RE: Re: Decision re Prostatectomy vs Brachytherapy

[Guest guest]

Joe wrote:

....

> I have been considering brachytherapy alone. There were some

> suggestions that I should look into supplementing it with

> external radiation or hormone therapy.

....

Joe,

I'd like to add a note about extensions of cancer outside the

prostate. If there is an extension of the cancer outside the

prostate and it can be detected by scanning - either a CT scan or

an MRI then (I think - I'm not positive about this) it can still

be treated by brachytherapy. The seeds don't all have to be

placed inside the prostate capsule wall. They can also be

inserted into tumors that extend through the wall. Furthermore,

the seeds have a range of several millimeters, so even if there

were cancer just outside the prostate, a seed a couple of

millimeters away would still treat it.

I'm not an expert on this. The radiation oncologists will be

able to tell you much more about 1) whether they are able to find

cancer just outside the prostate and 2) whether and how they

might treat it.

Also, it is my understanding that cancer outside of the prostate

may or may not be metastatic. Cancer that is an extension of a

tumor protruding outside the wall is probably still dependent on

the prostate environment - which slowly dies off after radiation.

So the extensions may die off with it.

I say all this not to argue against EBRT or ADT in addition to

brachytherapy, but just to point out that having some cancer

outside the prostate does not necessarily mean you are doomed if

you opt for plain brachytherapy. The treatment may still be

effective.

It's hard to know what to do. The more aggressive the treatment

you get, the more likely it is to completely cure the cancer.

However it's also more likely to cause undesirable side effects.

Even if we knew exactly what the tradeoff was (e.g., going from

75% chance of a cure to 85% chance, and from 10% chance of nasty

side effects to 20% chance), it would still be hard to choose.

As it is, we don't even know that much.

I think the best thing to do is to get a second opinion (if you

haven't already done so) before making your final decision and

then make the decision as best you can - and as we both said, not

looking back.

Best of luck.

Alan

[Guest guest]

Joe wrote:

....

> Finally, there is absolutely no real evidence that brachy is

> superior to surgery because it targets an extra-protate zone.

....

As far as I know, the success rate for surgery is as high as that

of any radiation treatment. Brachytherapy has advantages in

simplicity. The hospital stay is one night, sometimes less, and

you can return to work or normal life in a few days. Surgery is

more complex.

There are also different side effect profiles for the two

treatments, though both can have serious side effects if you are

unlucky.

But as for success rates, the statistics I've seen show that

surgery works as well as any treatment.

The key thing now is to find the best surgeon you can. I've seen

claims that the best surgeons have done at least 200

prostatectomies and do 50 or more per year.

Good luck.

Alan

[Guest guest]

Chuck Maack wrote:

> I don’t necessarily agree in all that was said in Alan’s post,

> particularly regarding “The seeds don't all have to be placed

> inside the prostate capsule wall. They can also be inserted

> into tumors that extend through the wall. Furthermore, the

> seeds have a range of several millimeters, so even if there

> were cancer just outside the prostate, a seed a couple of

> millimeters away would still treat it.â€

You may be right Chuck. I'm not an expert. I had a good size

extra-prostatic extension and was treated with HDR brachytherapy,

+ EBRT + ADT. The ADT was at my request. The rad onc thought it

wasn't a good idea but another rad onc I consulted insisted that

it was.

The sequence of my treatments was:

ADT started about 7 weeks ahead of radiation

HDR session

25 EBRT sessions

HDR session

I just assumed that one or more seeds were placed in the

extra-prostatic extension, but I don't know that for a fact.

Maybe it was only treated with the EBRT. And maybe HDR is done

differently from LDR.

....

> With your now remarking you have an enlarged prostate, and

> particularly if over 55cc/gm or so, it would be prudent to get

> the volume of that enlarged prostate down with short term ADT

> (LHRH agonist to shut down major production of testosterone,

> Avodart to reduce DHT, both resulting in gland reduction) to at

> least that volume for the surgeon to have sufficient room to

> make use of his “tactile feel†to separate the gland from the

> rectal wall and preserve neurovascular bundles. A too large

> prostate gland can make this more difficult even if the surgeon

> does have special “tactile feel.†Robotics negate the concern

> for tactile feel because of the outstanding visual within the

> abdomen as well as the visual when reconnecting the urethra to

> the bladder neck (anastomosis). The surgeon can “see,†he

> doesn’t need to be concerned about “feel.â€

I've seen different opinions about this. It's my understanding

that most surgeons don't use neo-adjuvant ADT (ADT administered

before another procedure.) I seem to recall reading that it can

make surgery harder - though your argument certainly seems

sensible. I've heard of men being turned down for surgery

because their prostates were too large.

This is a good question for Joe to ask the surgeon.

Alan

[Guest guest]

I, too, was going to go for Brachy until I was informed by my urologist that I would have to take Lupron shots for three months because of the enlarged prostate. If your cancer is non-aggressive, you may wish to consider a six-month of Avodart or Proscar (or its generic equivalent) to shrink the gland prior to surgery. This may help the surgery go more smoothly and with less urinary side effects.Louis. . . To: ProstateCancerSupport Sent: Sun, February 6, 2011 4:49:04 PMSubject: Re: Decision re Prostatectomy vs Brachytherapy

An update on my decision: I had a planning ultrasound on Friday. The rad onc told me that it showed a very narrow pelvic arch which would seriously compromise accurate placement of the seeds in certain locations. He could try hormone therapy for several months to reduce my enlarged prostate, but would still be dicey. He recommended surgery!

I would have chosen brachy in the end (pun intended) because of its anti-cancer long-term effectiveness and my uncomfortably high risk of extra-prostate extension. But, as one man wrote...it's 6 of one and half dozen of the other. So, surgery it is.

Alan, what you wrote below is also my understanding about brachy and any extra extension, which is why I wanted brachy. When I mentioned to the surgeons this potential benefit of brachy in a T2, Gleason 7 like me, they said "you can't have it both ways...if the seeds exert an extra prostatic influence, then there will be damage to blood vessels and nerves and side effects".

Finally, there is absolutely no real evidence that brachy is superior to surgery because it targets an extra-protate zone.

Joe

>

> I'd like to add a note about extensions of cancer outside the

> prostate. If there is an extension of the cancer outside the

> prostate and it can be detected by scanning - either a CT scan or

> an MRI then (I think - I'm not positive about this) it can still

> be treated by brachytherapy. The seeds don't all have to be

> placed inside the prostate capsule wall. They can also be

> inserted into tumors that extend through the wall. Furthermore,

> the seeds have a range of several millimeters, so even if there

> were cancer just outside the prostate, a seed a couple of

> millimeters away would still treat it.

>

> I'm not an expert on this. The radiation oncologists will be

> able to tell you much more about 1) whether they are able to find

> cancer just outside the prostate and 2) whether and how they

> might treat it.

>

> Also, it is my understanding that cancer outside of the prostate

> may or may not be metastatic. Cancer that is an extension of a

> tumor protruding outside the wall is probably still dependent on

> the prostate environment - which slowly dies off after radiation.

> So the extensions may die off with it.

>

> I say all this not to argue against EBRT or ADT in addition to

> brachytherapy, but just to point out that having some cancer

> outside the prostate does not necessarily mean you are doomed if

> you opt for plain brachytherapy. The treatment may still be

> effective.

>

> It's hard to know what to do. The more aggressive the treatment

> you get, the more likely it is to completely cure the cancer.

> However it's also more likely to cause undesirable side effects.

> Even if we knew exactly what the tradeoff was (e.g., going from

> 75% chance of a cure to 85% chance, and from 10% chance of nasty

> side effects to 20% chance), it would still be hard to choose.

> As it is, we don't even know that much.

>

> I think the best thing to do is to get a second opinion (if you

> haven't already done so) before making your final decision and

> then make the decision as best you can - and as we both said, not

> looking back.

>

> Best of luck.

>

> Alan

>

[Guest guest]

Joe wrote:

>

> Alan, Chuck and Louis, Thanks for your comments.

>

> 1.

....

And there was a lot useful information in your post.

Thanks.

Alan