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Newgurl2772
New User
Joined: 16 Feb 2008
Posts: 3
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 Posted: Sat Feb 16, 2008 3:08 pm Post subject: Treatment Options |
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Hello to all.
My father was recently diagnosed with prostate cancer. Here are the biopsy results. PSA 11 that is why he had the biopsy. previous PSA of 7. I think the level increased over a period of 6 months?? not sure. 8 samples taken. of that 8 only one was positive. 16% gleason scale of 6(3+3). tumor can not be felt on physical exam. biopsy only done because of increased PSA. positive only on one side. my dad states that the physician circled stage 3 in the "pamphlet" however when I spoke to physciain he stated the stage/grading as 2T1a. I am still a bit confused about grading. but I feel that the cancer has been caught early on so he has a good prognosis.
My concern is on treatment. should we do, seeds alone or seeds with radiation, surgery??? my Father is leaning more towards seeds. the surgery my bit a bit much for his life style. he is 67 years old. in farily good health. loves the outdoors and is very active.
I want to make him as informed as possible so that he can choose the best treatment for long term survival with great quality of life.
Any advice would be greatly appreciate.
God bless to everyone:)
Last edited by Newgurl2772 on Sat Feb 16, 2008 6:07 pm; edited 1 time in total |
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Replicant
Moderator
Joined: 01 Nov 2006
Posts: 206
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| Posted: Sat Feb 16, 2008 4:13 pm Post subject: hi |
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What a great daughter!
Your dad is pretty average--that's a very common Gleason. From the information you gave, and Dr. Walsh's book (Dr. Walsh's Guide to Surviving Prostate Cancer), p. 190, your dad's stage is T1c (not palpable, identified by needle biopsy because of elevated PSA level). T1a is when cancer is found incidentally during a procedure called TUR. T1b would be if cancer is found during a TUR and greater than 5% of the tissue removed was cancerous.
In any case--indications point towards an early, curable cancer. You should know that Gleason and clinical stage are just educated guesses. Definitive Gleason and stage can be obtained if the prostate is removed.
You didn't say what your father's PSA is, and has been. That's an important piece of the puzzle. With PSA, Gleason, and clinical stage, you can check the Partin tables online or in Walsh's book. Partin tables give you statistical odds of how far the cancer has spread. However, even assuming the worst for a moment, a PSA greater than 10--the odds are in your dad's favor for the cancer being confined to the prostate. 70%.
If your dad's PSA is very low (less than 2.5), the odds are 93% that the cancer is confined to the prostate.
Prostate-confined cancer is curable. So, potentially, is cancer that has poked it's head out of the prostate but hasn't yet learned how to survive without it (extraprostatic extension).
Don't panic--prostate cancer is very common, but relatively few men die from it. There's no need to rush--this cancer has been developing probably for a decade or more A few weeks of research and consultations can only help, not hurt.
I would recommend getting Walsh's book. It's very easy to understand, comprehensive, and reassuring. Besides that, I would recommend "Prostate Cancer for Dummies" by Paul Lange, MD.
Those books can help you chart out the options. There's also a new treatment decision tool for prostate cancer on the American Cancer Society website. It asks very detailed questions, and you would have know your father's entire medical history in detail.
The options run like this when it looks like the cancer is localized:
Watchful waiting (or "expectant management"): probably not a good option unless your dad expects to die from something else in the next 10-15 years. During watchful waiting, you get PSAs frequently and get regular biopsies (not fun, as your dad can attest).
Surgery--the most common primary treatment, and one that comes naturally to a lot of men ("get it OUT!"). Pros of surgery: you get the prostate examined in its entirety by a pathologist, if the cancer is confined prostatectomy offers the best long term odds, and if you have a recurrence it may still be possible to cure the cancer by radiation. Cons: it's major surgery, and there are always risks from general anesthesia, bleeding, etc. Plus almost all men suffer some combination of impotence and incontinence afterwards. Robot-assisted surgery is available (I had it) and it MAY offer benefits such as faster healing, shorter hospital stays, lower rate of side effects, but I think this is far from proven and depends a great deal on the skill of the surgeon. Patients should know there is a steep learning curve to robotic surgery--anyone going this route should find a surgeon who's done at least 30 and hopefully 70 or more.
Radiation: in various forms--seeds (brachytherapy), external beam (IMRT, IGRT, or protons), or some combination. Pros: no surgery, no long stay in the hospital, plus radiation can sometimes kill cancerous cells that have made it outside the prostate but which are still in the vicinity. Cons: no pathology report, and if you have a recurrence after surgery, salvage procedures are often very risky in terms of collateral damage. Also, at least IMRT has some possible side effects, although compared to surgery, they're usually mild and temporary. Protons are famous for having less side effects than IMRT. I'm not sure about IGRT side effects, although I know they're at least no worse than IMRT.
HIFU: high intensity focused ultrasound. Not available yet in the U.S. but some men travel abroad to have it. I don't know much about it.
Cryoablation--the entire prostate gland is frozen. My father had this done, and it was a complete success, but I don't know a whole lot about it, other than it has not exactly taken off, mostly because it hasn't lived up to its early promise. Probably not a viable option for most men.
Best wishes!
_________________
Replicant
Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com |
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Newgurl2772
New User
Joined: 16 Feb 2008
Posts: 3
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| Posted: Sat Feb 16, 2008 6:08 pm Post subject: Re: Treatment Options |
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| Thank you the information. it is most helpful. One question I have is can my Dad have surgery if he has radiation first? |
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Replicant
Moderator
Joined: 01 Nov 2006
Posts: 206
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| Posted: Sat Feb 16, 2008 7:06 pm Post subject: hi again |
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The short answer is no.
A salvage prostatectomy after radiation is fraught with danger. It is a technically challenging procedure. Some patients have severe incontinence afterwards that cannot be helped with medical intervention, for example.
In the medical field this is known as severe morbidity.
Although it is sometimes done--and I know of a recent success story-- it should not be counted on. I also know of a horrible situation where everything went south.
Walsh addresses this starting on page 403, saying that before 3D conformal radiation, salvage prostatectomy was a real nightmare--the prostate literally stuck to everything around it. Whether or not the newer radiation techniques make salvage prostatectomy possible remains to be seen.
On page 404 he cites a study by the Mayo Clinic. 199 men, following failed radiation, had either a prostatectomy (removal of prostate) or cystoprostatectomy (removal of the prostate and bladder). 15% of the men suffered from internal leakage--urine leaking into the tissues (extravasation). 22% had bladder neck contracture. 44% developed incontinence bad enough to wear pads on an ongoing basis. 4% had rectal injury.
So the long answer is, yes, it could be done, but it would be a difficult and risky operation.
Sometimes salvage cryotherapy (freezing) is done if radiation doesn't do the trick. Walsh says that while salvage surgery has higher side effects, it is more effective at cancer control than cryo in a salvage setting.
The last option would be more radiation--if brachytherapy alone was done, external beam could be tried. If external beam was tried, salvage brachytherapy. Walsh says there are some studies that this may be effective for some men, if done by a very skilled practioner.
All of this is MUCH more complicated and risky in terms of severe side effects than having salvage radiation after a prostatectomy.
Like I said, there are pluses and minuses to all treatment options. A major plus to me in choosing surgery was that if I had a PSA recurrence, maybe I could do radiation. And in my case, that turned out to be true. My PSA starting shooting up not long after surgery, and salvage radiation seems to have taken care of it, with fairly minimal and transitory side effects.
That doesn't mean I'm advocating surgery for anyone. Even looking at my case in hindsight--maybe if I had chosen radiation as my primary treatment, it would have taken care of my cancer in one step. There's no way to tell. I pat myself on the back for choosing surgery with radiation as a backup, but maybe what I did was put myself through major surgery unnecessarily.
As a friend of mine on another board put it--we gather information, evaluate the odds, and make a choice. Then we move forward and don't look back. As you can see, I'm not so good at the "don't look back" part!
When everything is taken into consideration, there are different "correct" paths. The trick is finding the path that is right for the individual. That can only be done by reading widely, asking questions, and consulting a good medical team.
_________________
Replicant
Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com |
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Newgurl2772
New User
Joined: 16 Feb 2008
Posts: 3
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| Posted: Sat Feb 16, 2008 7:17 pm Post subject: Re: Treatment Options |
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Yes I agree gathering information is the best way to make treatment decisions.
I dont want my Dad to go thru a major surgery if he does not have to. I just want to choose the best treatment that will give him good quality of life, have mininmal side effects and offer the best cure rate..
Just have to decided if that is seeds alone, or seeds with radiation or surgery. Given my Dads history PSA 11 gleason 6 (3+3) , only 1 of 8 biopsy positive 16%, can not be deteched on DRE..
Have members found that radiation (seeds + radiation) giving the same survival rate as or better than surgery?? |
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Replicant
Moderator
Joined: 01 Nov 2006
Posts: 206
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| Posted: Sat Feb 16, 2008 7:18 pm Post subject: partin table |
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Sorry! I see you DID list your dad's PSA. With a PSA of 11, a Gleason of 3+3=6, and a stage of T1C, your dad statistically has:
70% (74-66) chance of organ confined disease (a good thing!)
27% (30-23) chance of extraprostatic extension (not a good thing, not the end of the world)
2% (3-2) chance of seminal vesicle invasion (bad thing)
1% (1-0) chance of lymph node involvement (very bad thing)
The numbers in parentheses show the 95% confidence level of the stats--there is, for example, a 95% chance that if another study is done, between 66 and 74 % of the men will have organ confined disease when their PSA is over 10 and their Gleason is 5-6.
Source: 2007 Partin Tables, Table 3, Dr. Walsh's Guide to Surviving Prostate Cancer, p. 197.
Another set of tables is Han. The Han tables show the chances for a successful prostatectomy outcome.
With T1c cancer, Gleason 6, PSA 10.1 - 20, the percentage of men with undetectable PSA 10 years later is 90 (80-9 . Those are good odds!
If the stage is actually more advanced--say T2a, then the odds are still high for an undetectable PSA 10 years later--87% (61-96).
I hope that helps. Again, getting a copy of Walsh's book would help you tremendously.
_________________
Replicant
Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com |
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johnw100
Senior User
Joined: 15 Apr 2006
Posts: 131
Location: australia
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| Posted: Sat Feb 16, 2008 7:28 pm Post subject: Re: Treatment Options |
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Surgery is possible after radiation but it usually becomes an academic question not relevant to the situation. The surgery is more difficult and would need to be done by a very good surgeon.
A few brief observations:
Usually 12 biopsy samples are taken, the needles can miss a tumor or happen to hit a very small one by chance, especially when a small # of samples have been taken.
Biopsy readings are subjective. Slides should be sent for a 2nd reading, as you are considering agressive treatment based on the report.
Surgery is a major operation, although robotic surgery can provide a shorter recovery time.
Regardless of the treatment choice or method employed, the most important consideration is choice of the very best doctor available as he will provide your best chance of good long term prognosis with few short term and long term side issues.
Another treatment option is Proton. I've had very good reports from men who have been to Loma Linda. One consideration with Proton and EB Radiation is the long treatment period often required..
It's difficult to compare historical results of the various treatments available, as equipment and techniques have imporved grately. Many of the treatments imply similar results, so it can often come down to potential side effects and personal preferences.
As suggested, with only a small % of moderate gleason 6 in one sample, it's worth taking time to consider all options. |
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