 8 disease unless an expert opinion changes the GS.
You can key whatver data you wish into the Partin and Han nomograms.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
Terry, my apologies I am not sleeping and I got confused. The second post is the correct one (Ie 1 out of 12 positive the 4+4, but TURP showed both anterior lobes had cancer, but I am not sure it changes anything - as you say it is still Gleason 8.
Re: Image Guide External Beam Radio Therapy or Da Vinci?
BillG
Thanks - that is a good logic stream I think. I do like the idea of knowing what is going on - especially if it is good news! Perhaps less so if not! Then I might have wished I did something else! As far as I can tell from Terry's response it is a 50:50 toss up!
