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.
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?
Comparative Effectiveness of Radical Prostatectomy Versus External Beam Radiation Therapy Plus Brachytherapy in Patients with High-risk Localized Prostate Cancer
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.