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Re: Bracky v Prostatectomy

Hi Jules,

I am surprised to read that your urologist did an about-face and recommended brachy over surgery at your age. I say this because I am 55 and a friend of mine is 48 (we are both Gleason 6s) and both my urologist and his medical oncologist said that, due to our age, radiation therapy was not the way to go. Basically, there were two reasons that they gave for their opinions:

1) The longer you have to live, the more time the radiation has to possibly give rise to tumors in the bladder or colon (in essence, one cancer could get replaced by another).

2) Similarly, the longer you have to live, the greater the chance of experiencing recurrence and, while you can have salvage radiation therapy after failed surgery, it is not an option if you experience recurrence after "RT". It is my understanding that the less favorable options open to you at that point would be chemo, hormone therapy (and possibly HIFU, cryotherapy & surgery).

So, on your follow-up consultation it would be a good idea, IMO, to get him to address these issues. Good luck with whatever you decide.

Alan M in the USA

Re: Bracky v Prostatectomy

G'day Jules and welcome.

Here are my comments on your post:

My urologist recently changed his mind, recommending bracky after having previously recommended removal. Did he give any specific reason for changing his recommendation and why did he specify brachyhterapy instead of external beam raditioan (proton or photon)? If he didn't ask him to explain carefully to you what the change of mind.

He says that success rates are similar but side-effects reduced. Any comments? There are no good independent studies that demonstrate the truth of this statement. It appears from existing material that the single most influential aspect of good outcomes, both as to remission and side effects is the experience and track record of the medical team invovled. A good surgeon will generally get better results than a poor radiologist: an excellent radiologist will have better outcome than a poor surgeon.

That T1b staging of yours is unusual, especially when you note a PSA of 8.6. That PSA level would normally trigger a recommendtion for biopsy and if the biopsy ws positive the staging would be T1c.

T1b staging indicates that prostate cancer was found 'incidentally' and not as a result of an elevated PSA. This would normally be in conjunction with a TURP (Transurethral Resection of the Prostate) and, as you will see from this page STAGING T1b: tumor present, but not dectable clinically or with imaging; tumor was incidentally found in greater than 5% of prostate tissue resected (for other reasons)

So, if there is in fact positive material in more than 5% of the gland, some form of radiation might well be a better option than surgery. I say that because there are some studies that show a correlation between total mass of tumour and metastasis.

Do you have a copy of your biopsy report? What does it say? How many cores were taken? How many were positive? What was the estimated positive material in each sample? What part of the gland are the postive samples from.

Is the staging correct? What is your PSA record - did you have slow or fast rising PSA? Did you have a history of PSA variances - both up and down - prior to diagnosis?

All these - and many more - aspects of your diagnosis can point to one therapy being potential better than another - or even to whether you need immediate therapy.

Whatever your final choice may be, do not rush into a decision without understanding your options and the potential outcomes.

Good luck

Terry in Australia

Re: Bracky v Prostatectomy

Hi Jules,
There are some common misconceptions about brachy, like the ones listed above. There have been many studies on secondary cancers caused by radiation and this was true 15 years ago with the use of ERBT. The incidence of secondary cancers due to Brachy are zero, and those from IMRT are about .5% in 20 years.
There are also options for treatment should Brachy fail, which is very rare. You can be reseeded with low or HDR brachy, have cryosurgery or HIFU with the same success rate as salvage radiation after surgery.
You doctor is correct about the side effects which are generally much lower for Brachy than the other conventional treatments. It is a one hour outpatient treatment and you can resume normal activities the next day. There is about a 4-6 week period of increased urgency and frequency that are very tolorable. It is very important to get a Brachytherapist that has done at least 500 procedures if you want the best outcome. I had Brachy/IMRT 3 years ago and have no side effects with a consistant psa of .1 down from 40, with a large G4+3 tumor.

Re: Bracky v Prostatectomy

John,

With all due respect, since a fellow YANA member by the name of R Scott had this to say about your January 20th, 2012 post on the subject of proton versus photon: "I feel I must respectfully challenge some of the misinformation that your post on the subject contains", frankly I don't know whether to believe my urologist and my friend’s medical oncologist, or you. So, I will do my own research on the subject, although I have to say that I am in no hurry since I am on AS. Still, I invite you to provide supporting evidence for your claims and I would be perfectly happy to find out that you are right and that the doctors are wrong (particularly since it would expand my options if and when that time comes).

Perhaps you could start by addressing this October 30th, 2010 article on brachytherapy 15 year follow up data which can be found on the following website: prostatecancerinfolink.net/.../15-year-outcomes-after-brachytherapy-...

You said: "There are also options for treatment should Brachy fail, WHICH IS VERY RARE." However, the study figures appear to be in conflict with your statement. Is it because there have been significant improvements in brachytherapy since 1992?

The 15-year biochemical relapse-free survival (BRFS) when broken down by D’Amico risk group classification cohort analysis is

o 85.9 percent for low-risk patients
o 79.9 percent for intermediate-risk patients
o 62.2 percent for high-risk patient

Median time to biochemical failure (in those who failed) was 5.1 years

Note: The above percentages are based upon 215 patients with localized PCa treated between 1988 and 1992 with brachytherapy alone. BRFS was assessed based on use of the Phoenix (nadir + 2 ng/ml) definition.

It goes on to say:

"There is little doubt that the long-term outcomes of patients with localized PCa treated with brachytherapy alone in the modern era are closely comparable (and arguably superior) to the long-term outcomes of similar patients treated with radical prostatectomy. However, in the absence of a carefully controlled trial designed specifically to compare these outcomes, the newly diagnosed patient needs to come to his own decisions about therapy preference — preferably without being subjected to an overdue emphasis on the personal views of advocates for one or the other form of therapy".

"It is the case that in the only prospective trial designed to assess quality of life and satisfaction with outcome after treatment, patients treated with brachytherapy certainly expressed higher satisfaction levels than patients treated surgically in some areas."

Note: It is well worth your time to read this trial. If you would like to do so, go to the webpage and click on the link. Here's a sample of some of the things that you will read:

"Sexual quality of life scores were affected by all forms of therapy, with an average sexual quality of life score of 45 to 55 out of a possible 100 at 2 years after treatment for those who received nerve-sparing surgery, external beam radiotherapy alone, or any form of brachytherapy".

"Brachytherapy patients reported long-lasting urinary, bowel, and sexual symptoms, as well as transient problems with vitality or hormonal function".

Alan M in the USA

Re: Bracky v Prostatectomy

Alan,

http://www.prostate-cancer.org/pcricms/sites/default/files/PDFs/Is14-2_p3-11.pdf

This is a much later study of all Brachy published results that shows Brachy for low risk PC is in the mid 90%. It is the Prostate Cancer Study Group that reviewed over 700 published studies on all treatment options and is classified by DiAmico risk class.
I was also referring to local reocurrances as systemic reoccurrances are not elibible for any salvage therapy. There is also a published study by Dattoli on 1400 patients that showed all reoccurrances after seeds/IMRT to be systemic and not local.
Local failures are rare for low risk PC when done by an experienced Brachytherapist. There has been significant improvements in imaging to place the seeds and also the seed templets since 1992.

Re: Bracky v Prostatectomy

I attended a prostate group meeting last year at which a local radiologist spoke. After listening to him about the recent advances in Brachy I would now personally go with Brachy vs radical if I had my choice to do at this time. Being in my late 50's I chose radical 4.5 years ago as it had the best long term survival rate at that time. Now apparently the two procedures cure at about the same rate.

Re: Bracky v Prostatectomy

Jules,

I was 46 when I had seed implants. My urologist of course wanted to rip out the prostate, but I balked. After a while he advised that brachy should be fine for my condition. My family doctor just wanted me to do something, and was fine with brachy. I saw 2 radiation oncologists, and both were fine with performing brachy on a 46 year old. I chose the doctor who has performed in excess of 10,000 seed implants, and so far so good, but I am only 8 months post seeding. You can read more here if interested: http://www.yananow.org/display_story.php?id=924
Good luck to you, and take your time making a decision.

Re: Bracky v Prostatectomy

The most objective recent series of papers I have found addressing the difficult issue of comparing prostate cancer treatments are those from the Prostate Cancer Results Study Group. A summary of the group's rather rigorous evaluation criteria and results is available at:

http://www.prostatecancertreatmentcenter.com/ProstateCancer/ProstateCancerResultsStudyGroup.aspx

It is perhaps unfortunate that the lead on papers from this group has been by Dr. Peter Grimm (Prostate Cancer Treatment Center, Seattle), as too often critics assume a bias towards brachytherapy, Dr. Grimm's specialty. However, the doctors in the study group include nationally recognized surgeons, oncologists, radiologists, and pathologists.

If anyone wants more details than in the web site above, I have PDF files of a 2011 slide presentation (which includes links to over 50 reference studies) and a 2012 paper in the British Journal of Urology, International.

Cheers!
Jon in Nevada

PS- Studies on treatment outcomes are confounded by the fact that any analysis of 10 or 15-year results mean that the technology used now is 10 to 15 years old. We never will be able to get past this limitation in using long-term studies to try and justify a particular 'gold standard' for prostate cancer treatment....

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