Decision time

[hwrjr]

A recent biopsy revealed a Gleason 4+3 with PNI and I have scheduled focal salvage cryoablation at Duke Cancer Center on December 11. This is a recurring cancer following primary radiation 10 years ago. The doctor there, Dr Polascik, will perform the procedure and is very experienced in cryotherapy.

I had made tentative plans to travel to NY to see Dr Zelefsky for consultation on focal salvage brachytherapy on November 19, but now I’m having second thoughts about whether I should go. Here’s why:

When I made the appointment weeks ago, I did not know if I would qualify for cryotherapy at Duke. Now I know I do.

I think it's likely Dr Zelefsky will recommend ADT for a short period before and after the procedure. It's hard for me not to overstate how much I don't want to take ADT. I can’t say it’s a deal breaker for me, but it’s very, very close. It’s not needed for the cryoablation procedure.

As I noted, the biopsy at Duke reported PNI. Dr Polascik didn’t think it was particularly important but my reading says it could be. He offered full gland treatment if it worries me, but side effects are more likely. I don’t know what Dr Zelefsky will recommend for PNI, if anything. I suppose all he can do is treat the whole gland or hit me with some external radiation along the nerve path. I’ve already had primary radiation treatment and not looking for too much more. It might be pennywise and pound foolish to leave the PNI untreated through.

It’s expensive to travel to NY. $1500-2000 for air, lodging, and meals for two, for one night. How many trips might I need for the treatment and follow up? I’m fortunate in that I can afford it, but is it something that I really need to do?

I guess it comes down to this for me: how important is ADT and PNI? ADT might be the usual protocol as a combined treatment with radiation for a 4+3 , but doesn't enhance the cryotherapy effectiveness. I just don't know about PNI. I visualize cancer cells running along the nerve pathways unimpeded and that's worrisome.

[j-o-h-n]

What about a video conference with Dr Z. instead of a trip to nyc?

Good Luck, Good Health and Good Humor.

j-o-h-n

[hwrjr in reply to j-o-h-n]

I tried, but they said no.

[addicted2cycling]

My doctor who performed a triple freeze hemi-ablation using cryotherapy for the GL10 tumor in the right half of my prostate in 2015 at that time already had 25+ years experience of prostate cancer cryo ablation.

You might want to verify that your treatment will be a triple freeze.

good luck 👍👍

[Whitby2]

Not sure my experience will be helpful.

I had cryoablation procedure at MSK in NY last February - Dr. Jonathan Fainberg. Terrific doc & person. Highly recommended. Great staff. Had Gleason 4+3 w/PNI. Was on active surveillance from about 2019 under/Drs. Scardino & then Edhaie who took over when Scardino retired. Had BPH and PSA that kept creeping up. Routine MRIs & prior biopsies didn't pick up the cancer. PSMA picked it up after PSA jumped up. Had several second opinions prior to procedure to weigh the risks vs. QOL. The MSK team recommended cryoablation. I'm 80 yrs old, continue to work, and lead an active life. Had post-op complications with bladder spasms/infection, most likely caused by Foley. It was cleared up by Augmentin. Three month & six month post-op testing generally stable. PSA initially dropped about 90%. Next round of full tests in the beginning of January. So far, I haven't had any other form of treatment so I can't say anything about it.

Personally, I would want to meet docs in-person. In any case, I would talk to whomever you see to weigh your specific risks of PNI to help allay your worries.

Best of luck.

[hwrjr in reply to Whitby2]

whitbt2, thanks for your experience . It's good to read about another who had similar treatment that I will have. You did not say if you had focal or whole gland treatment. I have one tumor to treat so I will have focal salvage treatment. Plus, my case is different in that I have a recurrence after primary radiation so side effects risk can be higher.

If you had whole gland then you had much better chance at killing the PNI that may be spreading along a nerve in the prostate. My focal will only treat the tumor site and it's my hope the PNI is in that treatment area. If not, I will have to consider some other treatment in the future if the PNI shows itself. Cancer cells in the nerve do not usually increase PSA until it gets outside the prostate and spreads. I've read that post cryotherapy usually involves periodic mpMRI's and transperineal biopsies. Maybe one of the biopsies will show the PNI before it's too late.

I'm told I have to leave the catheter in for 2 weeks post-op. Not looking forward to that.

[Whitby2]

I had a partial gland treatment for a diagnosed 2cm anterior lesion. No evidence of METS. Cryoablation on right Anterior; right base, left base, right mid, left mid & apex sparring. Used triple fusion: ultrasound, MRI, & PSMA PET during procedure. I have had one post-op contrast MRI so far. Nothing of concern showed up. Next full testing beginning of January: MRI & PSMA, etc. Was on the leash with a Foley for a month. As mentioned, post-op complications with bladder spasms. Was told that I was a unicorn in their experience. Unique to my anatomy. Narrow urethra and significantly enlarged prostate. I had one transperineal biopsy pre-op which was for me much easier compared to the two previous transrectal biopsies.

Foley was difficult. No question. But I was also surprised how I was able to adapt and carry on with my life within the limitations imposed. Maybe it will be that way for you as well.

For second opinions, you could check with Dr. Herb Lepor at NYU Langone. Top notch doc who has been doing ablation procedures probably as long as anyone. Very experienced. Also Dr. Tim McClure at Cornell Weill. Also highly recommended. Terrific person, very helpful.

Can stay in NYC at the Helmsley Medical Tower at 1320 York Ave (70th Street). Reasonable prices. Near MSK and Cornell Weill and close to Langone. You let them know you are a medical patient at one of the hospitals. Reduced prices may be available. I stayed there a few times and found them very accommodating.

Hope this helps.