Re: Margins?

[Guest guest]

Lynn,

My understanding is that IF the cancer is contained within the 'capsule' of the prostate gland itself, and is not present in seminal vesicles, lymph or any tissue beyond the gland itself, then the 'margins' are deemed clear. Perhaps YET is the operative word on why DR did not suggest watchful waiting.

The anticipated rate of growth impacted my decision to have surgery. [3.5 yrs ago]. Cyberknife was a recent introduction at that time, and was not recommended because of the absence of track record. Reports I've read, and anecdotal reports from colleagues and

friends have been really promising. All these guys are happy. One is 3+ yrs out of cyber knife. I did robotic surgery at s Hopkins. PSA remains <0.1. I'm grateful for that.

Ancillary issues may also be a point of consideration for your husband and you. ED, incontinence and collateral impact from varying therapies are all a part of the equation.

I'm grateful that the margins appear clear. This is EXCELLENT news!

Every success in dealing with this disease. It does NOT have to define me. It has been and continues to be a nuisance, but it does NOT control my life. [OK, I'll get off my soap box now.]

H

Subject: Margins?To: ProstateCancerSupport Date: Monday, March 22, 2010, 11:52 AM

Hello, my husband was recently diagnosed with Pca. He doesn't have any of the symptoms of pca. He is 63 years old with a PSA of just under 7. It had been a little over 7 and his DRE's all were clear, but he wanted a biopsy just in case. The urologist who performed the biopsy did an DRE and found a lump. The previous DRE's showed nothing including the one two weeks before. I guess there is a lot of variability in those performing the DREs. Anyway, the Gleason came back as one 7 as 4+3 and several with 3+4. The doctor didn't say much for treatments but is sending him in for a CAT and a bone scan to verify that it has not spread. So, he doesn't have a stage yet. The doctor was emphatic that he didn't think that it had spread yet. In which case, why did he say watchful waiting was not a good option?My question is, my husband doesn't really want surgery. Sex is important to him and I am 20 years younger than him (so I believe there is a

manly thing going on with that which I totally understand). The doctor mentioned radiation and I have researched some of the treatments, but am a little confused. Cyberknife is said to be questionable when there is cancer "in the margins" (if I have this correct?) Can you have cance that is contained in the prostate, but that is still not appropriate for some types of radiation? Can you explain about the margins? Thank you all for your help.Lynn

[Guest guest]

LYNN wrote:

> Hello, my husband was recently diagnosed with Pca. He doesn't

> have any of the symptoms of pca. He is 63 years old with a PSA

> of just under 7. It had been a little over 7 and his DRE's all

> were clear, but he wanted a biopsy just in case. The urologist

> who performed the biopsy did an DRE and found a lump. The

> previous DRE's showed nothing including the one two weeks

> before. I guess there is a lot of variability in those

> performing the DREs.

Very much so. A good urologist will have much more experience

than a general practitioner in performing and understanding DREs.

It is very common for a doctor to perform one but not really

understand what he is feeling. Even some urologists aren't very

good at it (at any rate, mine wasn't.)

> Anyway, the Gleason came back as one 7 as 4+3 and several with

> 3+4. The doctor didn't say much for treatments but is sending

> him in for a CAT and a bone scan to verify that it has not

> spread. So, he doesn't have a stage yet. The doctor was

> emphatic that he didn't think that it had spread yet. In which

> case, why did he say watchful waiting was not a good option?

The CT and bone scans were probably unnecessary. With a PSA

below 20, 13% will have abnormal bone scans but only .3% will

have cancer in the bones. See:

http://www.prostatevideos.com/prostate-cancer/grading-and-staging-of-prostate-ca\

ncer/bone-scan-for-assessing-cancer-spreading-to-the-bones/

There are a couple of possible reasons why the doctor is against

watchful waiting. One is simply that many urologists are biased

in favor of treatment. It's how they make their livings.

But there is another and more legitimate reason. A Gleason 7

cancer is considered " intermediate risk " in spite of the

relatively low PSA. It is likely that years will go by with no

problem from the cancer. But at age 63, your husband could

reasonably expect to live another 20 years, and could live even

longer. Over that period, many experts believe that a Gleason 7

cancer is very likely to become metastatic and, possibly,

very painful, debilitating, and life threatening.

Treatment performed before the cancer spreads can be completely

curative. It isn't always so, but once the cancer has spread,

there is no known curative treatment. So if you and your husband

think that you will need treatment sometime, and you want to try

curative treatment rather than treatments that just hold the

cancer at bay (which don't work forever and have significant side

effects of their own), it may be better to try earlier rather

than later. The longer you wait, the more likely it is that the

cancer can become systemic and inaccessible to curative

treatment.

When your husband's doctor recommended treatment in spite of the

fact that he believes that the cancer hasn't spread yet, he

probably has the above issue in mind. While not every prostate

cancer expert would agree with him, most probably would. Here

are criteria for watchful waiting cited in an NCI publication:

* PSA ≤10 ng/ml.

* PSA density <0.2 ng/ml.

* Tumor stage T1c/T2.

* Gleason score ≤3 + 3 = 6.

* ≤2 positive biopsy cores.

Your husband passes the first criterion but fails the last two.

I don't know about the other two. Many doctors will only

recommend watchful waiting if all five criteria are met, or if

the patient is old enough or in poor enough health, that he is

not expected to live long enough for the cancer to kill him.

> My question is, my husband doesn't really want surgery. Sex is

> important to him and I am 20 years younger than him (so I

> believe there is a manly thing going on with that which I

> totally understand). The doctor mentioned radiation and I have

> researched some of the treatments, but am a little confused.

> Cyberknife is said to be questionable when there is cancer " in

> the margins " (if I have this correct?) Can you have cance that

> is contained in the prostate, but that is still not appropriate

> for some types of radiation? Can you explain about the margins?

Cancer " in the margins " means that the cancer extends outside the

prostate gland, i.e., the tumor has penetrated the wall of the

gland. This is different from being metastatic. The cancer may

still be directly attached to the prostate gland and not yet

capable of living at remote sites in the body.

Radiation can definitely work with cancer in the margins, and

some think that external beam radiation can work better than

surgery. But I don't know which forms of external beam radiation

are best.

Sexual after effects are pretty common with both surgery and

radiation. With surgery, they happen immediately, possibly

followed by a gradual recovery of function. With radiation they

happen later with a gradual loss of function. Some men survive

surgery or radiation with very little loss of function. Some

don't.

The best doctors have better track records with both preserving

potency and curing cancer, than the average or below average

doctors (and remember, 50% are below average!) However, I don't

believe the statements made by some doctors that " 95% of my

patients suffer no impotence. " If I heard a doctor say that, I'd

run the other way because I wouldn't believe anything he said.

Both surgery and radiation involve a lot of trauma to nerves and

blood vessels involved in getting and maintaining erections.

Having said that, I will also say that sex can work if the

partners are committed to making it work, even with a total

absence of erections. The machinery that enables a man to have

orgasms is not affected by radiation or surgery. Oral and manual

sex still work perfectly. A man who tries can certainly bring

his wife to a climax and a woman can do the same for a man, even

when there is no erection at all.

Furthermore, while damage to erections can alter one's sex life,

cancer can completely end it. Androgen deprivation therapy, the

most common and effective treatment for metastatic cancer, can

also pretty much end it. At any rate, it completely eliminates

the desire for sex.

I can't answer your question about CyberKnife. I don't know

enough about it. However, in my personal opinion, finding a top

notch surgeon or radiation oncologist, one who has great skill,

experience, and commitment to his or her patients, can be much

more important than finding a particular machine for applying

surgery or radiation. All of the major therapies can work. All

of them can fail. But each of them can only be tried only once!

If surgery fails, radiation sometimes works. If radiation fails,

HIFU sometimes works. But you can only try surgery or radiation

once each. You need the best practitioner you can find to take

that one shot at a cure.

I suggest that you and your husband learn as much as you can.

Some good sources of information include:

A Primer on Prostate Cancer: The Empowered Patient's Guide by

Strum and Donna L. Pogliano

Prostate Cancer for Dummies by H. Lange,

Adamec, and Adamec (a terrible title but I thought

it was a good book.)

Dr. Walsh's Guide to Surviving Prostate Cancer,

Second Edition by C. Walsh and Janet Farrar

Worthington

There are also useful websites:

The U.S. National Cancer Institute's publication on prostate

cancer:

http://www.cancer.gov/cancertopics/types/prostate

And a favorite of mine by our own Terry Herbert who helps out

with this newsgroup too:

http://www.yananow.net/

Best of luck.

Alan

[Guest guest]

Margins are the area at the edge of

treatment. In the case of surgery the pathologist looks at the edges of the

prostate where it was removed to see if there is any cancerous growth there. If

there is then it is considered that you have positive margins and indicates

that the cancer has spread past the prostate (stage 3) and some form of salvage

treatment should be considered. Negative margins means there was no carcinoma

at the edges and the cancer was contained in the removed prostate (stage 2) and

the prognosis is much better.

What is interesting is the scans can

indicate if the cancer has spread to other organs or in the bones but it doesn’t

do such a good job of telling if it has spread into the pelvic area. The pathology

from surgery is about the only way you can really tell if it spread outside the

prostate. Radiation oncologists usually will take an aggressive approach to

treatment and will try and radiate an area larger than the suspected cancerous

area increasing the chances of getting it all.

My biggest suggestion to you is take all

of the known information, biopsies, scans and blood work, and show them to

other urologists, radiation oncologists, and medical oncologists. Get 2nd

3rd and 4th opinions. By then you will be educated on

the pros and cons of all of your options. Only then should you both sit down

and make your decisions.

Another side note that you should know,

yes, surgery can leave you with ED (erectile dysfunction) problems but in some

cases it will heal with time. Radiation will not effect ED right away but may

cause problems 6 months latter. Even active surveillance can leave you with ED.

Make sure you discuss all of your options with everyone. Don’t forget

that there are some things that can be done to help with your ED problems once

you are cured. Remember, you need to be alive to have sex.

It is not going to be a fun journey.

Things that seem to be important right now may not be as significant once you

have been educated some more. This disease will put your husband through a lot

of tasks that are going to be very emasculating he is going to need a lot of

support from you. For encouragement take a look at the blog by Dana Jennings http://well.blogs.nytimes.com/tag/jennings/

he addresses some of these issues.

PS I am only 51 years old and going

through this. I understand your husband’s concerns.

From:

ProstateCancerSupport

[mailto:ProstateCancerSupport ] On Behalf Of LYNN

Sent: Monday, March 22, 2010 11:52

AM

To: ProstateCancerSupport

Subject:

Margins?

Hello, my husband was recently

diagnosed with Pca. He doesn't have any of the symptoms of pca. He is 63 years

old with a PSA of just under 7. It had been a little over 7 and his DRE's all

were clear, but he wanted a biopsy just in case. The urologist who performed

the biopsy did an DRE and found a lump. The previous DRE's showed nothing

including the one two weeks before. I guess there is a lot of variability in

those performing the DREs.

Anyway, the Gleason came back as one 7 as 4+3 and several with 3+4. The doctor

didn't say much for treatments but is sending him in for a CAT and a bone scan

to verify that it has not spread. So, he doesn't have a stage yet. The doctor

was emphatic that he didn't think that it had spread yet. In which case, why

did he say watchful waiting was not a good option?

My question is, my husband doesn't really want surgery. Sex is important to him

and I am 20 years younger than him (so I believe there is a manly thing going

on with that which I totally understand). The doctor mentioned radiation and I

have researched some of the treatments, but am a little confused. Cyberknife is

said to be questionable when there is cancer " in the margins " (if I

have this correct?) Can you have cance that is contained in the prostate, but

that is still not appropriate for some types of radiation? Can you explain

about the margins?

Thank you all for your help.

Lynn

[Guest guest]

Lynn:

I'm 2 years older than your husband but otherwise my situation was pretty similar. I went through 44 radiation treatments and have a PSA less than .1 and no signs of lingering cancer. I'm a long way from being out of the woods but at least for now am cancer free. No surgery, no chemo.

Tom

Margins?

Hello, my husband was recently diagnosed with Pca. He doesn't have any of the symptoms of pca. He is 63 years old with a PSA of just under 7. It had been a little over 7 and his DRE's all were clear, but he wanted a biopsy just in case. The urologist who performed the biopsy did an DRE and found a lump. The previous DRE's showed nothing including the one two weeks before. I guess there is a lot of variability in those performing the DREs. Anyway, the Gleason came back as one 7 as 4+3 and several with 3+4. The doctor didn't say much for treatments but is sending him in for a CAT and a bone scan to verify that it has not spread. So, he doesn't have a stage yet. The doctor was emphatic that he didn't think that it had spread yet. In which case, why did he say watchful waiting was not a good option?My question is, my husband doesn't really want surgery. Sex is important to him and I am 20 years younger than him (so I believe there is a manly thing going on with that which I totally understand). The doctor mentioned radiation and I have researched some of the treatments, but am a little confused. Cyberknife is said to be questionable when there is cancer "in the margins" (if I have this correct?) Can you have cance that is contained in the prostate, but that is still not appropriate for some types of radiation? Can you explain about the margins? Thank you all for your help.Lynn

[Guest guest]

If it comes to needing treatment, he might like to take a look at Brachytherapy. Here's a link:

http://www.prostate-cancer-institute.org/prostate-cancer-treatment/brachytherapy.html

Ted

>> Hello, my husband was recently diagnosed with Pca. He doesn't have any of the symptoms of pca. He is 63 years old with a PSA of just under 7. It had been a little over 7 and his DRE's all were clear, but he wanted a biopsy just in case. The urologist who performed the biopsy did an DRE and found a lump. The previous DRE's showed nothing including the one two weeks before. I guess there is a lot of variability in those performing the DREs. > > Anyway, the Gleason came back as one 7 as 4+3 and several with 3+4. The doctor didn't say much for treatments but is sending him in for a CAT and a bone scan to verify that it has not spread. So, he doesn't have a stage yet. The doctor was emphatic that he didn't think that it had spread yet. In which case, why did he say watchful waiting was not a good option?> > My question is, my husband doesn't really want surgery. Sex is important to him and I am 20 years younger than him (so I believe there is a manly thing going on with that which I totally understand). The doctor mentioned radiation and I have researched some of the treatments, but am a little confused. Cyberknife is said to be questionable when there is cancer "in the margins" (if I have this correct?) Can you have cance that is contained in the prostate, but that is still not appropriate for some types of radiation? Can you explain about the margins? > > Thank you all for your help.> > Lynn>

[Guest guest]

Lynn --

You ought to read:

" Saving Your Sex Life: A Guide to Men with Prostate Cancer " ,

.. . . Dr. Mulhall

It'll be scary for both you and your husband, but it's accurate.

Mulhall suggests that a man should _not_ choose treatment based on its sexual

side-effects. All the treatments are nasty.

Prostate cancer is usually " symptom-free " in its early stages. By the time

symptoms appear, the disease is usually well-advanced, and treatment is more

difficult and less likely to succeed.

>

> Hello, my husband was recently diagnosed with Pca. He doesn't have any of the

symptoms of pca. He is 63 years old with a PSA of just under 7. It had been a

little over 7 and his DRE's all were clear, but he wanted a biopsy just in case.

The urologist who performed the biopsy did an DRE and found a lump. The

previous DRE's showed nothing including the one two weeks before. I guess there

is a lot of variability in those performing the DREs.

>

> Anyway, the Gleason came back as one 7 as 4+3 and several with 3+4. The doctor

didn't say much for treatments but is sending him in for a CAT and a bone scan

to verify that it has not spread. So, he doesn't have a stage yet. The doctor

was emphatic that he didn't think that it had spread yet. In which case, why did

he say watchful waiting was not a good option?

>

> My question is, my husband doesn't really want surgery. Sex is important to

him and I am 20 years younger than him (so I believe there is a manly thing

going on with that which I totally understand). The doctor mentioned radiation

and I have researched some of the treatments, but am a little confused.

Cyberknife is said to be questionable when there is cancer " in the margins " (if

I have this correct?) Can you have cance that is contained in the prostate, but

that is still not appropriate for some types of radiation? Can you explain about

the margins?

>

> Thank you all for your help.

>

> Lynn

>