Advanced Prostate Cancer
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Prostatectomy for Stage 4

Hello - I wondered what the opinion of users was on the prospect of a prostatectomy for men who are newly diagnosed stage 4 (already metastasised)?

Obviously I’m aware that essentially the horse has already bolted, but can there be any benefit whatsoever from removing the prostate even at this stage? Any evidence to suggest it is a positive move despite the potential side affects that come with surgery?

Thanks

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Once the cancer has broken through outside the prostate you are not a canadate for surgery as in my case. Hormone thearapy with radiation is what i had. We would need your psa numbers and Gleason score to be able to comment on your particular situation.

Thomas

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But why is that? Because it will have no affect whatsoever or that it is standard protocol not to undertake it given the risks involved?

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Yes this was true for me also...

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This isn't always true. I had local mets, to some lymph nodes found via scans. But because I was young and otherwise healthy, my urologist agreed that surgery was an option. He said that there has been some studies that suggest positive outcomes by removing the original source of the cancer. So I received an RP, then when I still had some PSA, follow-up radiation. So I think the attitude toward debulking the prostate is evolving. It's not as straightforward as it used to be.

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There is no solid data on "debulking." Some database analyses suggest it may be beneficial, but for proof we would need a randomized clinical trial. They are ongoing, but it will take a few years. It is also not clear whether it is best to debulk with radiation or prostatectomy. This is discussed in the following articles:

pcnrv.blogspot.com/2016/08/...

pcnrv.blogspot.com/2016/08/...

This article discussing other options for men in your situation may be useful too:

pcnrv.blogspot.com/2017/06/...

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I was told at the time FDA linear treatment. At discovery in 2014 I was ready to hit it with all available options surgery, chemo and radiation. Couldn't find anyone to grant my wishes.

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In the past (and in most cases still followed) the thought was since the cancer cells are in the bloodstream why put the patent through all of the side effects. However there is growing (circumstantial) evidence that removing the primary source of cancer does lead to longer life. I had to argue with my surgeon to operate even though the cancer had spread to the pelvic area.

Listed below is an article (not a primary source article ) discussing debunking.

malecare.org/to-debulk-or-n...

You may have to make up your mind before all the data is in. The big question is can you live with the side effects surgery based on the possible positive effect it can have.

Walt (a chemist not a MD)

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Saw what Tall_Allen wrote---and I disagree--I have seen the reports and the papers and you can wipe your---know what with them. How about common sense????????? The Factory for output of the cancer into the body is the Prostate. In my case we all knew I was already Micro-Metastatic---with a nasty Ductal Cribriform Pathology---so I also knew I was on the cusp of designated Stage 4--and I also knew that my pathology had a strong tendency to defy radiation--longer treatments with poor results--and on top of that---that there was a strong tendency from reading papers about my pathology, that Neuroendrocrine Pca cells are found in some cases to stay behind in the Prostate and follow out of the Prostate Later, as they for some reason do not move as fast as Hormone Sensitive Pca cells.

So we debulked asap--and decided to deal with the cancer that escaped into my blood---since scans showed it had not landed anywhere, and while it was in the blood we could attack--the cancer in the blood more easily than if it were in the bone. So an ADT-3 that went to 4,5,6, and a special supplemental program---took me to 2 years later doing real fine, after my RP. My Docs, one the Head of Prostate Research Cancer at the Levine Cancer Institute--congratulated me on the decision I made with my Uro. My Uro, had over 1,000 RP's and has seen everything---urged me to take up with a highly respected RO---and even he leaned towards an RP.

My wife an Operating Room retired Nurse who had assisted in some 200 RP's screamed at me get that B------- out of you!.

Now I am not a Doctor--but I make my own decisions--and as a researcher not in the medical field, have nearly 4,000 hours of Prostate Cancer Research, as to studies--not in actual practice except on myself.

You will have to make your own decision, just like I did. Choose Wisely.

Nalakrats

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Nal,

you are 100% right...that TA guy brings up all these BS studies...like the one he referenced that the use of Lupron delays the onset of castrate resistance...everything I have read is you should have an RP even though there is metastasis...with an RP you are removing billions of cancer cells including the majority of PCa cells that are CR....where the use of Lupron does not delay the onset of CR an RP does.

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I am on board with Nalakrats. A lot of these papers are based on evidence taken from old studies previous to new treatments. With Stage IV cancer you don't have 10 years to wait for the results of new trials. The here and now is the trial we are living. If it didn't work the major research hospitals wouldn't offer it. There are documented cases of this thing being beat when metastatic. If you don't want to read about it there is enough information on Youtube showing the benefits of surgery or radiation. Kwons video of the amazing things they are doing should be enough to give the worst cases hope.

One thing is absolutely certain, if you don't try the cancer is not going away. I will never understand the whole quality of life argument either. How is there any quality if your not living? What kind of quality is it being on HT the rest of your life? With or without cancer there is risk involved in life. You will never know the potential outcome if you don't try.

I am certain and my doctor is too that with the amount of disease I had there is absolutely no way I would have an undetectable PSA and no evidence of disease if they didn't debulk. At 46 years old I wasn't going to lay down and accept palliative care. The amount of men in the past and even today that are denied treatment because of old school thought is terrible. I experienced this myself before finding a doctor that gave me a chance.

Push, don't accept no and fight for it. It's your life.

Ron

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Dear friends, there are so many variables involving all of us.. There are specific cases as mine that no PC specialist could allow a Prostatectomy. For many it maybe possible .Butfor me or someone that was in my condition surgery was impossible..ADT & RT so far and I’m happy to be breathing..

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This retrospective article from 2014 with 8185 patients supports debulking in patients with stage IV:

ncbi.nlm.nih.gov/pubmed/242...

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I read recently of a trial in Boston where 22 untreatable stage 4 (like me unsuitable for RP)were actually treated and pretty successfully.

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Read the paper here: ncbi.nlm.nih.gov/pmc/articl... Trying to get my urologist to move on this info, as I fit the oligometastatic profile.

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Good morning Jlc- I just had my prostate taken out in December. During the pathology they upgraded my Gleason to a 9 T3b. I had the Davinci laproscopic surgery.(nerves spared) I spoke to my new Uro and he said he would have removed it regardless. He is one of the foremost leaders in PCa treatment at Vanderbilt.

So yes to answer your question. My doctor feels there is a benefit to the surgery.

One upside to it is that, if you have any issues with your urine stream, it is relieved.

Erections aren't going to happen either way until you are off Hormone therapy from what I understand.

I just started ADT yesterday and am slated to start radiation in a couple of weeks. 6 months of ADT and about 2 months of radiation and then watch the PSA. So far so good. Getting ready for work right now.

The general consensus is that if there is a chance it will help delay the progression then do it. My wife and kids agree.

Best of luck in your fight. We are all with you.

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I am sure there is a solid scientific debate, but logically it seems if you can physically remove the cancer, even stage 4, and the impact is not life threatening, you should.

My friend had melanoma stage 4, his original doctor told him go home, you have 6 months to put your affairs in order. He walked out, went to MD Anderson. First thing they did was remove a portion of his lung and colon (and other 'clean up') to get as much as possible. He then was one of the first patients on Keytruda and for him, it worked very well.

The original rationale, was get as much as you can in order to help the chemical treatments. I know this was for melanoma vs prostate, but I think 'de-bulking' is part of most cancer treatments.

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Horst Zinche from mayo showed benefit to removing prostate with lymph node positive PCA a few decades ago. I myself wish I had done it with an expert early on. It must be an expert surgeon however. At 11 plus years I had mine debulked with radiation just recently, we will see how it goes.

Dan

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I think it's safe to say the answer is unanimous

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This recent article (2018) indicates worst outcome in aborted prostatectomies because of positive lymph nodes.

ncbi.nlm.nih.gov/pubmed/293...

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You are correct. Once the cancer has spread beyond the prostate there is no benefit in removing the prostate. In fact, why would your doctor risk your urinary function with such a futile procedure.

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Agree. Unless and until a benefit is proven, I wouldn't consider it. And even then, it would have to be convincing because of the potential for additional side effects.

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My doctor said no to removing the prostate said the recovery at this time wouldn’t help since the cancer is already as you say out of the chute .

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Hi

Please get some if the best opinions out there. I too was stage IV and had mine out with no regrets. I work with UCSF and Seattle Cancer Care I along with them elected to get rid of the source producing the boogers. I am on ADT holiday after two years. Life beats the side effects of surgery for me.

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BACKGROUND

I returned from MD Anderson yesterday. Recall I had PSA of 227 at diagnosis. 1 met in T8 vertebra. Had radiation to my spine (tremendous pain), early chemo (Stampede study), and been on Lupron since diagnosis in May 2015 at age 53. PSA dropped to undetectable for a year and a half. Then rose slowly to 1.8 before I started Zytiga in December. Now back to undetectable.

MY NEW STORY - RELEVANT TO THIS POST

In December I had a PET scan, prostate MRI and circulating tumor cell test. PET scan showed no active cancer outside the prostate and no sign of cancer in circulating tumor cell test. Diagnosis is oligometastatic cancer with 1 met that shows no activity.

I am going to have a robotic radical prostatectomy in July at MD Anderson. While this is ‘not the standard of care’, they are giving it a shot. The hope is that this will be curative (but of course no one knows for sure). And as numerous posts highlight earlier, we are several years away from having the facts to be more definitive if this is a good course of action or not. If my PSA stays undetectable for 6-months post surgery, I hope to stop ADT.

We had quite a debate regarding radiation vs surgery, but landed on surgery as the best option for me. It will ‘de-bulk’ (not proven to work for PCa, but a lot of examples where it does with other cancers), will help provide additional information for future staging, and preserves radiation for the future in case I need it.

I’m grateful that our doctors are adjusting their treatment plans to match their patient’s cancer. Not just using a one size fits all approach. I was told at diagnosis that ‘once the horse is out of the barn’ it does not make sense to remove the prostate. But clearly a lot has changed in 3 short years.

I hope my story helps. I’ll keep you posted on my journey. Thanks for all the valuable insight and information I get from my fellow warriors and caregivers!

James

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