I have a prostatectomy which is probably 6-8 weeks in my future. My outlook is that metastasis in imminent. (T3bM0n0 and no evidence of cancer outside the gland as of May 25 PSMA PET scan, but I am told I am intermediate/unfavorable and my PSA went from 10 to 12 in only a month.) Today is August 18.
I wonder if short-term Androgen Deprivation Therapy with one of the daily-dose Androgen-Receptor Inhibitors would reduce the likelihood of metastasis and improve the (admittedly slim) odds that the cancer is confined to the gland and the prostatectomy leave me cancer-free? (I figure the daily-dose options are probably quicker-acting.)
Anyone have any clinical evidence that would help persuade my urologist or surgeon to go beyond the NCCN guidelines?
This is an intuitive speculation (and because I am a layman, not persuasive), but the lead time to surgery has me worried and the idea that slowing the cancer is possible is attractive.
Some studies have suggested this is possible, reducing the size of the prostate (mine is 33.3 cc), thus making the surgery easier and reducing the incidence of positive margins. But they merely suggest further study is needed.
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I think you may be overly pessimistic about your prognosis, but I suppose it's best to prepare for the worst (but don't forget to hope for the best)! I didn't go the surgical route, but rather radiation (proton in my case), and they had me on ADT (Eligard and abiraterone+prednisone) for 6 months before that. Someone should chime in with their experience regarding ADT in the case of prostatectomy.
Out of curiosity, did you consider options other than surgery? I ask because most of us are diagnosed (usually by biopsy) by a urologist, who is in many cases a surgeon, and may be most prone to suggest that option. If possible, I suggest finding a facility that utilizes a team approach (usually including urologist, medical oncologist, and radiation oncologist), which should present you with all options appropriate to your case, possibly with assistance from other diagnostic tools, such as MRI and PSMA PET scan. I don't know where you live, but folks on here can point you to a center of excellence near you.
In any case, good luck with your treatment, and let us know how it goes!
Thank you Atdabeach. Yes, I did not post all my results. Only the final analysis. The radiation oncologists suggested 3 months ADT, EBRT and another 3 months ADT. Radiation kind of scares me, but they said I only had about a 6 out of 7 chance the surgery would get it all. I decided to take the slim chance that prostatectomy would get all the cancer and keep radiation as an additional tool if my gamble did not pay off. I figured, "low probability, high reward" was worth it. Luckily, there is a world-class surgeon here in Anchorage (and I could go to Fred Huthinson Center, University of Washington if I wanted).
I had 4+3 in several locations found in the biopsy, so Gleason 7. Negative CT scan, negative Bone Scan and at Fred Hutch, negavit PSMA PET Scan (though negative on these are not a guarantee of no micro-metastasis nor advancement in the meantime). Genomic test suggest moderately aggressive. I am rated "intermediate high risk" .
1) You are decidedly high risk, not intermediate risk. T3b has almost no chance of staying contained. You almost certainly will need ADT+salvage radiation. The thing about salvage radiation that most urologists don't disclose is that the side effects are much worse than if you had radiation from the start.
2) The type of radiation matters too. Brachy boost therapy (external beam radiation to a wider area with a brachytherapy boost to the prostate) has the best record of success:
3) For you, high dose rate brachytherapy is preferable because it can treat your seminal vesicles, while low dose rate brachytherapy (seeds) cannot (the external beam would then be used on them).
4) If you cannot get brachytherapy, hypofractionation can be used to boost the dose to the prostate:
Yes, TallAllen, the radiation oncologist explained most of that to me, but did not suggest any form of Brachy therapy, only the pelvic-wide therapy for 28 days. I acknowledge the depth of understanding you have, too and thank you for your insights to me and the others you have helped.
I also worry about incontinence since my bladder neck may be involved. But that is the only drawback to surgery I have foreseen. Erectile function already depends on a penile implant and recently my ejaculate is gone (whether by seminal vesicle involvement or the Flomax medication , I don't know).
Whether prostatectomy makes radiation more difficult is not something I knew anything about.
I recommend Mitch Kamrava at Cedars-Sinai for HDR brachytherapy -it's a 1-day procedure. You can get the additional external beam (about 20-25 treatments) done locally.
I was diagnosed at 52 years old with a PSA of 5.0 and Gleason 3+3 and opted for a RP given my young age at diagnosis. The prostate came out cleanly—negative margins, no SVI, no ECE, no LNI, nothing—but the Gleason was upgraded to 3+4 at the pathology.
In theory, I should have been "cured" given those outcomes, but 54 months after the surgery, my PSA returned. Thankfully, it grew at such a slow rate that I had six years of monitoring before it reached 0.2 ng/mL and we opted for salvage radiation with concurrent ADT. I completed the SRT in August 2022.
I had ED and stress incontinence after the surgery. It took the better part of six months after the surgery for me to become relatively "dry" with respect to the incontinence, and about 18 months to get an erection that was about 75% on a good day. In the year since SRT has ended, my ED has worsened but the incontinence has remained about the same so far. (Although I do seem to have mildly increased urinary urgency.)
So I have to ask: If you believe you're on the edge of metastasis, and Tall Allen believes your disease won't be contained, plus my own post-surgery recurrence experience with much better numbers going into the RP than yours, I'm trying to understand why you would want to undergo the RP at your age that has little chance of stopping the disease?
You'll likely be paying a high physical cost for very little, if any, reward in my opinion. At this point in your case, my approach would be to control the spread through radiation and ADT.
But it's not my choice to make, and I wish you all the best as you move forward.
Thank you for the well-reasoned argument in favor of radiation over prostatectomy. It is very persuasive (as is Tall_Allen's, too). I know I am taking a long shot. Especially since my situation is in several facets favors metastasis much more than yours.
Was the six years of monitoring in addition to the 4 and a half years of low PSA or concurrent (10.5 years vs 6 in total)? I plan on monitoring my PSA as frequently as allowed for the rest of my life as part of my choice.
The 6 to 8 weeks delay before surgery has me concerned about metastasis, hence my post, "ADT before Surgery?".
I am choosing prostatectomy because there is a non-zero chance that it will be 100% successful and I am hopeful I may be in the 1 out of 7 men who are lucky with RP.
I evaluated the risks, hope that I am not self-deluding and also hope that better radiologic or systemic treatments will be available if (or when) my cancer resurfaces.
Thanks for the added details. For what it’s worth, when I first went to Johns Hopkins after positive biopsy (10/10 cores positive, Gleason 9), I assumed they would recommend surgery. Instead, after a PSMA PET scan that showed some pelvic lymph node involvement, the team recommended radiation. I wondered why they wouldn't get that cancer-ridden prostate out of there, and then do adjuvant radiation to get the rest. The urologist made the point (which I totally understand now, but was new to me then) "Why have surgery, with its potential side effects, and then followup radiation, with its additional side effects? Just do the radiation to handle it all." Something you might want to consider, even though you currently don't think you have anything outside the prostate. One more related thought: my older brother had a prostatectomy when he was diagnosed 15 years or so ago. They found some cancer cells on the surface of the prostate, so did salvage radiation. He now has some degree of permanent incontinence from the surgery, along with radiation proctitis. He's more at peace with all that than I would be.
Atdabeach, I recognize that it is unlikely that I have clean margins 6/7 chance that I DO have metastasis. But a 1/7 chance I don't. I am taking that slim chance. As far as side effets of prostatectomy is concerned, erectile function is a non-issue since I have an implant already. Lack of ejaculate is not thrilling for me, but that is already gone (Flomax or the cancer, I suppose). Radiation oncologists wanted to irradiate my entire pelvis, playing the odds. I am taking the long shot.
But I will be watching my PSAs closely and having the removed tissue examined closely for all the information it can yield, something not available from radiation.
Justfor_, I thought that also. In fact there are studies on the matter. All the ones I have found so far conclude that more study is needed. But I read in another support group that ADT before surgery makes the prostate hard to handle. My thought was that slowing the GROWTH of the cancer would lessen the amount of (or likelihood of) metastasis.
"Why have surgery, with its potential side effects, and then followup radiation, with its additional side effects? Just do the radiation to handle it all."
WOW,I was delighted to read that as it is the reason I opted for RT/HT but it was my own reasoning and I always wondered if I made the right decision. Thanks for posting that.
In theory, surgeons should have been in favour of ADT prior to the procedure as it shrinks the gland. But they do NOT! I asked about it and their answer was that it "renders things blurred". Sure enough the pathology report will be affected, but I don't think that this is the prime reason. There must be something that they don't like about it probably needing extra attention or labour.
Justfor_, Yes it is possible there is extra trouble for surgeons to do a prostatectomy on a patient who has had ADT. I have been told that it makes the tissues more difficult to deal with (sourced from patients). I have also read in medical journals that researchers are interested in the benefits of pre-op ADT So, I guess the jury is still out.
There is one hypothetically additional benefit for having ADT before surgery. There is fear that spillovers of cancerous cells may contaminate healthy tissue during the prostate extraction process. To minimize this, some have tried to put the gland into a plastic pocket before extracting it. An experimental "improvement" to the whole procedure but not popular by any means. I just mention it to illustrate that the spillage fear raises some concern. Back to ADT, the rationale is that the more cells killed by ADT, the lower the possibility of spillage during extraction.
In my opinion you are both too optimistic that prostatectomy will ‘get it all’ and too pessimistic that you are bound for metastasis.
I was a PSA 16, 4+3 with several saturated cores. Pathology showed SVI and a positive node. Would not have gotten the RP had sensitive scans been available to me (June 2019).
I followed it with a trial of radiation, abiraterone, 4 rounds chemo and ADT for 18 months. Been undetectable since. ADT prior to RP is an option but it’s the RP choice that concerns me in a situation like yours.
Radiation has come a long way, I wouldn’t worry about sides from it as much as I would choosing a RP that has little chance of being curative.
London441, you are right when you say, "Radiation has come a long way, I wouldn’t worry about sides from it as much as I would choosing a RP that has little chance of being curative." But I am taking the "little chance". Low probability, high reward. And there is the chance that some more improvements in targeted chemotherapies, immunotherapy or better radiation techniques in the next few years it might take for my cancer to increase and require additional treatment, Optimistic, for sure, but it is the path I have chosen.
Of course, since surgery is likely to be 6-8 weeks in the future and something may come along in the meantime ... but I doubt it.
Interesting , most folks would choose the path with better odds of success? I think you should ook at TA's blog and review some of his summaries on studies comparing RP to RT for your diagnosis!!
I personally have not done research on the subject but I do have a friend that has done extensive research and had the procedure performed with remarkable results. If I were to do it all over again, I would give Proton Beam strong consideration.
Wonder why you believe metastasis is a forgone conclusion. Do you mean cancer being outside the gland? Our bio's are very similar. Wish I new all these good folks way before this journey. With failed surgery, (perineural, bladder neck, seminal vessical invasions, positive margins and into prostate Fossa, there was no visible metastatic disease according to PSMA. Post surgery- full pelvic IMRT and 6 months adjuvant ADT and now have undectable PSA and very little incontinance. Hot flashes, fatigue, and some weight gain did come with the package. Most people here at HU significantly more educated about this than I. Best wishes to my Northern neighbor.
Metastasis is not a foregone conclusion, but 83-87% likely according to the radiation oncologists. I know I am taking long shot, but here I go. Thanks for your good wishes.
I get that you're not concerned about impotence as a side effect of RP, but I would be far more concerned about the likelihood of incontinence. As far as I know, that's a frequent "feature" of RP, though often temporary, and not as often seen with radiation.
Also, with regard to the discussion above regarding proton, I can only relate my own experience. After my care team's recommendation of radiation instead of RP for my initial treatment, I opted for proton beam therapy, mainly because it happened to be available where I was being treated (Johns Hopkins @ Sibley Hospital in D.C.). I had ADT (Eligard and abiraterone+prednisone) for 6 months before proton, out of a planned 2 years total. I had 44 treatment sessions, each with a rectal balloon (as opposed to Spaceoar or similar) because of extracapsular extension. I had 28 full-pelvic sessions, followed by 16 of "prostate boost." My proton treatment ended only 4.5 months ago, but so far I have experienced exactly zero side effects. Of course, the most important metric by far will be whether the combined treatment regimen (proton + ADT) eradicates all of the cancer, and it will be years before that result is known. While Tall Allen and others have pointed out that there are yet (as far as I know) no definitive studies comparing the efficacy of proton to other radiation protocols, one of its selling points has always been (claimed) equal success at eliminating PCa, with less side effects.
As some one who has had it, I'm in the HDR brachy camp. You sound like a good candidate. I think at your age you would find the side effects of an RP worse. (My brother had one in his early fifties and his side effects are worse than my HDR brachy at sixty six. If you do choose this route you must go to a dedicated, top notch RO with lots of experience. I can recommend Daniel Fernandez at Moffitt in Tampa. TA has a much bigger library of top docs around the country.
As a GL 9, Stage 4 PC survivor (6/2019) with a high Decipher reading.(PSA topped at 8.6 prior to surgery)...I did surgery, ADT for 18 months and salvage radiation. At this time...undetectable PSA since ADT started (Orgovyx) and still at 16 months post ADT. T came back to normal in 45 days. No issues with EDT or incontinence...beyond those most 70 year olds face. We are all unique...so no silver bullets. I tend to find Tall Allen's advice to be most current. I am now a Patient Advocate for the last 2 years at SWOG and help design Oncology Clinical Studies and putting my MPH to work. Everything I have seen supports TA's advice at this time.
I believe I am with the best urologic/oncology surgeon in my State (Alaska). I have access to University of Washington Fred Hutchinson Center and went there for the PSMA-PET scan. The Radiation Oncologists I consulted are with Alaska Cyberknife and seem very well skilled, having studied at MD Anderson and others.
I would have liked to have had my case reviewed by the Tumor Review Board at Providence Hospital but that has not happened, so I am going with my gut and the recommendation of my urologist.
All this is courtesy of the Veteran's Administration which has provided, so far, very good care to me.
JWS13, I am 74 years old. Both my parents lived past 90 and I hope to match that. I don't know how the scoring system was invented, I just know it is used by the National Comprehensive Cancer Network (NCCN) and T3bM0N0 is what I got as a grade. M0N0 means no metastasis has been confirmed outside the prostate nor in the lymph nodes. T3b means very high risk and the cancer has spread into the seminal vesicles.
As far as ECE (Extra-Capsular Extension) is concerned, I suppose the perineural invasion (PNI) detected in the in the biopsy is that.
Does a Gleason of 7 contradict with a stage 3 cancer? Why do you ask?
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