Re: Decision re Prostatectomy vs Brachytherapy

[Guest guest]

Joe, a couple of thoughts.

First, if you haven't done so already, check out the Prostate Cancer Research Institute website. It generally has the latest statistics and studies.

Second, check out the prostate cancer calculator on the Memorial Sloan Kettering website. It constantly updates its nomogram on the outcomes of various treatments. Plug in your statistics -- PSA, Gleason, number of cancerous cores etc., and it will give you the probabilities of the various outcomes with the various treatments.

Third, check out the experiences of men with the various treatments on the Yananow website. They may alleviate some of your concerns

Fourth, whatever you decide, don't look back. Don't second guess. With whatever treatment you decide upon, the outcome will be a bit of a crap shoot. It will depend on your physiology, your particular cancer, and the skill of the person doing the treatments. It seems to me, the experiences on the Yananow website makes that clear: Two similar men with similar statistics and similar treatments, will often have different outcomes.

Good luck.

Mike

Subject: Decision re Prostatectomy vs BrachytherapyTo: ProstateCancerSupport Date: Friday, January 28, 2011, 6:11 PM

Hello all,I've posted here previously when I was first diagnosed about 10 mos ago. I decided early on to do active surveillance, even though I didn't really fit, monitored my psa 5 times in the last 10 mos and had an endorectal MRI. I followed a "PCa diet" over the period and told myself that I would abort if the psa started to creep up and it's starting to do that after going down initially. I also decided early on to do surgery if and when the time came, but recently heard a talk by a local radiation oncologist on his recent brachytherapy findings in over 1000 men which has caused me to look more closely at that option. It would be great to get some feedback from this group about how my thinking has been going. (The oncologist is Dr. Jim and I believe the paper will be published in a couple of months. Sorry, no reference available now.)Basic info - 63 y.o, PSA 7; Gleason 7

(3+4); T2a; intermediate risk. Biopsy Mar/10: 3/10 cores positive, one greater than 50%. All were on the right side (base and mid sections). Prostate volume about 33 cc. Nomograms have indicated a 35% probability of right sided extracapsular extension and 25% probability of positive surgical margin. The MRI report indicated some non-specific abnormalities all contained in the gland. Except for the cancer, I'm in good health and reasonably fit. I do have mild urgency and frequency symptoms now. (IPSS = 12)Up until recently I thought I would do surgery for these reasons:-probability of "cure" reasonably high (about 85%)-my impression from the urologist that in Gleason 7, better cure with surgery and that in the long-term it outperforms brachy from a side-effects perspective-the gland is OUT- cancer can't recur there and pathological info can be obtained

(e.g., actual Gleason grade, presence of extracapsular extension or positive margins, seminal vesicle invasion, etc.) to guide further treatment-surgeon indicated that even if pathology indicated positive margins or extracapsular extension, that didn't mean that surgery didn't cure the cancer and that additional treatment was necessary.-but, can layer additional radiation if needed (adjuvant or salvage)-PSA measure of cure or recurrence is unambiguous, no bounce-risk of leak incontinence was low and surgery might even help the irritative symptoms I've been experiencing- the skill/experience of the surgeon is at high levels; he felt that nerve sparing was possible on both sides -risk of impotence was high, but slow rehab and regaining of function was possible. Drugs and other procedures possible.All in all it has seemed pretty compelling for surgery, but based on my recent discussions with the

radiation oncologist I am leaning towards brachytherapy.The main reason is that the data his group has been gathering have indicated that 10 year cure with brachytherapy monotherapy in Gleason 7 is better than with surgery (for me 92%). This may be because the brachytherapy protocol here (and probably elsewhere) targets a radiation zone several millimeters beyond the prostate which may cover areas that would become a positive margin in surgery, even in the hands of the most skilled surgeon who is cutting wide. While there is no real evidence for this, it seems very relevant in my situation in which there is a fair risk of extraprostatic extension. QUESTIONS: Does this reasoning make sense to others out there? Are there studies that support my urologist's statement that surgery is better than brachy in Gleason 7? Or does the higher risk of adverse pathology in Gleason 7 in fact provide a better

rationale for doing brachy?A second key reason that brachytherapy has become appealing is that I've started to look at the quality of life studies—several recent studies indicate that it's rated as better after brachy at least in the first few years. So, the way I see it is with brachy there is a higher probability of cure with one treatment while maintaining an overall higher quality of life. With surgery there is a 20 to 30% chance I will require additional radiation.But there are as always the negative aspects--the higher risk of prolonged irritative and obstructive urinary symptoms (e.g.,urgency, frequency, pain, burning, blood in urine, slow, blocked flow)- I think this would be worse for me because I already having some symptoms. -fewer options if there is local recurrence. Can't do external radiation (does anybody know why?) and prostatectomy, hifu or cryo are poor options

apparently.-psa bounce -very small increased risk of radiation-induced tumors QUESTIONS: How have others dealt with these negative aspects of brachy in their decision making or after radiation? Am I making too much of the urinary symptoms? Have you found effective ways of treating the symptoms? Better stop here. Many thanks in advance for your comments. Joe ------------------------------------There are just two rules for this group 1 No Spam 2 Be kind to othersPlease recognise that Prostate Cancerhas different guises and needs different levels of treatment and in some cases no treatment at all. Some men even with all options offered chose radical options that you would not choose. We only ask that people be informed before choice is made, we cannot and should not tell other members what to do, other than look at other

options. Try to delete old material that is no longer applying when clicking replyTry to change the title if the content requires it

[Guest guest]

This is really a tough one. Only thing I'd add is that with surgery the doctor

(and you) can get a really good look at the cancer and its spread if any. The

pathology report with various node and vessel dissections can be pretty precise.

But the seeds are pretty much an outpatient procedure and that would be big plus

there. I do hope your watching and waiting didn't allow the cancer to escape.

[Guest guest]

Joe,

Dave in Tampa here. I am facing this same decision. My doctors have presented a united front in favor of Prostatectomy, This includes the radation onclolgist. I am told that the decision in my case hinge on two factors:

age, I'm 59

Gleason score, 4+3=7 in two lobes (right side involvement only)

I would be interested to know if anyone has recieved advise based on these two factors

Thanks

Subject: Re: Decision re Prostatectomy vs BrachytherapyTo: ProstateCancerSupport Date: Saturday, January 29, 2011, 2:10 AM

Joe,It seems to me that you've analyzed this about as well as anyonecan. I don't know if I have much to add, but I'll add some morethoughts to the excellent suggestions Mike Clowes has alreadymade.Claims of cure rates vary amazingly. I've seen some people whomI respect claim that surgery is the only treatment that works andthat radiation doesn't work. However I've also seen claims thatradiation actually works better for some patients and when donethe best way.As near as I can tell, the outcomes of radiation vs. surgery areabout the same. They may vary by a few percent, but not morethan that. But I'm no authority on the subject. As Mikesuggested, the Sloan-Kettering nomogram may be a relatively goodand unbiased source for data.Even more important than treatment modality, I suspect, is theskill and dedication of the doctor. I'm inclined to think that avery smart and

experienced doctor who is committed to hispatients will get better results than average whether he is asurgeon or a radiation oncologist. I seem to recall that thebest practitioners of either technique do at least 50 prostatecancer treatments a year and have already done 200 of them. Ican't cite a study for that but that's what I seem to remember.Whether you choose radiation or surgery, the first question thenbecomes, how good is the doctor? You only get one shot atprimary treatment and you want the best doctor taking that shot.If you do choose radiation, there are some decisions for you andthe rad onc to make which you probably want to discuss with him.These include:1. Should there be neoadjuvant ADT?2. Should there be external beam radiation to supplement thebrachytherapy?3. Should there be radiation given to seminal vesicles and lymphnodes.Each of those decisions

may trade off increased side effects fora higher percentage chance of a full cure. I think a rad oncshould be able to give you some thoughtful analysis and advice onthese issues beyond "Oh I always do that" or "Oh I never do that,it isn't worth it."Mike's suggestion to check out the yananow website is also a goodone. My own story is in there somewhere and lots more besides.Best of luckAlan

[Guest guest]

In a recent post either here or on the PPML mailing list, the following link was mentioned as an available resource: http://www.ProstateVideos.com . I went there and watched a lot of the videos so far, and I think they are helpful. It takes a while to watch them, but you seem to be someone who has spent a significant amount of time reading and researching your options etc. One of the things mentioned in the videos and and from a lot of other sources is that the results promoted by an individual practice may or may not be reliable, especially as they relate to reported side effects.

I think there may be a third option of doing homone blockade or other medical oncology approaches first before doing surgery and/or seeds or radiation. There are questions about when that would possibly be appropriate and when it would not etc. But, it is another approach.

Subject: Decision re Prostatectomy vs BrachytherapyTo: ProstateCancerSupport Date: Friday, January 28, 2011, 6:11 PM

Hello all,I've posted here previously when I was first diagnosed about 10 mos ago. I decided early on to do active surveillance, even though I didn't really fit, monitored my psa 5 times in the last 10 mos and had an endorectal MRI. I followed a "PCa diet" over the period and told myself that I would abort if the psa started to creep up and it's starting to do that after going down initially. I also decided early on to do surgery if and when the time came, but recently heard a talk by a local radiation oncologist on his recent brachytherapy findings in over 1000 men which has caused me to look more closely at that option. It would be great to get some feedback from this group about how my thinking has been going. (The oncologist is Dr. Jim and I believe the paper will be published in a couple of months. Sorry, no reference available now.)Basic info - 63 y.o, PSA 7; Gleason 7 (3+4); T2a; intermediate risk.

Biopsy Mar/10: 3/10 cores positive, one greater than 50%. All were on the right side (base and mid sections). Prostate volume about 33 cc. Nomograms have indicated a 35% probability of right sided extracapsular extension and 25% probability of positive surgical margin. The MRI report indicated some non-specific abnormalities all contained in the gland. Except for the cancer, I'm in good health and reasonably fit. I do have mild urgency and frequency symptoms now. (IPSS = 12)Up until recently I thought I would do surgery for these reasons:-probability of "cure" reasonably high (about 85%)-my impression from the urologist that in Gleason 7, better cure with surgery and that in the long-term it outperforms brachy from a side-effects perspective-the gland is OUT- cancer can't recur there and pathological info can be obtained (e.g., actual Gleason grade, presence of extracapsular extension or positive

margins, seminal vesicle invasion, etc.) to guide further treatment-surgeon indicated that even if pathology indicated positive margins or extracapsular extension, that didn't mean that surgery didn't cure the cancer and that additional treatment was necessary.-but, can layer additional radiation if needed (adjuvant or salvage)-PSA measure of cure or recurrence is unambiguous, no bounce-risk of leak incontinence was low and surgery might even help the irritative symptoms I've been experiencing- the skill/experience of the surgeon is at high levels; he felt that nerve sparing was possible on both sides -risk of impotence was high, but slow rehab and regaining of function was possible. Drugs and other procedures possible.All in all it has seemed pretty compelling for surgery, but based on my recent discussions with the radiation oncologist I am leaning towards brachytherapy.The main reason is

that the data his group has been gathering have indicated that 10 year cure with brachytherapy monotherapy in Gleason 7 is better than with surgery (for me 92%). This may be because the brachytherapy protocol here (and probably elsewhere) targets a radiation zone several millimeters beyond the prostate which may cover areas that would become a positive margin in surgery, even in the hands of the most skilled surgeon who is cutting wide. While there is no real evidence for this, it seems very relevant in my situation in which there is a fair risk of extraprostatic extension. QUESTIONS: Does this reasoning make sense to others out there? Are there studies that support my urologist's statement that surgery is better than brachy in Gleason 7? Or does the higher risk of adverse pathology in Gleason 7 in fact provide a better rationale for doing brachy?A second key reason that brachytherapy has become appealing is that I've started to look at

the quality of life studies—several recent studies indicate that it's rated as better after brachy at least in the first few years. So, the way I see it is with brachy there is a higher probability of cure with one treatment while maintaining an overall higher quality of life. With surgery there is a 20 to 30% chance I will require additional radiation.But there are as always the negative aspects--the higher risk of prolonged irritative and obstructive urinary symptoms (e.g.,urgency, frequency, pain, burning, blood in urine, slow, blocked flow)- I think this would be worse for me because I already having some symptoms. -fewer options if there is local recurrence. Can't do external radiation (does anybody know why?) and prostatectomy, hifu or cryo are poor options apparently.-psa bounce -very small increased risk of radiation-induced tumors QUESTIONS: How have others dealt with these negative

aspects of brachy in their decision making or after radiation? Am I making too much of the urinary symptoms? Have you found effective ways of treating the symptoms? Better stop here. Many thanks in advance for your comments. Joe

[Guest guest]

Hello all,

Thanks to Mike C, Alan M, Tom M, D, L. , Larry C and M for

your helpful comments re my posting of Jan 28:

I have been considering brachytherapy alone. There were some suggestions that I

should look into supplementing it with external radiation or hormone therapy.

The option of supplementary external radiation is not offered in the centre

here. The centre has been doing seeds since 1997; it's the largest program in

Canada and one of the largest in the world, over 3300 patients in the province

of BC have been treated. They have reported in published studies that

brachytherapy alone has been very effective in " low tier intermediate risk "

patients (where I have been clasified), as effective as in low risk patients

They have done supplementary hormone therapy in the past in GS7, but not anymore

on a routine basis. They don't think I need it.

So those are some reasons why I haven't considered supplementing with radiation

or hormones, but I recognize it could be prudent and that a number of centers do

IMRT + seeds and I appreciate the ecommendations to do so given my nos and risk

of extra-prostatic extension.

Here's a reference to a very recent paper by the group here comparing

brachytherapy and surgery.

Pickles T, WJ, Kattan MW, Yu C, Keyes M. Comparative 5-year outcomes of

brachytherapy and surgery for prostate cancer.

Brachytherapy. 2011 Jan-Feb;10(1):9-14.

And this one reports on their brachytherapy findings in over a 1000 men. An

update with to be published soon.

WJ, Keyes M, Palma D, Spadinger I, McKenzie MR, Agranovich A, Pickles T,

Liu M, Kwan W, Wu J, Berthelet E, Pai H. Population-based study of biochemical

and survival outcomes after permanent 125I brachytherapy for low- and

intermediate-risk prostate cancer. Urology. 2009 Apr;73(4):860-5; discussion

865-7. Epub 2009 Jan 24.

I still am undecided. I have a planning ultrasound tomorrow. I'll try to keep

in mind Alan's advice: " whatever you decide, don't look back. Don't second

guess. With whatever treatment you decide upon, the outcome will be a bit of a

crap shoot. "

I'll flip a coin. Thanks,

Joe

[Guest guest]

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]

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]

Hi Chuck, Alan and others,

Just got some more info on some brachy issues previously discussed from a

radiation oncologist on another forum.

I quote..

" On the issue of damage to surrounding tissues from the extraprostatic

irradiation compared with surgery, are the surgeons suggesting that their knife

is not likely to damage those same structures? With respect to injury to these

tissues from brachy, let the data stand on its own which is to say that all the

reports on brachy have used this approach with some extraprostatic radiation,

and the results with respect to ED and incont and rectal injury are still at

least as good, or better, than surgery.

As for seeds in the periprosatatic area, yes, by necessity, some seeds are

always, and have always been, placed in the periprostatic tissue even in low

risk pts. "

Joe Z.

>

> Good to see you are doing your homework, Joe. Empowerment has a great deal

> of importance when in discussion (and debate?) with one's physician as to

> what constitutes the most appropriate treatment for that patient.

>

> Keep up your research and study. Unfortunately you will find that you can

> never absorb enough. There is so much to learn and science and medicine

> seems to change day-by-day. Embarking on gathering all one can regarding

> understanding prostate cancer and its treatment can become an obsession. I

> know!

>

> Chuck

>

>

> From: ProstateCancerSupport

> [mailto:ProstateCancerSupport ] On Behalf Of Joe

> Sent: Tuesday, February 08, 2011 7:39 PM

> To: ProstateCancerSupport

> Subject: Re: Decision re Prostatectomy vs

> Brachytherapy

>

>

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

>

> 1. Re. location of seeds and impact of radiation. My understanding has been

> that for permanent brachy monotherapy , seeds are confined to the prostate

> and are placed in a more concentrated fashion in areas where there is likely

> to be more tumor. The situation at the Dattoli Centre combining DART with

> brachy, with some seeds in peri-prostate areas is not brachy monotherapy and

> is interesting to hear about. Thanks, Chuck for doing that research. At our

> center the radiation emitted from seeds placed in the prostate extends 3 to

> 5mm beyond the prostate. I don't know what the rad oncs would say about the

> damage this causes in extraprostate tissue and associated side effects.

>

> Here's a relevant quote from an article by Dr. Grimm et al:

>

> " In early stages, there is a very low risk of disease in the seminal

> vesicles or lymph nodes, and only a modest risk of disease that extends

> through the outer wall, or capsule, of the prostate. Fortunately, the

> disease that goes through the capsule is almost always within several

> millimeters of the prostate and is easily covered by the implant

> volume....Note again, however, that capsule penetration does not mean that

> disease is beyond the surgical or implant margin. Typically, surgical and

> radiation margins are 4mm - 15mm beyond the prostate. " (Prostate Seed

> Implantation for Prostate Cancer. PCRI Insights, November 2003, vol. 6, No.

> 4)

>

> 2. Re. prostate volume impact on surgery. My prostate volume a few days ago

> in the planning ultrasound was estimated to be 52 cc. This was a surprise

> because 10 mos prior it was 33 cc in my biopsy. The rad onc said the

> increase was not because of growth over the period, but because the

> estimates at biopsy are crude and fairly often inaccurate (but a 20 cc

> difference seems huge to me).

>

> Chuck, you indicated that reducing the volume will give the surgeon more

> room to use tactile feedback to help with preserving nerves, e.g. I haven't

> come across this. Dr Walsh in his 2007 book says that giving hormones

> pre-surgery " may mislead the surgeon into thinking the cancer picture is

> rosier than it actually is and thereby encourage a less aggressive cancer

> operation " . The surgeon may be reassured falsely, he says, about the extent

> of disease and spare the nerves when he shouldn't (p. 245) Anyway, I will

> have to ask the urologist about the impact of a large prostate on surgical

> accuracy, on urinary and nerve sparing outcomes and whether ADT can help. My

> understanding from the surgeons here is that ADT can reduce the likelihood

> of positive margins, but has no impact on biochemical recurrence. And at our

> center it is no longer given. Walsh says the same-no impact on PSA

> recurrence.

>

> 3. Re. Robotic vs open. I have gravitated towards open because of the

> extensive experience and reputation of one of the open surgeons here and I

> think it is important to have tactile feedback, although Chuck is saying

> that the improved vision with robotic can compensate. More questions to put

> to the urologist.

>

> Thanks for your good wishes,

> Joe

>

>

>

>

> .

>

>

> <http://geo.yahoo.com/serv?s=97359714/grpId=4926965/grpspId=1705061630/msgId

> =28717/stime=1297215521/nc1=1/nc2=2/nc3=3>

>