Prostate cancer best option?

[pj17]

Biopsy and MRI shows cancer confined to prostate. Gleason score 7 psa 4.6. Is surgery or radiotherapy best option? I am a fit 67 yo.

[Sten]

pj17 Hi Is your Gleason score 4-3 or 3-4? 3-4 is better than 4-3 but both are considered moderate. My Gleason score is 4-5 (9), biopsy taken 2011, my latest PSA (april) was 5.8, but I am 82 years old. Perhaps Bicalutamide (tablet) would be an option for you, ask your doctor. Your PSA is not very high either. Best, Sten

[Hidden]

Hi such a shock to be told, I know but now is the time to be positive, have you thought of Brachytherapy?

[mike72]

At 66 I was diagnosed with a higher PSA, same gleason code. My consultant wanted to do an operation ( keyhole surgery ) and explained that if I had radiotherapy and it did not work, I could not have surgery later. I opted for the surgery in 2010. For more info contact the Prostate Cancer Charity, and they will send a free info pack with all the answers. Good luck

[domani19]

hi pj 17 if there is an option of surgery I would seriously consider doing it , I have recently had it done after much deliberation as to what to do , you must remember that both treatment options are fine , the difficult issue is making a choice , good luck wishing you well Ken

[Dr_WHO]

While it may not sink in yet, having a Gleason of seven means that you are in the "I can be cured" camp and not the "how do we manage it" camp. That is a great thing. You have to do what you think is best for you. The advantage of surgery is that you would get a better evaluation of the prostate and a better staging of the cancer. The pathology report is more accurate than the biopsy report. Sometimes these values will vary. In addition, they normally take out some pelvic lymph nodes to see if the cancer has spread. (Note, they normally take out the lymph nodes first to check for cancer. Unless you tell them otherwise before the operation If they find cancerous lymph nodes most surgeons would stop the surgery and not remove the prostate. As others have stated you can have radiation after surgery but not the other way around. Radiation scars the area to bad.

For me, I had a Gleason of 8. Had surgery where they removed a 74 gram prostate along with 14 lymph nodes, one which was "100% cancer". The pathology report was Ductal prostate cancer (very rare and agressive) T3N1. Surgery was followed by 38 rounds of radiation, Lupron and then Zytiga. I still go on multiday bike rides, SCUBA, long walks, etc. I still wear a pad (about 18 months out from surgery), but my leakage is less than 10 grams a day.

[pjoshea13]

PJ,

When I was faced with this issue 13 years ago, I found an online calculator, that, based on age, Gleason, stage, etc, gave 10 year survival. I was shocked to find that (in my case), surgery had a 5% advantage.

The father of a friend called me to try to convince me that surgery wasn't the best option. He said that I should speak with Dr Myers, who was only 30 minutes away in Charlottesville, VA. I called him & he said he would see me the next day.

I did speak to him briefly, but discovered that he did not accept insurance, so I did not have the consultation. On the way out, the two ladies at the front desk pleaded with me to get a 2nd opinion from an oncologist. "Urologists are too eager to cut."

My urologist knew I was going to see Myers. He told me that if Myers recommended radiation, I was to get a 3rd opinion "from a urologist!"

This is how I became aware that there was no agreement as to the best treatment. I later read a study that showed that treatment was influenced by whether one first saw a urologist or an oncologist.

Over the years, I have seen studies that compared primary treatments. Surgery has always done better.

[1] Here is a paper from May: "EBRT was associated with higher overall (HR: 1.41 ...) and PCa-specific (HR: 2.35 ...) mortality."

[2] (2015). "Men receiving EBRT had higher 10-yr PCSM {prostate cancer-specific mortality} compared with those treated by RP across the range of nomogram-predicted risks of BCR {biochemical recurrence}: 5Y-PFP {5-yr progression-free probability} >75%, 3% versus 0.9%; 5Y-PFP 51-75%, 6.8% versus 5.9%; 5Y-PFP 26-50%, 12.2% versus 10.6%; and 5Y-PFP ≤25%, 26.6% versus 21.2%. After adjusting for nomogram-predicted 5Y-PFP, EBRT was associated with a significantly increased PCSM risk compared with RP (hazard ratio: 1.5 ...)."

[3] (2014). "With an overall median follow-up of 76 months, 35 (9.3 %) men with high-risk PC died due to PC (23 in the RT group and 12 in the RP group). The 5-year estimates of cancer-specific survival rate for men treated with RP and RT were 96.5 % ... and 88.3 % .., respectively."

There are more studies, but I took the most recent.

In spite of the studies, the anti-urologists claim that RP is not the gold standard of treatment.

Dr Myers, however, speaking of the side effects of radiation, described it as "the treatment that keeps on giving."

-Patrick

[1] ncbi.nlm.nih.gov/pubmed/285...

[2] ncbi.nlm.nih.gov/pubmed/252...

[3] ncbi.nlm.nih.gov/pubmed/248...

[Steveo3312 in reply to pjoshea13]

I just read an article and it said that most of the surgical cases that are successful in long term, the surgeon used radiation to kill any of the microscopic cells that may have left the prostate which is definitely a possibility from T1C stage and up.

See Memorial Sloan nom calculator.

So then I say to might self if you are going to hit it with the kitchen sink and increase the odds of the man's quality of life to suffer then why not look at Proton Therapy or MRI guided radiation, at least this way you are reducing the chances are incontinence and sexual impotency.

[Hidden]

Hi PJ17 I agree with what others have said. With a PSA of ONLY 4.6 and a Gleason of 7 (Hopefully 3+4) and MRI good, you stand a good chance of being "cured". Survival rates for radiotherapy, I believe are the same as for prostatectomy. There are several reasons why you might opt for surgery rather than radiotherapy which others have alluded to. i.e. from surgery they send what they've removed to the lab and they can tell if all the cancer cells have been removed by looking at the "margins" of the gland.

They can also repeat the Gleason score. My went up, but only from 3+4 to 4+3, still 7!

What swayed me was that after prostatectomy you should have no prostate cells left at all. If they went cancerous once, why not again? If you have none, then they can't.

Also, after surgery, your PSA should be zero, and as long as it remains zero you know there's no recurrence. I presume also if it remains zero for 5 years or less then you would be discharged as "cured". Radiotherapy leaves cells behind, even if they are healthy. You'll still have PSA so presumably that may have to monitored for life.

AS others have said, if surgery "fails" you can have salvage radiotherapy. If radiotherapy fails then you can only have more radiotherapy with accumulative damage.

A further disadvantage of radiotherapy is collateral damage. Particularly your bowel and bladder. It damages them. It also draws out the treatment, which I believe can make you feel unwell. Surgery is over with in a much shorter time.

The downside of surgery is the higher possibility of urinary incontinence and erectile dysfunction which to be realistic, it will never be the same as it was before the surgery.

There are things that can be done to minimise both incontinence and the degree of erectile dysfunction. You will probably get lots of advice on incontinence.

Personal experience and the research I've read on this supports the conclusion that medics tend to think older men are asexual. They don't like talking about it anyway. Especially with older men.

It might not be at the forefront of your mind at the moment but if you opt for surgery and you think you may regret being impotent later, you need to act NOW.

If you're bothered about this, read on, If you aren't bothered, read on anyway.

Make sure you ask for a "nerve sparing" prostatectomy if this is possible. If it's offered to you great, but if it isn't mentioned then the possibility is that you won't get it, so ask! This is the number one factor, if the surgeon damages or removes the nerves as the operation traditionally did, the probability of permanent impotence is virtually 100%

Another factor is your erectile function now, if it's not good now, then you may lose it after surgery. If the medics don't assess it, I suggest you assess it yourself. To be, more objective about this, (you may be better or worse than you think) use a validated tool e.g. the International Index of Erectile Function. It's easy to download it, just google it.

Start on PDE5 inhibitors (e,g. VIagra) a soon as the catheter is out! Whether you think you need it want it or not because it will help prevent deterioration of erectile tissues which happens as a consequence of surgery (and radiotherapy)

There are other things you can do, but those are the immediate ones if it's of concern to you.

If not, then surgery is probably a good option for you.

[pj17]

To all who responded to my query..I really appreciate your generosity in sharing the results of your research, experience and advice. Some of the information is quite technical so I will go back over it.

[KwaiChang]

Diagnosed 14 months ago, gleason 3+4, PSA 6.06. (MRI six months earlier showed nothing abnormal.) Had mandatory bone scan to ensure cancer hadnt spread. All ok.

Decided immediately to opt for robotic prostatectomy. why risk radiation and potentially leave cancer cells inside you. Met surgeon who was the most positive man I have ever met.Explained all potential risks of surgery but had never had any patients experience them. Totally reassured, Had operation six weeks later. Total success. Wore catheter for three weeks, and daily self injected with NHS supplied blood thinning agent for 28 days, to avoid blood clots

Pathology report was perfect, and I am dry as a bone. Never experienced any leakage after first few days having had catheter removed, Obviously wore pads. Still perform pelvic floor exercises each morning. My first multiple 12 months of PSA post op blood tests show undetectable readings ie less than 0.01.Perfect.

Have always been extremely fit, slim, non-smoker and keen nutritionist,

Am totally convinced my excellent state of health, enabled me to recover so quickly, and would recommend the surgery EVERY time

[Bluetick in reply to KwaiChang]

My surgery was a nite mare . Have psa at 4.3 now. Ran 3 post op infections, and passed a plastic clip through my penis

At 2 months. Now I have refused conventional treatment

And have gone with alternative

Treatments. Also incontinent at 4 pads a day. Trying to remain

Optimistic.