Surgery+RT+ADT or just RT+ADT ?

I'm getting close to making a decision on my primary treatment for my
High-Intermediate risk Pca (PSA 16).
The more I research, the more confusing (and stressful) it seems to
get!

After reading many stories of surgery patients, it seems that surgery
usually leads to having radiation and hormone treatments later anyway,
especially for higher risk PSA's like mine.

If that is my likely path with surgery, wouldn't it be better to just
start with RT+ADT and avoid the probable side effects of surgery added
on top of the radiation?

Does having surgery first before radiation really help?
Do the side effects from both really "add up"?

I'm curious what people think who have been down this path.

If you had it to do over, would you have skipped the surgery and gone
right to just radiation and ADT?

I have always been under the impression that surgery is only used when the
spread of Prostate Cancer is unlikely. With high numbers in PSA and any
other scans which may indicate spread, I would think that an Oncologist and
their methods would be in line......
jloomis
"prostwell" <prostwell@westernwares.com> wrote in message
news:1d1f8e13-1f38-43a8-9488-e9b3def7c533@k20g2000vbp.googlegroups.com...
> I'm getting close to making a decision on my primary treatment for my
> High-Intermediate risk Pca (PSA 16).
> The more I research, the more confusing (and stressful) it seems to
> get!
>
> After reading many stories of surgery patients, it seems that surgery
> usually leads to having radiation and hormone treatments later anyway,
> especially for higher risk PSA's like mine.
>
> If that is my likely path with surgery, wouldn't it be better to just
> start with RT+ADT and avoid the probable side effects of surgery added
> on top of the radiation?
>
> Does having surgery first before radiation really help?
> Do the side effects from both really "add up"?
>
> I'm curious what people think who have been down this path.
>
> If you had it to do over, would you have skipped the surgery and gone
> right to just radiation and ADT?
>

I did have a bone and cat scan, which did not show any spread.
The PSA of 16 is "borderline" for possible extra-capsular spread.

My urologist recommends surgery, then IMRT+ADT if margins turn out
positive after surgery.

The Rad oncologist recommends radiation(seeds or proton)+ADT.

I'm wondering if any group members regret doing the surgery if they
had to go on to SRT later anyway?

What are your Gleason score, age and any other pertinent information
that the doctors gave you.....that will help immensely. At age 70, most
men are given the choice of radiation or surgery......with radiation
being the preferred route. (speaking for my husband only.....and a few
others who felt the same way)

Heather

"prostwell" <prostwell@westernwares.com> wrote in message
news:a43fa8b6-b41b-47c0-af7f-6456981d532f@u10g2000vbd.googlegroups.com...
>I did have a bone and cat scan, which did not show any spread.
> The PSA of 16 is "borderline" for possible extra-capsular spread.
>
> My urologist recommends surgery, then IMRT+ADT if margins turn out
> positive after surgery.
>
> The Rad oncologist recommends radiation(seeds or proton)+ADT.
>
> I'm wondering if any group members regret doing the surgery if they
> had to go on to SRT later anyway?
>

Heather,

I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a

I'm thinking there's 50/50 odds that I'll need radiation, even if I do
surgery first.

So.. should I skip the surgery - what's the point?

-Rick

I can't give you any advice.....I am not a doctor. And I see you have
spoken to both a radiation and medical oncologist. This is where you
have to come to whatever decision you feel the most comfortable with.

People on this group can point you to studies and so on, but none of us
can make that decision for you. I think you are already leaning to one
at this point, but maybe if some of the fellows chime in, that will
help.

I am thinking to myself that asking someone to say "I was unhappy with
my decision" is a bit much to ask. So what is your "gut feeling"??

All the best.....Heather (wife of Ron)

"prostwell" <prostwell@westernwares.com> wrote in message
news:ad37bb26-67a5-4844-b346-b514faa91d44@z9g2000yqi.googlegroups.com...
> Heather,
>
> I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a
>
> I'm thinking there's 50/50 odds that I'll need radiation, even if I do
> surgery first.
>
> So.. should I skip the surgery - what's the point?
>
> -Rick

Where are you at and what Dr.s have you contacted.
I would be sure to get in touch with a Prostate Cancer Specialist,
regardless if they are an oncologist or a surgeon.
I would get at least another opinion, or 2.....and see both the surgeon and
the oncologist. Get a feeling of the Dr. or Dr. Oncologist....you have to
be sure you "like" the Dr. and they are professional in their field.
You cannot ask a person what I should do. You have to make that decision
based on the meetings with the pro's
This is a hard time.
I was confused also, and almost went for just Radiation......
I went on and when I was 49 had RP.....
I am 59 now.
So far my PSA is less than 0.01......
so, hang in there, get some professional help and I mean "Specialist"
john
"prostwell" <prostwell@westernwares.com> wrote in message
news:ad37bb26-67a5-4844-b346-b514faa91d44@z9g2000yqi.googlegroups.com...
> Heather,
>
> I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a
>
> I'm thinking there's 50/50 odds that I'll need radiation, even if I do
> surgery first.
>
> So.. should I skip the surgery - what's the point?
>
> -Rick

jloomis wrote:
> Where are you at and what Dr.s have you contacted.
> I would be sure to get in touch with a Prostate Cancer Specialist,
> regardless if they are an oncologist or a surgeon.
> I would get at least another opinion, or 2.....and see both the surgeon and
> the oncologist. Get a feeling of the Dr. or Dr. Oncologist....you have to
> be sure you "like" the Dr. and they are professional in their field.
> You cannot ask a person what I should do. You have to make that decision
> based on the meetings with the pro's
> This is a hard time.
> I was confused also, and almost went for just Radiation......
> I went on and when I was 49 had RP.....
> I am 59 now.
> So far my PSA is less than 0.01......
> so, hang in there, get some professional help and I mean "Specialist"
> john
> "prostwell" <prostwell@westernwares.com> wrote in message
> news:ad37bb26-67a5-4844-b346-b514faa91d44@z9g2000yqi.googlegroups.com...
>> Heather,
>>
>> I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a
>>
>> I'm thinking there's 50/50 odds that I'll need radiation, even if I do
>> surgery first.

On what basis 50/50? Is there any study supporting that? If so, why
would the consensus practice guidelines applied to your facts be
indifferent? Did you ask the two docs this question? Did you ask them
whether their advice would differ if they didn't have the specialization
they have?
>>
>> So.. should I skip the surgery - what's the point?
The point may be that you have two weapons at your disposal now. If you
go for RP and it fails, you can still try RT, but not the other way
around.
>>
>> -Rick
>
>

On Thu, 4 Jun 2009 09:22:00 -0700 (PDT), prostwell
<prostwell@westernwares.com> wrote:

>I'm getting close to making a decision on my primary treatment for my
>High-Intermediate risk Pca (PSA 16).
>The more I research, the more confusing (and stressful) it seems to
>get!
>
I sympathise fully with that, I think the problem stems from the
differing nature of the outcomes of the main primary treatments. These
are hard to compare. It would be mite easier if the balance in terms
of life expectancy etc where significantly different but the further
you look the more blurred this distinction becomes.

>After reading many stories of surgery patients, it seems that surgery
>usually leads to having radiation and hormone treatments later anyway,
>especially for higher risk PSA's like mine.

Some might have favoured surgery because salvage RT can be applied
later. You can't start with RT and then go for surgery afterwards.

>
>If that is my likely path with surgery, wouldn't it be better to just
>start with RT+ADT and avoid the probable side effects of surgery added
>on top of the radiation?
>
>Does having surgery first before radiation really help?
>Do the side effects from both really "add up"?

Inevitably the risks are going to be additive. But these are
measurements of risk and cannot possibly predict what will happen to
you personally. You might come through either/both/neither treatments
well/badly or anything in between.

Clearly, more treatments means more risk but you cannot equate risk
with the outcome for the individual.

>
>I'm curious what people think who have been down this path.
>
>If you had it to do over, would you have skipped the surgery and gone
>right to just radiation and ADT?

If the outcomes re survival/recurrence for a single therapy (RP or RT,
not both) are broadly similar, and if it can also be shown that SRT is
effective after RP (certainly there are some here who've been pleased)
then I think it's unlikely that RT alone would be as good as RP+RT
(adjuvant or salvage). But I don't know if there's a study which
bears this out (ron?).


In fact I started out favouring RT but over time decided RP was what I
was going to do. The main factors were: a peeing problem which had
worsened over the 2 years I spent on watchful waiting; a gradually
reduced fear of the prospect of the knife; a morbid and exaggerated
fear of post-RT bowel problems - a fear which ran roughshod over the
apparently statistically low chance of any serious outcome; a meeting
with a charming and experienced surgeon who assured me I'd no longer
have a problem peeing (though the risk of urinary incontinence was
never denied) and, finally, the possibility of salvage RT should it
prove necessary.


Best of luck - I know the quandary you're in.

On Thu, 4 Jun 2009 16:57:25 -0700 (PDT), prostwell
<prostwell@westernwares.com> wrote:

>Heather,
>
>I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a

Have you already mentioned the tumour volume ? (# cores in
biopsy/percentage for each core)

High volume could lead to a suspicion of positive margins and then
perhaps a decision on RT as the prefered therapy?

>
>I'm thinking there's 50/50 odds that I'll need radiation, even if I do
>surgery first.
>
>So.. should I skip the surgery - what's the point?
>
>-Rick

"prostwell" <prostwell@westernwares.com> wrote in message
news:1d1f8e13-1f38-43a8-9488-e9b3def7c533@k20g2000vbp.googlegroups.com...
: I'm getting close to making a decision on my primary treatment for my
: High-Intermediate risk Pca (PSA 16).
: The more I research, the more confusing (and stressful) it seems to
: get!

The research is necessary for your psychological sturdiness down the road.
Once you make your decision, know that you have made it with your eyes open
and all the knowledge you could beg, borrow, or steal and which would fit in
your head. It's tedious, necessary, and temporary.

: After reading many stories of surgery patients, it seems that surgery
: usually leads to having radiation and hormone treatments later anyway,
: especially for higher risk PSA's like mine.

That's not true. It's an understandable misconception having heard from so
many of us who have had a recurrence. And, it may happen to you. Nobody
knows. But, according to the Parin Tables with your PSA, Gleason, and
current stage, Partin predicts about 11% of the patients with organ confined
disease will survive without recurrence. The worst case scenario, capsular
penetration, is predicted to be about 43% on average (though I often wonder
if that will change after more years of data are put into it. As a matter
of fact, you can go to the Sloane-Ketting site and put your numbers into
their calculator. You will find that many more people with 15 PSAs have
years of non-recurrence than those who have a recurrence.
:
: If that is my likely path with surgery, wouldn't it be better to just
: start with RT+ADT and avoid the probable side effects of surgery added
: on top of the radiation?

Even if that were your likely path (which it is not unless your doctor knows
something that I don't about capsular or seminal vesicle involvement
already) the reason most of us go to surgery is because it is the best
chance at a cure. It is not best by much, but it is best. If you have both
bowers and the lead, you go with the bowers.
:
: Does having surgery first before radiation really help?

If you are cured, hell yes! If not, maybe. At least you've debulked and
there is something for the lab to do a detailed biopsy so you know exactly
what you're dealing with the rest of your life.

: Do the side effects from both really "add up"?

The side effects aren't much different.
:
: I'm curious what people think who have been down this path.

:
: If you had it to do over, would you have skipped the surgery and gone
: right to just radiation and ADT?
:
I am a failure and, if given the same set of circumstances, I would do it
again.




--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32 PSAD .056 years
Lupron 07/03 (1 mo) 8/03 and every 4 months there after
PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years
Casodex added daily 07/06
PSA undetectable since, < 0.04 on 10/09/08
Illegitimati non carborundum

"Heather" <no.one@home.invalid> wrote in message
news:h09opk$ib7$1@news.eternal-september.org...


: I am thinking to myself that asking someone to say "I was unhappy with
: my decision" is a bit much to ask. So what is your "gut feeling"??

We have had numerous people express their displeasure with decisions they
made. I, for one, am very sorry I waited until 2000 for my 'next' PSA. If
I had kept on track, I might be cured right now.

I don't recall any being disatisfied with their decision to cut it out; even
if cutting it out didn't work. I have heard some dismay over having
selected other modalities. But, no one should be upset about any decision
that was based on learning everything there was to learn and basing a
decision upon what they found.


--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32 PSAD .056 years
Lupron 07/03 (1 mo) 8/03 and every 4 months there after
PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years
Casodex added daily 07/06
PSA undetectable since, < 0.04 on 10/09/08
Illegitimati non carborundum

I've included below a list of studies that compare survival for
various PCa treatments; the differences appear to be more pronounced
for localized, higher-risk disease. Also, the Hopkins' nomogram
paper, which can be found at

http://www.prostate-help.org/download/jhnomo.pdf

provides some idea of the biochemical recurrence rates, as a function
of disease characteristics, experienced after surgical treatment.

It is also important to recognize that there are surgeons (and I
presume radiation oncologists as well) who specialize in treating high-
risk PCa. Horst Zincke at the Mayo Clinic is perhaps the best at
this. He has published a number of papers on the surgical treatment
of high-risk PCa...Best wishes and good health, ron

-----------------------------------------------------------------------------------------------------------------------------
The following long-term studies show a survival advantage associated
with surgical treatment and compare RP, RT and WW:

Urology. 2006 Dec;68(6):1268-74; Long-term survival probability in men
with clinically localized prostate cancer treated either
conservatively or with definitive treatment (radiotherapy or radical
prostatectomy); Tewari A, Raman JD, Chang P, Rao S,
Divine G, Menon M.

J Urol. 2007 Mar;177(3):911-5; Long-term survival in men with high
grade prostate cancer: a comparison between conservative treatment,
radiation therapy and radical prostatectomy--a propensity scoring
approach; Tewari A, Divine G, Chang P, Shemtov MM, Milowsky M, Nanus
D, Menon M.

J Urol. 2007 Mar;177(3):932-6; 13-year outcomes following treatment
for clinically localized prostate cancer in a population based cohort;
Albertsen PC, Hanley JA, Penson DF, Barrows G, Fine J.

Arch Intern Med. 2007 Oct;8;167(18):1944-50; Short- and Long-term
Mortality With Localized Prostate Cancer; Merglen A, Schmidlin F,
Fioretta G, Verkooijen HM, Rapiti E, Zanetti R, Miralbell R, Bouchardy
C.

M. Menon, et,al., AUA paper 0509

The following reference compares RP, RT and pADT:

Presented by Matthew R. Cooperberg, MD, et al. at the Annual Meeting
of the American Urological Association (AUA) - April 25 - 30, 2009 -
McCormick Place Convention; Prostate Cancer: Localized - Prostate
Cancer Mortality Outcomes Following Surgery, Radiation Therapy, or
Androgen Deprivation Therapy for Prostate Cancer: A Risk-Adjusted
Analysis of a Large, Multicenter Cohort

The following reference compares RP and RT:

J Clin Oncol. 2003 Jun 1;21(11):2163-72; Cancer-specific mortality
after surgery or radiation for patients with clinically localized
prostate cancer managed during the prostate-specific antigen era;
D'Amico AV, Moul J, Carroll PR, Sun L, Lubeck D, Chen MH

prostwell wrote:

> The more I research, the more confusing (and stressful) it seems to
> get!

I felt the same way ... until the pieces of information melded into a
clear solution after I read the pertinent chapters of several PC books.
Each book added significant useful pieces to the puzzle and eliminated
some misfits. Do you feel you've read too much, or maybe not enough? I
don't recall delving into many studies until I had to choose a second
treatment, where nuances and newer options became more important.

> After reading many stories of surgery patients, it seems that surgery
> usually leads to having radiation and hormone treatments later anyway,
> especially for higher risk PSA's like mine.

I know you didn't mean it as such, but "Leads to" sort of implies
causality. My hope, and the books and other research I read, didn't just
imply anything; they came right out and said, with a variety of caveats
in specific cases, "The highest cure rate is with surgery".

Bingo, because the specifics of my PC favored surgery anyway.

> If that is my likely path with surgery, wouldn't it be better to just
> start with RT+ADT and avoid the probable side effects of surgery added
> on top of the radiation?

The books, collectively, will cut through much of the confusion with
such statements as, "youth favors ..." or "mets favor ...", or "this SE
is more prominent with ...". Pretty soon one's own personal "best
choice" emerges from the morass.

> Does having surgery first before radiation really help?

Sure ... if it cures you with minimal SEs. No, if it does not cure you
and leaves you with a permanent wet cat -- and little else -- in your
pants.

> Do the side effects from both really "add up"?

Yes, if surgery weakens your functionality and RT finishes it off. But
would RT have finished you off anyway? Who knows? OTOH, surgery is much
less likely to leave us with bowel problems, and leaves us with the
option of a second curative treatment. RT risks the former and all but
eliminates the latter option.

> I'm curious what people think who have been down this path.

Which path ... surgery first, or RT first? My surgery left me wet and
relatively limp. But pads take care of the first nuisance, patience
takes care of the latter, I have another curative card to play, and *I
DON'T HAVE A YEAR OR A LIFETIME OF BOWEL PROBLEMS*.

> If you had it to do over, would you have skipped the surgery and gone
> right to just radiation and ADT?

Radiation *AND* ADT as a first treatment for PC probably confined to my
prostate? No way in holy hell.

> I did have a bone and cat scan, which did not show any spread.
> The PSA of 16 is "borderline" for possible extra-capsular spread.

Yes, the 16 does complicate things, but even the most ardent ADT
afficionado will admit that ADT also complicates things. That fine line
may be where more research into current studies may pay off. For
example, would RT+ADT add a week, or a year, or a decade compared to RP
for the median bear? Equally important, what are your priorities ...
max longevity, running as many marathons as you can, notching as many
bedposts as you can, wearing khaki pants to the ball game, a
trouble-free rear end, maximizing your odds of a cure at any cost, etc.?

> My urologist recommends surgery

Duh.

> The Rad oncologist recommends radiation

Duh.

> I'm wondering if any group members regret doing the surgery if they
> had to go on to SRT later anyway?

I hope to hell I get to try SRT if and when my PC returns. That would
mean I still have a reasonable chance of curing it ... otherwise I
wouldn't bother with it.

I.P.

Yes, there is a high volume of (mostly-90%) grade 3 (10% grade 4)
cancer in 5 of 6 needles in the left node, 80-90% involved.
Only 2 3+3 needles in the right node are slightly involved.

RRP surgery would spare only the right nerves, but *might* still be a
complete cure.. and I could "save" radiation as a back-up plan
or it might lead to radiation anyway if margins are positive, and I
will have the side effects of *both* treatments.
(That's my dilemma)

RT (proton) would radiate a 13mm margin, which seems to be a plus for
this modality if there is extra-capsular spread.
Also, combining ADT+RT is supposedly approaching the same cure rate
(80-90%) as surgery.
But I might be looking at late side effects, like rectal/bladder
bleeding, secondary tumors, etc.

I wonder if anyone in this newsgroup started with RT and has had long
term success with this route alone?

> >I'm 59 yrs, Gleason 3+4=7, PSA 16, T2a
>
> Have you already mentioned the tumour volume ? (# cores in
> biopsy/percentage for each core)
>
> High volume could lead to a suspicion of positive margins and then
> perhaps a decision on RT as the prefered therapy?
>

Thanks for your feedback, Steve.

Delaying getting a PSA test is my first regret also...

It helps to know that this was a tough decision for everyone.

The hindsight, knowledge and wisdom from others on this group is
really wonderful.

-Rick

Thanks for these references!

I wonder, Is there any way to locate these online, or purchase them in
paper form?

On Jun 5, 12:06*pm, prostwell <prostw...@westernwares.com> wrote:
> Thanks for these references!
>
> I wonder, Is there any way to locate these online, or purchase them in
> paper form?

Most journal websites allow you to pay a fee and then have access to a
specific article for a specific period of time. The medical library
at a nearby hospital is nice enough that, when I e-mail them a few
journal references, they'll e-mail me back the pdf files...ron

"prostwell" <prostwell@westernwares.com> wrote in message
news:fa9fbd6f-77fa-45a1-b9e1-d8376b239177@v4g2000vba.googlegroups.com...

: Yes, there is a high volume of (mostly-90%) grade 3 (10% grade 4)
: cancer in 5 of 6 needles in the left node, 80-90% involved.
: Only 2 3+3 needles in the right node are slightly involved.

I have to admit, that is less encouraging. If your Gleason was 8, I think
you'd be looking at RT. You definitely have a hard decision ahead.



--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32 PSAD .056 years
Lupron 07/03 (1 mo) 8/03 and every 4 months there after
PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years
Casodex added daily 07/06
PSA undetectable since, < 0.04 on 10/09/08
Illegitimati non carborundum

On June 5, Ron replied to prostwell:

> Most journal websites allow you to pay a fee and then have access to a
> specific article for a specific period of time. The medical library
> at a nearby hospital is nice enough that, when I e-mail them a few
> journal references, they'll e-mail me back the pdf files.

True enough.

But here's an alternative that's both free and prompt: Got to Pub Med, a
service of the US National Library of Medicine, at www.pubmed.gov

Search for the article by first author (e.g. Strum, SB) or by article
title. Bingo, a summary. On the right side of the page is a list of
related articles. Also, many times it it possible to access the full
text of the article, free.

Regards,

Steve J

"prostwell" <prostwell@westernwares.com> wrote in message
news:a43fa8b6-b41b-47c0-af7f-6456981d532f@u10g2000vbd.googlegroups.com...
>I did have a bone and cat scan, which did not show any spread.
> The PSA of 16 is "borderline" for possible extra-capsular spread.
>
> My urologist recommends surgery, then IMRT+ADT if margins turn out
> positive after surgery.
>
> The Rad oncologist recommends radiation(seeds or proton)+ADT.
>
> I'm wondering if any group members regret doing the surgery if they
> had to go on to SRT later anyway?
>

This morning was my 38th (of 39) salvage radiation treatments. I
"graduate" on Monday.

I had RRP just about five years ago. Do I now regret having had the
surgery, or the surgery only, back then. No...and here is why not. In
2004, with my Gleason 7 diagnosis and every indication of organ-confined
disease, I felt I had a good chance of a complete cure with surgery. If
it did fail, I would have the chance to fall back on SRT. After the
surgery, the pathological examination of the prostate did indicate the
location of part of the tumor very near the bladder neck.

I had four and a half years of PSA at <0.1. I had about the same level
of erectile dysfunction after the surgery that I had going in, and still
do. I was dry three months after the surgery, and have remained so
since. When my PSA began to slowly rise late last year, we began
planning for salvage radiation therapy, which began on 4/9. I have an
appointment in 6 weeks for another PSA draw, and I'm hoping and praying
for an undetectable reading.

Will I regret any of it down the road? No. My body has had almost five
years to recover from the insult of the surgery before having to endure
the insult of radiation. I know that the effects of radiation are
cumulative and there is the chance that I will experience some side
effects later on. Right now, I have none from the radiation except some
late afternoon tiredness. Also, I know that the SRT may not be
successful, either. I guess I'll just cross that bridge when and if I
have to.

But, regrets? No. I did as much research and soul-searching as I could,
and made my decisions. No looking back.
--
JerryW

Please respond to group; email address is not valid

2/11/04 PSA 2.6, Suspicious DRE (age 62)
2/23/04 Biopsy: Gleason 3+4=7, T2a, left lobe
5/18/04 RRP, Path: Gleason 4+3=7, T2c, both lobes
Fully continent by 9/04
PSA through 4/22/08: <0.1
PSA 10/22/08: 0.1
PSA 1/19/09: 0.2
PSA 3/31/09: 0.2
SRT (39 txs) begun 4/9/09

JerryW,

Thanks for posting your history, and why you made your choices.

I hope the SRT takes care of the "scraps" that the surgeon missed
years ago.

BTW, what dosage are you getting?
Is it IMRT? Over the prostate bed, whole abdomen?
(How do they approach SRT?)

-Rick

Steve,

> I have to admit, that is less encouraging. *If your Gleason was 8, I think
> you'd be looking at RT. *You definitely have a hard decision ahead.

So, back to my original question.

My urologist is not suggesting salvage radiation, so much as adjuvant
radiation if margins are not clear.

Let's say I was Gleason 8 then...

Is it worth having surgery to "de-bulk" the tumor, then follow with
ADT and RT in 3 months?
Or just start with RT and ADT (e.g. protons) and get it all with one
modality.

Maybe the jury is out on whether debulking the tumor helps before
radiation - I'm not sure.
(I wonder if any studies are out there?)

-Rick

Thanks, Steve - I'll check this out!

> But here's an alternative that's both free and prompt: Got to Pub Med, a
> service of the US National Library of Medicine, atwww.pubmed.gov

"prostwell" <prostwell@westernwares.com> wrote in message
news:06c01c1a-a5d1-40fb-aed9-c17ae16982aa@t11g2000vbc.googlegroups.com...
> JerryW,
>
> Thanks for posting your history, and why you made your choices.
>
> I hope the SRT takes care of the "scraps" that the surgeon missed
> years ago.
>
> BTW, what dosage are you getting?
> Is it IMRT? Over the prostate bed, whole abdomen?
> (How do they approach SRT?)
>
> -Rick

Rick, the SRT I'm receiving is a form of IMRT (Intensity Modulated
Radiation Therapy). I am receiving 1.8 Gys per fraction for the 39
treatments for a total of 70.2 Gys. The area being irradiated is the
prostate bed, including a small part of the bladder and rectum. The
bladder is included because of the proximity of the original tumor to
the bladder neck. The small portion of the rectum is just in the way. I
have three small (about the size of a grain of rice each) transponders
implanted outlining the prostate bed. This permits the equipment to more
accurately maintain the target area in real time during the treatments.

Good luck in making your decision.
--
JerryW

Please respond to group; email address is not valid

2/11/04 PSA 2.6, Suspicious DRE (age 62)
2/23/04 Biopsy: Gleason 3+4=7, T2a, left lobe
5/18/04 RRP, Path: Gleason 4+3=7, T2c, both lobes
Fully continent by 9/04
PSA through 4/22/08: <0.1
PSA 10/22/08: 0.1
PSA 1/19/09: 0.2
PSA 3/31/09: 0.2
SRT (39 txs) begun 4/9/09

"prostwell" <prostwell@westernwares.com> wrote in message
news:751d36f6-81a8-48ec-bfdd-3af1e510c8cc@q37g2000vbi.googlegroups.com...
Steve,

> I have to admit, that is less encouraging. If your Gleason was 8, I think
> you'd be looking at RT. You definitely have a hard decision ahead.

So, back to my original question.

My urologist is not suggesting salvage radiation, so much as adjuvant
radiation if margins are not clear.

Let's say I was Gleason 8 then...

Is it worth having surgery to "de-bulk" the tumor, then follow with
ADT and RT in 3 months?
Or just start with RT and ADT (e.g. protons) and get it all with one
modality.

Maybe the jury is out on whether debulking the tumor helps before
radiation - I'm not sure.
(I wonder if any studies are out there?)

-Rick

"prostwell" <prostwell@westernwares.com> wrote in message
news:751d36f6-81a8-48ec-bfdd-3af1e510c8cc@q37g2000vbi.googlegroups.com...

Let's say I was Gleason 8 then...

==> But, it's not. But, if it was, I would better understand your desire
to dismiss surgery. Because at G8, it is clear that most men who chose
surgery ended up having SRT and ADT. But, not all. You just heard from Mr.
Loomis, WhiteSoxFan, and IP -- all G8s and all surgery patients. But,
that's Gleason 8. You have to make youre decision based on a Gleason 7.

Maybe the jury is out on whether debulking the tumor helps before
radiation - I'm not sure.
(I wonder if any studies are out there?)

==> Yes, the jury is out on that worldwide. Some apply ADT to shrink the
tumor before radiation. Both seem intuitive, but are not supported by any
studies of which I am aware.



--
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000 G7 (3+4), T3cN0M0 Neg margins
PSA <.1 <.1 <.1 .27 .37 .75 PSAD 0.19 years
EBRT 05-07/2002 @ 47
PSA .34 .22 .15 .21 .32 PSAD .056 years
Lupron 07/03 (1 mo) 8/03 and every 4 months there after
PSA .07 .05 .06 .09 .08 .132 .145 PSAD 1.4 years
Casodex added daily 07/06
PSA undetectable since, < 0.04 on 10/09/08
Illegitimati non carborundum

On D-Day, Steve K wrote:

Quoting Rick

> Maybe the jury is out on whether debulking the tumor helps before
> radiation - I'm not sure.
> (I wonder if any studies are out there?)

Steve replied

> ==> Yes, the jury is out on that worldwide. Some apply ADT to shrink the
> tumor before radiation. Both seem intuitive, but are not supported by any
> studies of which I am aware.

Supplementing Steve's post: There are four pages of links on PubMed, a
service of the US National Library of Medicine, at www.pubmed.gov

Here's a reference to one, from the February 1, 2008, issue of the
Journal of Clinical Oncology: Roach M 3rd, et al., "Short-term
neoadjuvant androgen deprivation therapy and external-beam radiotherapy
for locally advanced prostate cancer: long-term results of RTOG 8610."

Conclusion: "The addition of 4 months of ADT to EBRT appears to have a
dramatic impact on clinically meaningful end points in men with locally
advanced disease with no statistically significant impact on the risk of
fatal cardiac events."

To see the article, links to related articles, and a link to a free copy
of the full text of the study, go to www.pubmed.gov and search on the
PubMed ID # 18172188

Regards,

Steve J

I'm having trouble finding some of these at pubmed -- but it did get
me using the site for more research.

For example, here's a recent article showing better results with
radiation than surgery:

http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum

CONCLUSION: This retrospective intention-to-treat analysis showed a
significantly better outcome after EBRT than after RP in patients with
high-risk prostate cancer, although a well-conducted randomized
comparison would be the best procedure to confirm these results.

The sample size was small, only 162(RT) vs 122(RP), but they are
fairly recent, unlike a lot of studies looking at reatment in the
1990's.
Followup was only about 3 years.

Maybe for my intermediate-high risk situation, RT *is* the right
choice after all...

-Rick

Thanks Steve,

I also found that article today on pubmed about ADT+RT being better
that just RT.

As much as I don't like it, I *am* convinced that adding 4-6 mo of ADT
with any RT that I might do is worth it.
(This is the *only* recommendation that all the doctors I've talked to
agree on.)

This still doesn't address whether surgery + RT + ADT is better than
just RT + ADT.
(IOW would 79.2 Gy of radiation to the prostate be just as effective
as removing it and trhen applying radiation to the "bed"?)

Here's the wonderful menu of choices I've been offered:
1) Da Vinci RRP, then if margins positive IMRT+ADT(3 yrs) 3 months
later.
2) Brachytherapy+IMRT+ADT with 3 years of neoadjuvant/adjuvant ADT.
3) Proton Beam Therapy(PBT) with a 13mm margin + 6 months neoadjuvant
ADT.
4) PBT with a 1mm margin + EBRT + 6 months neoadjuvant ADT.

Most people on this list would recommend 1), it seems. (BTW, it's
great to hear everyone's thoughts!)
On a proton-enthusiast list, they would say 3) as "just as effective"
with less SE's - no question.

Here's my current thinking on these:

1) If RRP did the trick, great - despite the possible incontinence.
My Urologist has done over 400 RRP's and I trust him to do a good
operation, but it *is* a major operation with all the risks that
entails.
But with a PSA of 16, I'm afraid I'd be right on to the RT+ADT and
enjoy the side effects of all modalities.
On the other hand, getting the thing "outta there" and having the
information from the pathology is definitely attractive.
The vagueness of a radiation "cure" is disconcerting (but getting
follow-up PSA's sounds stressful for all.).

2) This might be the best cure, but at what cost in quality of life?
I'm not really considering this one.

3) With recent increases in dose to 79 Gy and adding the temporary
ADT,
statistics (mainly from Loma Linda and Boston) point to around 85%
odds for 8-yr disease free survival (bNED) as likely.
(The HAN tables gives only 78% odds for surgery.)
And I have yet to find a proton patient that complains about any
SE's beyond temporary mild rectal bleeding.
But, is 13mm enough of a margin? Would radiation really take care of
the whole prostate tumor?
And, I.P. and others have pointed out, this eliminates RT as a back-
up plan.

All I do know, is that I need to make a choice and get on with it -
I've researched until I'm near crazy.

-Rick

On Jun 6, 11:44*am, Steve Jordan <mycrofts...@cox.net> wrote:
> On D-Day, Steve K wrote:
>
> Quoting Rick
>
> > Maybe the jury is out on whether debulking the tumor helps before
> > radiation - I'm not sure.
> > (I wonder if any studies are out there?)
>
> Steve replied
>
> > ==> *Yes, the jury is out on that worldwide. *Some apply ADT toshrink the
> > tumor before radiation. *Both seem intuitive, but are not supported by any
> > studies of which I am aware.
>
> Supplementing Steve's post: There are four pages of links on PubMed, a
> service of the US National Library of Medicine, atwww.pubmed.gov
>
> Conclusion: "The addition of 4 months of ADT to EBRT appears to have a
> dramatic impact on clinically meaningful end points in men with locally
> advanced disease with no statistically significant impact on the risk of
> fatal cardiac events."

On Jun 6, 12:55*pm, prostwell <prostw...@westernwares.com>
wrote...snip...

> I'm having trouble finding some of these at pubmed -- but it did get
> me using the site for more research.

IJROBP, J. Urol and Urology all charge for their papers.

> For example, here's a recent article showing better results with
> radiation than surgery:

> Followup was only about 3 years.

This is a key point that limits the strength of the article's
conclusions. Although the abstract does not call out what definitions
of failure (DOF) were used, it's likely that ASTRO or Phoenix was used
for the RT arm and PSA>0.2 ng/ml was used in the RP arm. It has been
documented in peer-reviewed studies that for RT studies to be
meaningful they must have a median follow-up greater than 5 years.
This is because of the effects of 1) ASTRO backdating on statistical
projections, 2) the time required to nadir in RT patients and 3) the
requirement to have either 3 consecutive PSA rises (ASTRO) or a PSA
rise >2 above nadir (Phoenix). These effects combine to make it more
difficult for men to fail within 5 years, and when they do, at least
with ASTRO, their failures are called at the first PSA rise
(backdating) which skews the projections. Studies have examined a
cohort of men treated with surgery and compared the cohorts failure
projections generated by both the ASTRO and PSA>0.2 DOFs. At times
less than 5 years, the ASTRO method is much more forgiving than
PSA>0.2 in terms of calling failures (in other words if the PSA>0.2
DOF projects a 10 year biochemical failure rate of 30%, the ASTRO
method would project a 15% failure rate, give or take. Even out at
median study times of 8 years, there is still a bias making the ASTRO
failure rate less than the failure rate using PSA>0.2.

> Maybe for my intermediate-high risk situation, RT *is* the right
> choice after all...

That may well be. As one moves from high-risk to low-risk, the effect
of treatment methods upon freedom from disease appears to lessen.
Picking the "best method" only comes into play if one lives in a city
that has both great surgeons and great radiation oncologists (NYC, San
Francisco, maybe a few other places), or if one is willing to travel.
Otherwise "best practicioner", be it RT or RP, trumps "best
method."...ron

DO NOTHING, GIVE UP MEAT, SUGARS, ALCOHOL EAT RAW, SIMPLE, BUT A LOT MORE
EFFECTIVE
THAN RADS AND CUT. GUARANTEE YOU WILL OUTLIVE ALL ON THIS GROUP WHO THE
OTHER WAY

<oitbso@yahoo.com> wrote in message
news:cafaddde-072d-45ad-854b-694759687811@t10g2000vbg.googlegroups.com...
On Jun 6, 12:55 pm, prostwell <prostw...@westernwares.com>
wrote...snip...

> I'm having trouble finding some of these at pubmed -- but it did get
> me using the site for more research.

IJROBP, J. Urol and Urology all charge for their papers.

> For example, here's a recent article showing better results with
> radiation than surgery:

> Followup was only about 3 years.

This is a key point that limits the strength of the article's
conclusions. Although the abstract does not call out what definitions
of failure (DOF) were used, it's likely that ASTRO or Phoenix was used
for the RT arm and PSA>0.2 ng/ml was used in the RP arm. It has been
documented in peer-reviewed studies that for RT studies to be
meaningful they must have a median follow-up greater than 5 years.
This is because of the effects of 1) ASTRO backdating on statistical
projections, 2) the time required to nadir in RT patients and 3) the
requirement to have either 3 consecutive PSA rises (ASTRO) or a PSA
rise >2 above nadir (Phoenix). These effects combine to make it more
difficult for men to fail within 5 years, and when they do, at least
with ASTRO, their failures are called at the first PSA rise
(backdating) which skews the projections. Studies have examined a
cohort of men treated with surgery and compared the cohorts failure
projections generated by both the ASTRO and PSA>0.2 DOFs. At times
less than 5 years, the ASTRO method is much more forgiving than
PSA>0.2 in terms of calling failures (in other words if the PSA>0.2
DOF projects a 10 year biochemical failure rate of 30%, the ASTRO
method would project a 15% failure rate, give or take. Even out at
median study times of 8 years, there is still a bias making the ASTRO
failure rate less than the failure rate using PSA>0.2.

> Maybe for my intermediate-high risk situation, RT *is* the right
> choice after all...

That may well be. As one moves from high-risk to low-risk, the effect
of treatment methods upon freedom from disease appears to lessen.
Picking the "best method" only comes into play if one lives in a city
that has both great surgeons and great radiation oncologists (NYC, San
Francisco, maybe a few other places), or if one is willing to travel.
Otherwise "best practicioner", be it RT or RP, trumps "best
method."...ron

On D-Day, Rick wrote:

> I'm having trouble finding some of these at pubmed -- but it did get
> me using the site for more research.

It is necessary to be certain that spelling is correct.

Which "these" are the problems? It looks to me as if a couple of
references are to presentations at meetings, not to published papers.
Those will not be found on PubMed, which is for published,
peer-reviewed, papers.

And a hint: the thundering-long URL (154 characters) can be reduced to
the 25 characters of http://tinyurl.com/kul768 by use of
http://tinyurl.com/ This would be helpful to folks who cannot use URLs
that run off the side of the screen.

Regards,

Steve J

prostwell wrote:

> Would radiation really take care of the whole prostate tumor?
> And, I.P. and others have pointed out, this eliminates RT as a back-
> up plan.

If RT w/ or w/o RP would "take care of the whole prostate tumor", then
RP would be unnecessary and you would not need a backup plan.

OTOH, if we reversed "RP" and "RT" in that sentence, it would still be
true.

Does that (non)distinction help pick a cure? i.e., Does it give your gut
free rein to choose?

Given that lack of knowledge for the cure potentials in your case, maybe
the SE profiles could/should be your tie-breakers. RP SEs tend to
diminish as the post-op years go by, and seldom involve brown shorts or
bowel cancer; RT SEs can increase as the post-rad years go by and focus
on your bowels.

Presuming equal cure rates, those comparisons are no-brainers to me.

I.P.

The Man wrote:
> DO NOTHING, GIVE UP MEAT, SUGARS, ALCOHOL EAT RAW, SIMPLE, BUT A LOT MORE
> EFFECTIVE
> THAN RADS AND CUT. GUARANTEE YOU WILL OUTLIVE ALL ON THIS GROUP WHO THE
> OTHER WAY

DAMN! Hear that THWACK? It was the sound of my palm hitting my forehead,
HARD. Just think of all the the thousands of hours I wasted reading
hundreds of books and articles and studies to pick treatments and
protocols, when all I really had to do was read those 19 words of wisdom.

Now, exactly *what* is it we're supposed to do? I get the vegetarian
part (no, thanks), but how, exactly, do we avoid sugar? A couple of
shots of alcohol daily is/are *healthy", raw is risky and not uniquely
healthy, simple is Twinkies (or is it "Twinkies is simple" ... I never
can keep that golden mantra straight, and are they healthier deep-fried
or in a cheese'n'caramel fondue), and is a "rad" a radish or Elton
John's shades? Oh, yeah ... "cut" ... is that a noun, verb, or
adjective? And who backs that guarantee ... General Motors? Lehman
Brothers?

Sheesh.

I.P.

"I.P. Freely" <fuhgheddaboutit@noway.nohow> wrote in message
news:nTXWl.6951$v24.6759@newsfe13.iad...
: The Man wrote:
: > DO NOTHING, GIVE UP MEAT, SUGARS, ALCOHOL EAT RAW, SIMPLE, BUT A LOT
MORE
: > EFFECTIVE
: > THAN RADS AND CUT. GUARANTEE YOU WILL OUTLIVE ALL ON THIS GROUP WHO THE
: > OTHER WAY
:
: DAMN! Hear that THWACK? It was the sound of my palm hitting my forehead,
: HARD. Just think of all the the thousands of hours I wasted reading

It seems these three frauds (indeed if they are three and not one) have put
I.P., Steve J., and me all soundly on the same side.

We owe them (him) some gratitude.

On June 7, Mike Freely replied to Rick:

(snip)

> Given that lack of knowledge for the cure potentials in your case, maybe
> the SE profiles could/should be your tie-breakers. RP SEs tend to
> diminish as the post-op years go by, and seldom involve brown shorts or
> bowel cancer; RT SEs can increase as the post-rad years go by and focus
> on your bowels.

Mike may have had an excellent point. Several years ago.

Regards,

Steve J

"Radiation treatment today is *not* your grandfather's radiation treatment."
--Christopher Rose, MD
Radiation Oncologist
At the 2007 PCRI Conference

Yes, it was the meeting presentation that I had trouble with.

BTW, if anyone is interested in some recent information about proton
therapy, I found these powerpoints fascinating:
http://www.aapm.org/meetings/09PRS/M...rogramInfo.asp

These discuss some of the practical issues and challenges of proton
therapy, but still conclude that PBT is better than IMRT, as far as
radiation therapy goes - both in terms of cure rate and bad side
effects. (This topic is being hotly debated, it seems)

-Rick

> Which "these" are the problems? It looks to me as if a couple of
> references are to presentations at meetings, not to published papers.
> Those will not be found on PubMed, which is for published,
> peer-reviewed, papers.
>
> Regards,
>
> Steve J

Well, (deep breath) I think I've made a decision.

Thanks to everyone for their input.

From everything I've studied, and at my age and health, it seems that
my best chance for beating my intermediate-high risk Pca would be
surgery.

I have a good local Da Vinci surgeon who is willing to "do the deed"
in two weeks, and I'm ready to get on with it.
I've talked with several of his patients, who all report excellent
results.
He does 2 or more prostatectomies every week for several years now.

I'm accepting the (considerable) risk of incontinence, impotence and
recurrence with surgery - pretty scary stuff.
Depending on the pathology and post-surgery PSA, of course this might
be followed by radiation and ADT... the whole nine yards.

The certainty of the information from the surgery pathology, along
with knowing whether it was successful in the near term with a PSA
reading in 6 weeks, are major benefits to me.

Maybe I'll get incredibly lucky and the surgery will do the trick -
I've heard that this does happen sometimes.

Starting with "Plan B" (radiation) seems like a bad idea at my age of
59, despite the better side effects and easier treatment.
I might still need to use radiation if my PSA does start rising, in
which case this should still be a better chance to beat it than
radiation alone.
Success from radiation is just too vague and nervewracking, not to
mention the late rectal side effects.

If I were in my seventies, the choice would be much easier - proton
therapy without question.

Wish me luck!

- Rick

On Wed, 10 Jun 2009 13:05:13 -0700, prostwell wrote:

> Well, (deep breath) I think I've made a decision.
>
> Thanks to everyone for their input.
>
> From everything I've studied, and at my age and health, it seems that my
> best chance for beating my intermediate-high risk Pca would be surgery.
>
> I have a good local Da Vinci surgeon who is willing to "do the deed" in
> two weeks, and I'm ready to get on with it. I've talked with several of
> his patients, who all report excellent results.
> He does 2 or more prostatectomies every week for several years now.
>
> I'm accepting the (considerable) risk of incontinence, impotence and
> recurrence with surgery - pretty scary stuff. Depending on the pathology
> and post-surgery PSA, of course this might be followed by radiation and
> ADT... the whole nine yards.
>
> The certainty of the information from the surgery pathology, along with
> knowing whether it was successful in the near term with a PSA reading in
> 6 weeks, are major benefits to me.
>
> Maybe I'll get incredibly lucky and the surgery will do the trick - I've
> heard that this does happen sometimes.
>
> Starting with "Plan B" (radiation) seems like a bad idea at my age of
> 59, despite the better side effects and easier treatment. I might still
> need to use radiation if my PSA does start rising, in which case this
> should still be a better chance to beat it than radiation alone.
> Success from radiation is just too vague and nervewracking, not to
> mention the late rectal side effects.
>
> If I were in my seventies, the choice would be much easier - proton
> therapy without question.
>
> Wish me luck!
>
> - Rick

I had a RRP in 2000 at age 49 and had to follow up this spring, 8 and a
half years later, with salvage radiation (IMRT) due to rising PSA. But I
still feel that starting with the RRP was the way to go. My first PSA
after the salvage radiation was .02 and hopefully it'll go even lower. I
hope your Da Vinci goes well. Keep us posted. You'll get lots of help
here with any questions you might have on down the road. Good Luck Rick!

Vince



--
PSA 4.73 07/2000 @ 48
Biopsy 07/2000 G7 (3+4)
RRP 09/2000 @ 49 G7 (3+4), T2b Neg margins
PSA < 0.1 for 14 months post op
PSA .8 .8 .6 .8 04/2008 thru 12/2008
IMRT 02/2009 - 04/2009, 38 treatments, 60.8 Gy total
PSA .02 05/18/09