I am 80, with a Gleason 7 3+4, and I'm scheduled for radical prostatectomy in 2 weeks. My 3T MRI showed a strong likelihood of significant cancer with some mild extra-prostatic extension and suspected capsular invasion, all on the left side. My biopsy confirmed cancer in multiple samples: (left base: 60% of 1 of 3 cores; left mid: 75% of 1 of 3 cores; left apex: 15% and 20% of 2 of 3 cores; left anterior: 20 % and 80% of 2 of 3 cores; CF1: 15% of 1 of 3 cores). All the right-side core samples were benign tissue. My urologist says I am not a candidate for Hifu because I have too much high-volume cancer. He thinks that because I am otherwise very healthy and should live well into my 90s, my best option is robotic prostatectomy, which he has done about 4500 times. He is extremely confident about my not becoming incontinent, and he sees a strong likelihood of my eventually regaining erectile capacity (my wife and I still enjoy intercourse, but my libido is not nearly as insistent as it used to be, and the incontinence issue is now a more salient, everyday consideration). Do you agree with his plan, or do you think that the much less invasive Hifu procedure should remain a live option for me?
Go through with radical prostatectomy... - Prostate Cancer N...
Go through with radical prostatectomy or explore Hifu?
Have you consulted with a radiation oncologist? If not I'd do that before making any decisions. Also don't forget that an RP may not do the job and you will still need radiation and hormone therapy. I decided to have an RP knowing there was a high chance I would need additional treatment because I had serious urinary issues. The RP solved the urinary issues but I just finished 32 radiation sessions and am on ADT for 24 months.
Was your cancer metastatic? My CT scan and bone scan were both negative for metastatic disease (I do realize that it could still be metastatic despite those findings).
HIFU doesn't work. Here's the data:
prostatecancer.news/2021/03...
With EPE, the likelihood of "getting it all" with surgery is small. Be wary of surgeons who make that claim:
healthunlocked.com/prostate...
Only 35% of men who have a prostatectomy retain erectile function sufficient for intercourse. Almost all men have a decline in erectile function (and many also have size loss).I chose SBRT because about 65% of men retain function sufficient for intercourse. Thankfully, I had no ED.
It appears you have not yet done due diligence in exploring your options. You have plenty of time to decide, but only one chance to get the right therapy for you. Get some second opinions.
Depends on the surgeon. 80% of my surgeons patients retained sexual function after. 2 years.
Is he telling the truth? Statistics from US hospitals tell a very different story.
I’m going to add something here, first his age of 80 yrs of age on surgery, second, any
Cormorbidities and third , if he was 55, definitely surgery, what is it with you and your bias against surgery
Radiation may be too hard on him as well as with the position of the prostate.
You got a tumor freaking remove it, you going to melt it away, it’s absurd
The whole medical field is working, going ass backward
You obviously don't understand how radiation cures cancer (nothing melts). For many years they ONLY gave radiation to men over 70 because the side effects were so much less. Radiation is similarly curative to surgery for favorable risk PCa, but seems to work better for unfavorable risk PCa. For younger guys (I was 57 when treated), surgery can give many years of incontinence and erectile dysfunction.
You had your prostate removed?
SBRT
so you were fine, so this paper SBRT after RP. Shows toxicity may occur
So with Olgio metastatic what is the best radiation to treat APCA May I ask?
Let's not hijack the thread from the OP. But, to answer your question, SBRT had good results when used to debulk the prostate when men were originally diagnosed with oligometastatic PaCa:
prostatecancer.news/2018/09...
Thank you, agree not to HJ thread
He's lying. I know plenty of guys in their 40s and 50s that have had RPs and their stats are nowhere near that high, much less in your 80s.
Statistics from Dr. Thomas Ahlering’s patients #1255-1615
He is certainly a legend in his own mind, and is well-known in Irvine. If he had numbers like those, he would have published them in a peer-reviewed journal.
Here is what has been published:
prostatecancer.news/2016/09...
Even those who regain erectile function after surgery, seldom regain baseline function. Only 16% of those with good baseline erections, operated on at MSK, one of the world's actual best, regained baseline function:
ncbi.nlm.nih.gov/pmc/articl...
He’s well known outside Irvine. When Mitt Romney found out he had prostate cancer he went to Ahlering. He could have gone anywhere. And his results are from his patients. He team follows up with his patients every 4 months after surgery with a continence and ED survey prior to their follow up visits, also every 4 months. The data is from his patients responses.
Be wary of hot dogs who do not publish data in peer-reviewed journals.
From his website, let's see it in a medical journal for peer comparison and review.
T_A,
Remember our discussion on ablation therapy last year in which you referenced Dr. Ehdaie as being opposed to ablation therapies, HIFU being one of the ablation therapies used?
A link--again--this one doesn't have the video in which Dr. Ehdaie speaks supportively about the benefits of ablation for --certain patients. Copy all between the lines--
________________________________________________________________________________________________
High-Intensity Focused Ultrasound (HIFU) Can Control …
mskcc.org/news/high-intensi......
Jun 14, 2022 · Now a landmark clinical trial has demonstrated this less-invasive method works well for many patients. The phase 2 trial, led by MSK urologic cancer surgeon Behfar Ehdaie, …
____________________________________________________________________________________________
I agree with you, without reservation, that this member, due to the amount of cancer found, should not consider ablation of any type --as a treatment.
From Smarks42's post--
"My 3T MRI showed a strong likelihood of significant cancer with some mild extra-prostatic extension and suspected capsular invasion, all on the left side. "
Once there is a "likelihood" that cancer isn't confined within the capsule that would in my opinion, disqualify ablation.
It might be a good idea for Smarks to confer with Dr. Ehdaie! No one here has the certificate on a wall such as Dr. Ehdaie. As you, T_A. are friendly with Dr. Ehdaie perhaps you would be kind enough to put Smarks in touch with him.
Some HIFU docs will tell their patients who have biopsies showing cancers in numerous locations that the aggressive cancers will be ablated and the other less aggressive will be on an "active surveillance" type of status. As discussed in the past, the transperineal biopsy can reach areas that trans rectal can't.
The advances in imaging, ablation technology and experience of some doctors has, as Dr. Ehdaie has acknowledged, made ablation a viable treatment for --some--the appropriate patients.
In the end, it is up to each individual to select what type of treatment they will choose. I agree with you that there is just too much cancer for ablation.
Currumpaw
HIFU would be a ridiculous choice, as I said.
Ehdaie did a trial using HIFU on patients who were intermediate risk, not high risk (EPE is high risk), Even so, 60% had cancer in their prostates 2 years later.
Yet, six months ago Dr. Ehdaie promoted HIFU for the appropriate patients.
There are a few articles on the screen by respected sources reporting about Dr. Ehdaie's enthusiasm for ablation as a viable treatment for --again-- the appropriate patient.
The OP is not an appropriate patient.
That is exactly what I said in my first reply to you. An excerpt from it is below.
"I agree with you, without reservation, that this member, due to the amount of cancer found, should not consider ablation of any type --as a treatment.
From Smarks42's post--
"My 3T MRI showed a strong likelihood of significant cancer with some mild extra-prostatic extension and suspected capsular invasion, all on the left side. "
Once there is a "likelihood" that cancer isn't confined within the capsule that would in my opinion, disqualify ablation."
I would not have used the word ridiculous however, but a gentler admonishment such as "inadvisable" might be more appropriate considering the stress that cancer patients live with.
We agree that when so much cancer is found ablation isn't an option.
As you mentioned late last summer, you are somewhat friendly with Doctor Ehdaie and even speak with him at times. I think it would be wonderful if you could ask him to contribute his experience and knowledge to Malecare in some way and speak of any emerging treatments and imaging advances. You do have some enviable connections.
Currumpaw
This forum is not for doctors; it is for peers. I know many doctors.
I know a few doctors too. Sorry if I wasn't clear enough. Darryl posts some articles and videos that doctors are kind enough to make available or just plain make for Malecare and it's members. Some that Darryl has posted have been quite informative and interesting.
Currumpaw
it worked really well for us. Even with metastatic lymph nodes, relieving the tumor burden has given us 20 years with no incontinence or impotence. You’re wise to pick a surgeon with a good track record and high volume practice. Good luck
Totally agree. Who’s your surgeon?
My 2 cents worth: get second opinions from uro, RO, and medical oncologist. From what I've read, surgery is more likely to lead to incontinence and lack of sexual function than is radiation.
EdinBaltimore
I was diagnosed 8 months ago at age 73. My first inclination was “just get it out”. My urologist was certainly willing to do RP, but he said that, at my age, he wanted me to explore options with a radiation oncologist. I have a degree in statistics so I looked at many studies to see if I could mathematically pick my best path forward. I thought I could boil this decision down to a simple equation with a definitive answer. Not so. I had to add QOL to my process and look at established treatments with good data and promising new treatments with incomplete data. My decision is detailed in my profile. Look at all options available to you and make your best choice. Doctors generally guide you to protocols in their sphere of specialties, so be wary of narrow vision.
BanjoPicker said: " Doctors generally guide you to protocols in their sphere of specialties." This is true however well-intentioned your doctor is.
I chose HIFU at age 66. 6 1/2 years later I am doing fine. No problems with ED or incontinence. Talk to a HIFU surgeon. Make sure if you go this route that he is experienced. I chose full-gland ablation as opposed to focal, or partial ablation. I was a good candidate for full gland ablation as I had already had TURP (roto rooter) surgery for an enlarged prostate. You didn't mention prostate size. HIFU is unable to fully treat abnormally large prostates. A radical prostatectomy is the most invasive treatment option. I wouldn't go there, especially at your age. Incontinence is a real threat with that procedure. Read Dr Scholz "Invasion of the Prostate Snatchers" book.
There have been great advances in radiation therapy. It makes zero sense to go with surgery.
It sounds as though RP may be the best choice: get rid of the prostate, the source of the cancer. But get second opinions on other treatment. Don't listen to the know-it-alls on this site (you know who you are) who consistently recommend against RALP! Do your own research and listen to actual doctors (not would-be ones here) and make the choice best for you.
I decided on RALP in my case (Gleason 3/4). Once the prostate is removed, pathologists can determine more accurately your situation--along with intraoperative examination of the area near the excision. In my case, my Gleason became 4/3, but with no spread outside of the prostate itself.
I will say that there are side effects for RP, some of which may be permanent, others which may improve over months and even years. I experienced immediate, total impotence and minor incontinence. Both improved over time. It took over a year for my penis to be able to get some kind of erection or at least tumescence. Sexual potency wasn't an issue since I am single, so release consists of masturbation. My libido tanked at first, but now I can masturbate with some tumescence, and obtain a good orgasm.
In short: get second opinion and do more research. Best of luck to you.
Thanks Jeff, also to others here who have offered advice and support. I agree that the information provided by intra- and after-operation pathology reports in the RP could be extremely useful for later treatment, if needed. I have some “mild” EPE on left side, and if the slice of margin he takes from there comes back negative, he can complete the operation and save the nerve bundle to the left of that. But I’m now trying to get a 2nd opinion from a radiation oncologist here before I go ahead with the RP. I appreciate the guys on this thread who have nudged me to do that. I don’t have much time though; surgery scheduled in just 13 days!
That's what I did. I got a 2nd opinion from a radiation oncologist, and chose RALP after seeing her. RP does have serious side effects, tho I'm glad I chose it in the long run. Best wishes!
The fact that you are on this site asking for help with this RP decision says to me that you have reservations. Don't be rushed into a surgery that could render you incontinent. Tell them you need more time to think it over. What's the rush? Yeah, your urologist wants to fill in his dance card, to put it crudely. Be your own advocate. Don't worry about hurting his feelings. As far as 'information for later treatment' -- well there are scans for that, as well as PSA tests, to determine cancer activity or progression.
sorry you find yourself in this situation. we have all been there. not going to preach a particular modality because it is very much up to the individual. some have the mindset that they need to "cut it out"; others would never consider the surgery. age is an interesting factor in this process. just me, but at 40 i might hesitate more about getting radiation (sbrt) knowing how many years i had left and the prospect of the radiation causing more problems down the line. i think a younger guy can bounce back better from an RP and regain most of what is lost (particularly with a good surgeon). as for me, i was 55 facing the same 3+4. kind of a "tweener" in my age analysis... but, opted sbrt. my good friend and peer went RP. both in our 50s... as for my recovery, i basically jumped off the table and resumed my life. some short-term gastro issues and my private life is not a bowl of cherries, but no ED. full strength, exercising, working, acting, riding a bike, a motorcyle etc.. full life. friend was recovering for 3-6 months. then, had painful orgasms (still does) for 18 months. 2 years later got fully back into fitness etc. who knows, perhaps i was a penny wise and a pound foolish (although i doubt it); but my ability to bounce back would be something i would greatly consider if i were in my 70s or 80s. yes, it sucks to have radical surgery at a young age but the body can tolerate it better. at 70 or 80, i would lean even stronger toward radiation. definitely advise you to at least speak to an RO and consider some of the treatment options (seeds are a one and done.. _) BEST OF LUCK TO YOU!!!!!!!!!!!!
In addition to the comments already posted, I have another observation. I'm sorry, I'm no doctor, but I thought that RP isn't generally recommended for people over 70. At least I have seen this in a number of places, for what it's worth. 🦊
Just adding my voice to the chorus: don't let yourself be rushed (I'd probably cancel that surgery date, I'm sure they'd be happy to fit you back in if appropriate), and look very seriously at radiation options. I didn't notice if anyone suggested a PSMA PET scan, but that would more definitively show whether there is spread outside the prostate, which makes all the difference. In my case, with some spread to pelvic lymph nodes (confirmed by PSMA), I was initially surprised that my doctors didn't recommend surgery ("just get it out of there!", I thought). But they made the salient point that with any extra-prostatic involvement, I would need followup radiation anyway, so why endure surgery and its after-effects AND radiation and its side effects as well? Pick one or the other (and ADT, if appropriate), and hopefully be done with it.
In any case, best of luck to you brother, and please let us know how it goes!
For me, I regret not waiting for the shock of my dx to subside. I’m pretty sure my prostate would still be in operation today if I’d done the research before having the surgery. I too was told about
1. nerve sparing, 2. sexual function return and 3. bladder control would all be intact with 2 years of surgery but none were.
I say slow that roll, ask more questions and learn the disease and what’s best for you concerning the fight strategy. This forum is the best place to ask those questions
Good luck brother
You guys are great--thank you, thank you! So many thoughtful and well-informed comments, many of which offered by those with more knowledge than I. Let me share with you where I've landed, in the hope that my process may be useful to people near my age (80) and older. I still haven't heard back from the RO practice that I called for a second opinion. They have all my info. One of their 2 docs might still phone me with their opinion (no charge), but I'm temporarily stalled in their billing dept., probably because my insurance is likely out of their network, and they might not want to bother with me unless they're confident I would continue with them after the opinion. I told them I'm fine with paying for this opinion, so we'll see what they say. With so many geezers like me in Sarasota, FL, all the best docs are overworked and even when you're "in network," you can wait a long time to get in, even for a 15-minute phone conversation. If these folks turn me down, I've decided to go with my RP as scheduled on Feb 1st. Yes, I hear the chorus of voices from many of you that this decision is too important not to postpone my RP and look carefully at all my options. So here's my reasoning:
(1) I do trust my Uro--the way he thinks and the 4500 RPs behind him. I read an interview online of 3 leading Uros, all of whom agree that the skill and experience of the surgeon makes a big difference outcome-wise. With my "mild" EPE and the in-surgery pathology report of a slice of that margin, I feel confident that he will know how much (if any) of the nerve bundle he needs to cut to maximize my safety going forward.
(2) I have no evidence so far of metastatic disease. MRI and CT scans were negative; nothing seen in lymph nodes and nearby organs. Bone scan negative. Last PSA was 5, not so bad for a guy with some high-volume prostate cancer. Yes, I do hear your voices again: None of this is any guarantee that the cancer hasn't spread and that I won't need radiation in the aftermath.
(3) Aside from my addled brain, very little is physically wrong with me, and my Uro wants me to start walking at least a mile a day one week after surgery. Two weeks after that he believes I should be able to do everything I was doing before. Yes, erectile ability could take quite a bit longer, but the point here is that being 80 doesn't necessarily disqualify someone for RP. A lot depends on the health of the 80-year-old.
(3) At 80, I now think quite differently than I did even just 2 or 3 years ago. Reaching my age very often changes you. I've had a charmed life--a 57-year marriage to a wonderful woman, along with children and grandchildren that are splendid human beings, plus many achievements in my academic field that make me very proud. I don't mind leaving when it's my time to go, but my life feels like it's been on hold for 2 months already, and I don't want to wait much longer. Rolling the dice on behalf of a possible "one and done" feels very attractive to me, if it could mean less time at doctors' offices afterward.
(4) Sex is less insistent for me. The law of entropy has finally quieted my libido down. I hardly masturbate any more between episodes of intercourse, which we still enjoy together every couple of weeks or so. This is new and different; just a year or 2 ago I would have done anything to preserve my sexual intensity, but other things are more important now, such as my everyday continence, which my Uro is very confident of preserving, along with a newly revitalized strong, steady stream, which he doesn't think will take long to resurface. What a relief that would be! Talk about a change in perspective and values!
(5) Like anything else, the way we think about prostate cancer is embedded in our own development, and age is a big part of that. See the books by Louise Aronson (Elderhood) and by Atul Gawande (Being Mortal), which brilliantly document how the needs of people my age are submerged if not totally ignored in medical training, practice, and research. Surely, one of our greatest developmental challenges is coming to grips with our own mortality. Nowadays my spiritual readiness to leave this life is becoming more central to me than prolonging it.
All for now, network brothers! I will keep you posted.
Get an opinion on SBIR radiation treatment.
I agree with the comment Atdabeach - did you do a PSMA PET to confirm there is no evidence of spread outside the prostate? If so, surgery is off the table. If you had an RP and then found out mets outside the prostate ... that would be a definite bad outcome - and something that would kill my confidence in the doc who suggested the RP.
And although the 3T MRIs are great, "suspected" means not sure.
There are also some new urine liquid biopsy tests that are not too expensive - the Sentinel from mir scientific - that would indicate the aggressiveness of your cancer. Pee in a cup, send it to their lab, get their exosome genetic analysis in a couple of weeks. You probably have to push your urologist to get this, it is "brand new".
Postpone the surgery. Get second opinions. Get more diagnostics. Don't let an "artificial" deadline rush a decision you may regret. RP is a one-way therapy. So is radiation, but as many point out, it is pretty damm good these days. Find a center that offers MRI-guided SBRT and see if you qualify for that.
Let us know how it goes ....
I didn't read your post, but if you can organize it could you do SBRT of your prostate with MRI Linac? 38 Gy in 5 fractions? Some 80 years old on this site even reported that they didn't have ADT after radiation.
I would not do operation as you could become incontinence. The beauty of the SBRT is that you have to show up only 5 times for one hour and the radiation is delivered with surgical precision margin of error is only 1 mm. No side effects or toxicity. I did that way and I am happy.
SBRT could even help you with your immune system fight the cancer.
When I visited Dr. Kwon he was nice about HIFU, but he called it "pre-treatment." Meaning you'll be back. Maybe you should look at radiation.
Newly diagnosed - Gleason 4+3
Open or Robotic Prostatectomy
Post Radical Prostatectomy on 5/9/17
Prostatectomy with pre-ADT?
