Initially I was diagnosed with Gleason 3+4 cancer on both sides of the prostate in 2015. After four years of AS and monitoring; my PSA that increased from 1.5 to 3.1. I decided to undergo TULSA ablation of 75% of my prostate in 2019. PSA after treatment increased from a low of 0.4 to 1.2 over the course of 5 years. In July 24 I had an MRI and targeted biopsy that found G6 (2nd opinion G=3+4) in the remaining prostate tissue (10 ml volume). In addition, I just had a PSMA scan that did not show "active" cancer anywhere including the prostate! Why?
So my question is do I continue AS, or seek curative treatment. I'm sick of AS and now considering either BT or SBRT and would like to know which one has the lowest side effects (especially urinary toxicity). Who is the best radiologist?
IPSS=9, Prostox= low risk
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tasseo
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I tried Tulsa Pro unsuccessfully and PSA gradually rose to 2.4. I had a relationship with Mayo Clinic so I made an appointment with Dr. Kwon in Rochester and he took a Choline scan that didn't show much but he said it looked like I had a 26cm prostate. That showed up green on his choline scan. So I guess the Tulsa Pro machine didn't work. He told me to come back when PSA got to 5. Which it did after I tried some DHEA to increase testosterone. That seemed to jog it. That was back in late 2020. So maybe wait till it rises further. 1.4 still pretty low. Especially with a negative PSMA scan, although PSMA scans really aren't designed to find PCa in the prostate. or what is left of it for you. Not sure why exactly but it has been discussed here. Probably just let PSA be your guide. Eventually I had IMRT at a different Mayo branch.
You are among many men that have been duped by the promises of the TULSA-PRO "used car salesmen." Even when the entire prostate is treated it doesn't work in many men:
I honestly don't understand why more patients don't sue. Maybe they do, and it's settled out-of-court to keep it quiet.
But the question at hand is what to do now. You don't have enough prostate volume to treat focally or stick radioactive implants into. That leaves whole gland external beam RT.
In this trial, IMRT cured almost ¾ of patients who were recurrent after HIFU, and urinary side effects were low:
I would definitely not recommend AS. With pattern 4 and a small prostate, the cancer cells don't have far to go to migrate out of the prostate. Heat-ablated prostate cancer looks and absorbs indicators differently, so it is not surprising that it doesn't show up on a PSMA PET/CT.
If you are in LA, I would recommend Amar Kishan as the top radiation oncologist.
tall_allen, I’ve looked up this ”prostate cancer news” you keep posting here—you had sent me the this earlier in a different post. It looks official, but it’s nothing but a compilation assembled by a blogger, maybe some good information, maybe not. But to name it “prostate cancer news” as though it’s some official publication is misleading.
I’m looking into Tulsa pro myself, and will be visiting the two best in the country this month for consults before I make my decision. One thing the research does show on SBRT is that erectile dysfunction increases over time after treatment because of the radiation damage to the neurovascular system surrounding the prostate gland; 25% incidence of ED after one year, after five years up to 60% ED.
I write it and compile that information. If anything is incorrect or incomplete, please let me know.
Please provide a link to the research that says "SBRT is that erectile dysfunction increases over time after treatment because of the radiation damage to the neurovascular system surrounding the prostate gland; 25% incidence of ED after one year, after five years up to 60% ED."
My memory estimate was close. Here are some studies.
National Library of Medicine, "Erectile function after stereotactic body radiotherapy for localized prostate cancer," 2017.
"Results: The median (interquartile range) follow-up was 56 (37-73) months and the response rate at 2 years was 84%. For those with functional erections at baseline, 57% and 45% retained function at 24 and 60 months, respectively. On multivariable analysis for 24-month erectile function, significant variables included higher baseline sexual HRQoL (adjusted odds ratio [aOR] 1.55 per 10 points, 95% confidence interval [CI] 1.37-1.74; P < 0.001) and older age (aOR 0.66 per 10 years, 95% CI 0.43-1.00; P = 0.05). At 60 months, baseline HRQoL and age remained associated with erectile function, along with body mass index (aOR 0.45, 95% CI 0.26-0.78; P < 0.001). The 24- and 60-month models had excellent discrimination (c-index 0.81 and 0.84, respectively). Erection rates after SBRT were not statistically different from model-predicted rates after EBRT or brachytherapy for the whole cohort and the cohort with baseline erectile function."
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This study noted below was published in 2023 analyzed 90 men with localized prostate cancer who had normal erectile function (ED) before undergoing SBRT. After a median follow-up of 6.5 years, 43% of these men developed grade 2 to 3 ED, while 57% maintained their erectile function, so the results seem a little better, maybe due to pre-existing normal erectile function, maybe due to in treatment advances, maybe due to more experienced clinical personnel.
"Urethra-Sparing Prostate Cancer Stereotactic Body Radiation Therapy: Sexual Function and Radiation Dose to the Penile Bulb, the Crura, and the Internal Pudendal Arteries From a Randomized Phase 2 Trial", 2023
"Results: After a median follow-up of 6.5 years, 43% (n = 39) of the patients developed ED+, and 57% (n = 51) remained ED-. The dose delivered to the crura was significantly higher in ED+ patients than in ED- patients (7.7 vs 3.6 Gy [P = .014] for the Dmean and 18.5 vs 7.2 Gy [P = .015] for the D2%, respectively). No statistically significant difference between ED+ and ED- patients was observed for the dose delivered to the PB and IPA. The median ED+-free survival was worse in patients receiving a crura Dmean ≥ 4.7 versus 12 versus ≤ 12 Gy (54.9% vs 68.9%, P = .015). No ED+-free survival differences were observed for doses delivered to the PB and IPA. Decline in EORTC QLQ-PR25 sexual functioning was significantly more pronounced in patients with higher doses to the crura."
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The Cleveland Clinic is currently pursuing a study to refine SBRT techniques to minimize side effects. One is the POTEN-C trial which is investigating a nerve-sparing approach to SBRT, aiming to preserve erectile function while maintaining a good cure rate.
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tall allen, I'm truly sorry you had a bad TP experience. That being said, cherry-picking "data" by anyone to support possible conscious or unconscious confirmation bias isn't helpful, and on this site may be harmful. Your eye-catching "prostate news" is cherry picked by you and you clearly have a TP axe to grind. In one of your replies to me in a different post, you said the FL doctor had done thousands of procedures which was untrue--I know because I scoured his website and watched ALL of his videos and found no claims of the sort.
Newly-diagnosed men, and others seeking more treatments, on this and other forums are searching for a treatment that will cure the cancer and not leave them impotent and incontinent. If anyone wants to understand why preserving erectile function after treatment for PC is a toss up, this video of a 3D-model of the prostate anatomy from the American Urological Association cleared it up for me--there are nerves and blood supply lines everywhere surrounding the prostate gland.
IDK how they usually do SBRT in Europe, but when it was done for me at UCLA, my crura were contoured, and I did not receive more than a nominal reflected dose (< 2Gy). As you can see in that trial you posted, 72% of men whose crura were spared, had no loss of erectile function (62% overall). Spratt with vessel-sparing reported 78% potency preservation (67% overall after 5 yrs):
I had a very good SBRT experience and retained full potency. I did not have Tulsa-Pro.
You are incorrect in assuming I "cherry-picked" any data. I made a rigorous attempt to include all the data published in reputable peer-reviewed journals on clinical trials of all focal thermal therapies. I can do this because I can continually update the data (rather than adhere to a closing date as in a Cochrane Review). If I missed any trials, please give me the link, as I strive for completeness. I have no axe to grind-- I am seeking truth. You ignore it at your peril.
PS- Which Florida doctor are you talking about? The only Florida doctor who has done thousands of prostatectomies is Vipul Patel in Orlando. He has done over 18,000!
I was on a panel with him a few years ago, in which he promised that he would only treat patients with PCa on an IRB-approved clinical trial. He has apparently reneged on that promise, lured by big bucks from making unsubstantiated promises to vulnerable patients.
I had focal laser ablation in 2018 with a un scrupulous doctor in Florida. The pca came back and I found an article of utsouthwest regarding Tulsa Pro. I went to Dallas for consultation and their recommendation was sbrt which was done late last year with minimal side effects until now. My psa is down to .58 after 3 months. The treatment I received at this hospital was done very organized to reduce my travels and avoiding unnecessary risk
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