My 65-year-old husband was diagnosed with prostate cancer in August 2019. Initial PSA 22 (free PSA 29). Gleason score 8; T3 (or 4). Cancer confined to right side of prostate with a large invasion into seminal vesicle; no sign of any other mets (undetermined mass in colon currently being investigated). He has had a PET CT with fluciclovine as well as a pelvic and chest CT and a bone scan. He has had no treatment at this point.
His local urologist says the tumor is too advanced and complicated, so he would not feel comfortable doing the surgery; he said that it's likely to need to be operated on by open surgery, not robotically. He has referred us to doctors at Stanford University and University of California San Francisco (we live in central California).
We would like to know from others what their experience is with open surgery outcomes in a complicated situation, and if anyone with such a situation opted out of surgery and went straight for radiation, and if so why and how did it turn out.
If we opt for surgery, having a top-notch surgeon would seem to be a necessity. Any surgeon recommendations or suggestions on where to go for the best treatment would be appreciated (we are willing to travel).
Any information or suggestions would be welcomed. Thanks for your help.
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BattleMountain
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For high risk PC, the therapy with the best outcomes at top institutions is brachy boost therapy. At UCSF, you can get 20-25 treatments with a high dose rate brachytherapy boost and about 2 years of ADT.
If LA is better, you can get high dose rate brachytherapy at Cedars-Sinai (Mitch Kamrava) or UCLA (Albert Chang). You can have the external beam part of the treatment by a convenient local facility. At UCLA, you can also get in on an experimental trial of SBRT monotherapy by my RO, Chris King.
Is there a consensus which treatment has best outcome also for healthy 65 yr men?
The study:
Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer
wrote:
We therefore compared OS of EBRT + BT versus RP in comparatively young (≤65 yr) and healthy men (Charlson Comorbidity Index = 0) with high-risk localized PCa in the National Cancer Database. Inverse probability of treatment weighting (IPTW) adjustment was used to balance baseline characteristics. Median follow-up was 92 mo (interquartile range 78–108). Using IPTW-adjusted Cox regression analysis, EBRT + BT was associated with a higher risk of all-cause mortality compared with RP (hazard ratio = 1.22, 95% confidence interval 1.05–1.43). In young and healthy men presenting with high-risk localized PCa, RP showed statistically significant OS benefit compared with EBRT + BT.
You have to understand levels of evidence. Database studies like the one you site are practicly useless. The consensus at the top institutions is that the study I cited is more depositive (which is why many of them signed onto it.)
Agree, only an RTC will give the highest level evidence. The only randomized trial examining surgery in this setting is the SPCG-15. clinicaltrials.gov/ct2/show...
SPCG-15: a prospective randomized study comparing primary radical prostatectomy and primary radiotherapy plus androgen deprivation therapy for locally advanced prostate cancer.
I would assume that there is no consensus among the top institutions, which treatment has the best outcome, otherwise this RTC would be pointless and also unethical. Am I wrong?
We always have to make decisions using the best info we have, and so far the study I cited is the best we have. It reflects best practice at top institutions. Unfortunately, SPCG-15 does not include brachy boost therapy or external beam treatment of the pelvic lymph nodes, but, oddly, it does include extended PLND and salvage radiotherapy. It also does not include PET scans for patient selection. So I'm afraid it will tell us little. It is already irrelevant.
At dx my prostate was filled with cancer, 11 out of 12 sectors and into the seminal vesicles. G8. In my case mets in the ilium and rib bones. My IMRT (30 sessions) produced only minor side effects and appears to have been successful, but it’s only been three months since last radiation session. Used to pee 4 or 5 times per night, now once or none. ADT (abiraterone and Lupron) before and after. I would go with TA’s recommendation for brachytherapy, however, as the RT of choice.
I had a very similar profile, PSA 29, t3bN1M0 +SV and chose HDR-BT + IMRT as seen in my profile with great results so far.
My cancer at dx was similar, dx Sept 2018, age 59, psa 25, 12 of 14 cores positive, both sv’s, lymph node, and bone met (pubic ramus). Same with me, urologist said surgery would be very difficult if I could find a doctor to do it.
My treatment was adt(lupron then orchiectomy, zytiga and flomax), radiation to prostate and sv’s, and separate radiation to bone met.
I have done really well with this treatment, with psa undetectable, and few limiting side effects.
The only thing I wish I’d done at the start is get a Gallium 68 PSMA-PET scan. Then you will know where all the cancer is.
And, you do have a few months before deciding what to do, and I’d recommend not rushing. But, I am not a doctor, and many of the guys posting here are much more knowledgeable than I.
It has been routine to do a bone scan/CT for high-risk patients, but I agree with you that there is an important opportunity to use PSMA-based PET scans instead. I hope that when the NIH study is completed, the FDA will approve it for that purpose.
When your own Urologist was shy about performing a prostatectomy, that told you all you need to know about surgery in your case..Using the open procedure will not improve the outcome (JMHO) I agree with TA, the combined beam plus brachy radiation method will give Hubby his best chance..Radiation has improved tremendously over the past 10 years, surgery is still the same...In my opinion, that has allowed radiation to take the lead in treating high-risk PC. Choose the people who will be treating your husband carefully..The best doctors deliver the best outcomes..
Just to clarify, the PET scan was done because the CT scan and bone scan showed possible areas of mets, which fortunately did not show up on the PET. Unfortunately the PET lit up a mass on his colon, which we are following up with a colonoscopy next week.
It seems both Stanford and UCSF have advanced radiation treatment. What criteria should we consider in deciding between them? What questions should we ask? How do we choose a doctor?
Stanford is an hour closer than UCSF (2 hours), but UCSF seems to have more clinical trials happening. I've seen websites for radiation treatment centers elsewhere in California, which we would be open to traveling to if there was a significant difference in treatment.
Hi. I had similar diagnosis but no seminal invasion so ended up with RALP at Stanford (also from central ca) with Dr Chung. Clear lymph nodes (0/15) and I thought things were over...but persistent PSA so subsequent scan identified 2 avid lymph nodes and I ended up with EBRT anyway, again at Stanford with Dr Swift. 10 months down the road and the PCa has been undetectable so I’m happy. In hindsight, wish I had known more about Brachy Boost as TA suggests, since the surgery didn’t finish the job, but pre-surgery everything looked fine on scans including GA-68 PSMA. 1 year post surgery now and no major side effects...but still on ADT & Zytiga for a few more months to hopefully put this all behind me. Best of luck - UCSF and Stanford were both very supportive.
I had the old fashioned open RPD and two hernias repaired. Typical Foley for a week, incontinence for a month and total loss/use of little ole "rickie". If you're in New York City area see Dr. James Eastham at Memorial Sloan Kettering Cancer Center.
Dr James Brooks at Stanford is an expert on the open procedure if you want to consult there. I didn’t have as complicated surgery but I did get his feedback on open v robotic. Brachy should definitely be considered as part of your treatment options for high risk disease.
Also, you might consider consulting with a medical oncologist at either Stanford or UCSF for radiation or surgery options and advice. UCSF does three times the prostate cancer volume than Stanford but your husband would probably have similar outcome at either since both are excellent centers.
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