Advice on treatment: RP v radiation? ... - Prostate Cancer N...

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Advice on treatment: RP v radiation? New, here.

Adf2529
Adf2529

Otherwise healthy m 65 yr. On active surveillance PSA 5.8. MRI's all clear. Two fusion biopsies. In 2018, Gleason 3+3, one core only, low volume. 2019 Gleason 3+4. One core only, same localized area, 40% vol.

Considering RP, hi energy brachytherapy, and SBRT.

Just received Oncotype (high risk) and Genomics DX (intermediate risk) test results.

How should I factor the genome test results in the consideration of 1) staying on active surveillance, and 2) RP v. brachytherapy or SBRT?

THANKS.

21 Replies
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If you only had a small amount of Gleason pattern 4, you might be able to stay on AS, but the "high risk" on Oncotype probably means treatment is in your near future. All the treatments you are considering are likely to be curative. Here are some questions to ask yourself:

pcnrv.blogspot.com/2017/12/...

Adf2529
Adf2529 in reply to Tall_Allen

Thank you for your response. Very much appreciated. By "near future", I guess you mean that if one is headed toward treatment -- by virtue of the high risk Oncotype report -- might as well be sooner rather than later.

Tall_Allen
Tall_Allen in reply to Adf2529

I just meant that you have some risky genomics going on, and you won't be able to sit on it for 20 years or even 5 years, as some can. When you feel comfortable getting treated is up to you. You have plenty of time to meet with experts and make a decision that's right for you.

Adf2529
Adf2529 in reply to Tall_Allen

Thanks!

Adf2529
Adf2529 in reply to Tall_Allen

So part of my struggle re treatment is this: if the various treatment options are "likely" curative for my stage of localized pca (notwithstanding Oncotype result worry), and the biggest cost is ED (my words), why not favor some form of radiation that has better outcomes concerning ED?

I think the answer is that the question hinges on ED (and urinary) outcome vs. certainty of cancer. The surgeons say, we can have full confidence that we've gotten everything out with RP. The radiologists say, our data shows comparable survival outcomes to surgery.

Just thinking aloud here.

Tall_Allen
Tall_Allen in reply to Adf2529

For localized PC, the oncological outcomes are exactly the same, but the side effects are different. That was proven by the ProtecT randomized clinical trial:

pcnrv.blogspot.com/2016/09/...

RP provides no more certainty than RT. Even those with clear margins after RP can have a recurrence. The differences are:

1) you get a pathology report with RP

2) if your PSA goes to undetectable after RP and if it stays there afterwards, it helps you feel more confident. After RT, it can take several years for PSA to reach nadir, with bounces along the way.

I was comfortable not knowing what was in there, and I was willing to wait for nadir if it meant retaining potency. But men have different dispositions.

Adf2529
Adf2529 in reply to Tall_Allen

Yes. I’m thinking along the same line. I had a UroLift Implant a year ago, to correct long term BHP symptoms. I wonder if you’ve heard anything re the suitability for RT when a UroLift is present.

Tall_Allen
Tall_Allen in reply to Adf2529

I don't know of any contraindication, but ask an RO.

Good luck with whatever you decide. I chose surgery which was the best option for me. I did not want to worry. I am doing well.

I had 45 treatments for my G9 (3 cores positive, 2 G9, 1 G6, PSA less than 2.) That's 25 to the prostate bed and the prostate, followed by 20 "boost" to the prostate only. A total of 81 Gray.

The treatments were done on a Varian EDGE machine, their current newest model, used for both conventional treatment and SBRT. The treatment was IG/IMRT/ARC with 3D "cone" imaging done at the start of every treatment.

This is done along with 2 years of ADT (some studies say 18 months, some 36 months, my medical oncologist who is very much up to date on studies said the majority of studies show 1-2% difference in ADT after 18 months... so that's probably going to be my choice depending on PSA scores going forward.)

My diagnosis was my PCA was localized in the prostate with a possible small extra-capsular-extension [ECE]. T3B by one oncologist, T2B by another.

6 weeks after completion of radiation treatments - my PSA was not detectable. My hope is it stays that way.

My choice was based on following a number of forums where I observed many people who had RP having recurrences that required radiation, or an upgraded Gleason score after RP that indicated radiation and ADT, or more extended spread found on RP. That along with talking with a number of older friends who'd had RP and wished they hadn't influenced my choice.

As far as the success of modern radiation treatment there are a number of papers that address treatment given today (not treatment given 20 years ago - a failing of many long term result papers..)

ncbi.nlm.nih.gov/pmc/articl...

ncbi.nlm.nih.gov/pubmed/304...

ncbi.nlm.nih.gov/pubmed/196...

Given the relatively lower risk of your PCA, it may be worth thinking about quality of life in making your decision.

If you decide to go with radiation - while the choice of a radiation-oncologist you trust is primary, the facility and equipment should also be taken into account.

With the EDGE machine, fiducuial makers were not needed, and SpaceOAR was unnecessary. My RO would have done these if requested, but he had two reasons he suggested not to - one was to avoid stirring up the area - creating possible pathways for further spread of the cancer. The other was interesting - he said by relying on the markers it wasn't as accurate targeting the prostate since the markers can move a bit even day to day. By not having them the technicians will concentrate on the 3D-Cone CT scan done each day and manually locate and identify the prostate. He felt there was a much less chance of undesirable side effects doing it this way. So far my side effects have been really minimal considering the dose I received.

Good luck with your treatment, whichever you decide on. When looking at what guys recommend for you - take into account "confirmation bias" - the natural response of recommending what you had done as a way of confirming to yourself that you made the right decision. I'm aware of it - and admit to it.. in this case it still seems the right decision for ME - but you have to decide what works for you.

Don

Adf2529
Adf2529 in reply to Don_1213

Thanks, Don. Side effects? Did you consider high energy brachytherapy?

Don_1213
Don_1213 in reply to Adf2529

Mild urinary urgency, less then before my diagnosis, treated by doubling Climax. On weekends a bit of bowel upset, treated with Imodium.

And no, I never considered any form of beachy. Too invasive and didn't want to stir things up. Treatment with the latest machines seem to give seem to be achieving the same results with a much less invasive treatment using IG/IMRT/ARC. The claimed accuracy with the new machines is 1mm. That's as good as you're gonna get

Don_1213
Don_1213 in reply to Don_1213

BTW, the bowel side effects were only on Saturday (and might have been caused by Friday nights dinner, I enjoyed myself since I didn't have to be empty then next morning) and urinary symptoms are really almost non-existant 8 weeks after treatment. I now typically can go through the night without getting up to pee. That's way better then before treatment.

Adf2529
Adf2529 in reply to Don_1213

thanks!

This was informative. When I asked my husband's urologist about something like an oncotype(my exact words), he said they didn't have anything like that that was reliable for prostate cancer.

I tend to agree with Don1213 - having had a similar experience to his.

I also had a hi-tech oncology (third party) test which showed CTCs.

The good news was that the CTCs were below a significant point, meaning that my nadir was holding (>0.02) and that my immune system and/or treatment has put me into remission.

It does boil down to informed choices. I'm no fan of RP, but the results speak for themselves.

Many men go that route and the outcomes tend to be pretty satisfactory.

It isw the side effects that make me think I'd avoid it if possible and hope that RT and perhaps some duration of ADT (18 mos ?) might be curative.

I keep reading about what was missed during RP, that leads to trouble down the road that concerns me.

Those stats are too high - causing me to wonder how and why this continues to appear to repeat itself in a certain % of patients ....

Welcome to the brotherhood. If you read some of the sad stories of men who have had RP it should ease your decision.

I'm glad I had the VMAT radiation. I didn't want RP because I didn't want to deal with both incontinence and immediate ED -- which, by the stats, may or may not recover. You would have to resort to an implant to resume penetrative sex. I'm in my 11th month of 18 months of ADT. If you do ADT you must be made aware

that your libido is likely to collapse within the first few months. Despite this, you must make efforts to keep erections going or risk permanent ED. I invented a simple loop-in-a-cord device called the Loop, which has saved my erectile function during ADT. I've posted about it several times. Check it out. Good luck with whatever treatment you choose, but I recommend RT over RP.

I think it's important to remember that results re: incontinence and ED are variable, not just between treatment modalities but of course between different clinical pictures. Before my RP last September I was told the surgeon would likely be able to spare nerves on one side but not the other. Postop I was told he was able to save most of the nerve on the other side as well. Nevertheless (and though improving) I continue to have ED 8 months postop. My understanding is that your ED may progress for some time after RT. The biggest factor in my choosing RP over RT is that in the case of recurrence, salvage RT after RP tends to be easier than salvage surgery after RT.

Good luck.

Don,

Who was your RO?

Doug

Don_1213
Don_1213 in reply to Garp41

Garp - did I ever reply to this?

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