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Re: Is surgery a good option for my 74 year old father?

Sandy,

Danny Staggs has given you some good advice. From the information you have supplied there is no need for your father to rush into any therapy. A delay of some months is unlikely to affect any outcome and you and he can evaluate all the options available and make a decision that is best for HIM, not for anyone else.

I was 20 years younger than your father when I was diagnosed in 1996. I chose not to have surgery or any other treatment at that time. I say this to tell you where I am coming from rather than to suggest he should make the same decision as I did, but it is important to know that a long delay is not always a bad thing.

I would like to suggest that as a first step you download (or ask me to mail you) a copy of the booklet I wrote for newly diagnosed men and their families A Strange Place I suggest this because the booklet gives you the basic 'language' you will need to interpret the information you will be getting. You will know what a Gleason Grade is, what PSADT means and why it may be important and so on.

While you are absorbing that, please consider getting a second opinion on the biopsy. This link Recognised Expert Pathologists suggests some experts and as Dr Strum is quoted as saying there:

The Gleason score is a critical item; it is used as a variable in virtually every prognostic and treatment algorithm. An accurate GS mandates an expert pathology opinion from a PC pathology expert.

The problem you will face is the one we all faced when we were diagnosed - there is no certainty. Diagnosis is an art rather than a science and there is very little agreement amongst the urologists and other medical advisors as to what is the 'best' treatment. Although surgery is often labelled "the gold standard" of treatment, all the information we have to date is that there are no studies which show definitively that one therapy is superior to another either as to 'cure' or to side effects. The biggest single factor in having a high number of remission free patients with minimal side effects is the expertise of the people carrying out the therapy. It is hardly surprising that the best people get the best results. A medical student graduating at the bottom of the class is still a doctor, although they may not be the best person to consult.

Amongst the key factors to be included in any evaluation is your father's life expectancy. One of the tables used in the US gives a range of between 5 and 15 years life expectancy with a median of 10 years for a man of 75. The chances of a prostate tumour with the distinguishing features identified so far proving to be fatal in that time frame are slim - probably less than 5% at 10 years even if there is no immediate therapy.

You might like to go along to Treatment Experiences and click on the link Age at Diagnosis over 70 and you will see a number of older men who have contributed their stories. That may give you a good view of how and why they made their decisions - and what the outcomes have been. You can't make a decision solely on "do what I did" - but it is very helpful to be able to see how the various treatments on offer have turned out for older men.

Good luck with your quest and if there is anything specific you need to know, keep asking until you get a good answer.

Terry in Australia

Re: Is surgery a good option for my 74 year old father?

I was 59 and had a prostatectomy. My gleason was 3+3=6, PSA 6 after biopsy. The cancer was in the fatty tissue outside of prostate and gleason was upgraded to 7. I am now scheduled for salvage radiation due to a rising PSA, 18 months later. You won't know for sure that it is contained until after surgery. I would talk to a radiation oncologist prior to making decision. Good luck and tell your dad not to get discouraged. Learn all you can and you won't be so fearful.

Re: Is surgery a good option for my 74 year old father? (Lots of additional info from Dr. Walsh)

Hi Sandy,

In addition to the excellent & thorough advice you have gotten so far, I thought I would give you some additional insight from the world-renowned urologist/surgeon Dr. Patrick Walsh from Johns Hopkins Hospital who authored THE book on Prostate Cancer (PCa) entitled “Guide to Surviving Prostate Cancer”. Despite being an open radical prostatectomy (RP) surgeon, the book gives a surprisingly objective look at the different treatment options and even recommends that some patients not seek treatment due to their age & overall health. I am going to give you some excerpts from this book as it relates to your father, but it would be worth your time to obtain a copy. If you do, you will find that it is written in layman’s terms so it is easy to understand.

First of all, Dr. Walsh believes that those seeking treatment should have at least 10 years of life expectancy left & be in overall good health. (I want to add that this view is shared by the U.S. Preventive Services Task Force (USPSTF) & other similar organizations around the world). In a quote from the book, under the heading “Men Who Probably Don’t Need to Be Cured”, he says: “To put it bluntly, at the top of the list should be men who are too old or too ill either to undergo the rigors of treatment or to live another ten years—long enough for such treatment to be worthwhile. These men are very unlikely to die of prostate cancer, and if the cancer progresses, their symptoms can usually be managed well with hormone therapy. Also, in this group should be men who don’t want to experience the side effects associated with surgery or radiation”. For these patients, he recommends “Expectant Management” or “Active Surveillance” (AS) as it is often called.

As far as surgical complications are concerned, he has this to say: “In men over 70, surgery carries a higher risk of incontinence & impotence”, but he adds that the side effects of surgery are highly variable, depending on the skill & experience of the surgeon. (Danny & Terry have already given you excellent advice on finding one of the best doctors in his field despite which treatment option you choose).

In regards to the effectiveness of RP, you don’t need his book to google “The Hans & Partin Tables” put together by the doctors at Johns Hopkins. You didn’t say what your father’s clinical stage is (it sounds like T2c, meaning the cancer is palpable & involves both lobes, but I can’t be sure). With the clinical stage and the knowledge that your father has a PSA of 20 & a Gleason score of 7 (4+3), you can use The Hans Table to determine the likelihood of having no detectable cancer at 10 years following RP. (If he is a T2c, the likelihood of being cancer free at 10 years is 59%). The Partin Table uses the same information to determine the extent of the cancer (or pathologic stage as it is called). For example, it will give you the likelihood that the cancer is organ confined, and in the case of a T2c with your father’s PSA & Gleason stats, it is only 11%. It also gives the likelihood of extraprostatic extension (or capsular penetration as it is sometimes called), as well as seminal vesicle & lymph node invasion. It should be noted that this information is based on 5000+ J Hopkins patients & therefore should be considered a best case scenario since JH is one of the best hospitals for cancer in the country.

The Doctor has this to say if a man is in his seventies & the Tables suggest that cure is unlikely: “The question here is whether a man who may not live long enough to die of PCa should be put through an operation with an uncertain likelihood of cure. Surgery has more side effects in people in their seventies. So, for this man, radiation therapy is a better, more reasonable option”.

Lastly regarding age, he talks about how a family history of longevity, low blood pressure, not having diabetes, not smoking & having no history of heart disease may cause you to live long enough to need to be cured. (I should add that he states that AS may be a better choice if the patient has trouble breathing). For the record, one website I checked out lists the average life expectancy for a man in the USA to be 75.6 years, but of course, many men live a lot longer than that. My Dad, for example, is well into his eighties and going strong. I wish your father the same longevity.

Best Wishes,
Alan in the USA

Re: Is surgery a good option for my 74 year old father? (Lots of additional info from Dr. Walsh)

I am 75 and three years post-treatment. My ongoing journal thourghly documents my experience. You and your father may find it helpful; see http://protondon.blogspot.com/
Regards Don O.

Re: Is surgery a good option for my 74 year old father?

Just wanted to thank everyone for your kind responses to my earlier query. Also, an update that my father opted for Laparoscopic Prostatectomy. Surgery will be conducted by an experienced surgeon. It is scheduled for the first week of March. Please pray for my father and send positive thoughts his way, for his full and speedy recovery. Thank you again! Sandy

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