Decision re Prostatectomy vs Brachytherapy

[Guest guest]

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