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Posted 12/14/2009 2:45 PM (GMT -5)

 

I have spent countless hours researching statics and probabilities between the two options for my father.  I understand the less evasive benefits of Brachy but I do have some concerns over long-term success (chem. Reoccurrence) as it seems to be a higher chance then for prostectemy.  My dad is 57 psa 5.9 and gleason 3+4. I also am concerned that although this is what his biopsy showed that in the end the pathology could be upgraded making the surgical option the better way to go. .  I am looking for any insight into how many of you reached your decisions for treatment--- either way..... If this debate has already been exhausted could someone direct me to the post I would greatly appreciate it …..Thanks

Posted 12/14/2009 2:56 PM (GMT -5)
Because I had a G9, Brachy wasn't available to me, so I can't speak to the Brachy side.

My choice was between IGRT and surgery. I just didn't think I could live for the next 10 to 20 years not knowing what was there in the first place. At least now I know what I had, and what to expect, and therefore how to plan.

You could have further testing and have a better idea, but until they pull that little sucker out and lay him on the lab table, you just won't know.

On the other hand, I don't have any better odds of non-reccurence than if I had IGRT.

Goodlife
Posted 12/14/2009 3:02 PM (GMT -5)
Fully understand your situation. What to do and which method, the biggest problem for all PCa patients. This is one of those decisions that only you or actually your father can make. For all the reasons to go one direction or the other, there is no one method better than another in the broad scheme of things.

I chose surgery, because my doctors indicated that I was a good candidate based on my age. My wife wanted it "out" and then there was the pathology report that would come with surgery (for my own personal comfort), so that was reason at the time to think that surgery was the best route for me. Looking back...not so sure anymore. Am I second guessing...a little. The side effects from the surgery seem to bother me more now than I thought it would at the time. And based on what I have learned since my surgery, I might have gone a different direction. But what is done is done and I will move forward.

Best of luck in your decision process.
Posted 12/14/2009 3:11 PM (GMT -5)

The other challenge that I find is that no matter how many opinions you get the surgeons want to have surgery and the radiologist want to treat.  My initial thought was as long as you have a prostate you have cancer- So remove it. But as time goes by and I put myself in his shoes I really struggle to reach a decision...

Posted 12/14/2009 3:21 PM (GMT -5)
I was a candidate for any/all treatments based on my biopsy stats, general good health, and physical condition. I narrowed to Brachytherapy or Robotic prostatectomy. I consulted a B-Therapist, two surgeons in addition to my own uro-surgeon, and finally, a medical oncologist specializing in PC. He told me that both treatments had the same rate of success, and then went on to my reasoning for leaning towards surgery. In the end, I wanted to look forward to a possible/eventual return (no guarantees)of erectile function rather than wait for a possible/eventual failing (again, no guarantees) of erectile function, as well as being more comfortable knowing the prostate had been removed. The oncologist validated my decision process, but did not try to persuade or dissuade me. So do the research, ask endless questions of medical practitioners and lean on the forum here for input.

Good luck on the journey,

Arnie in DE

Posted 12/14/2009 4:18 PM (GMT -5)
Steve,

When I was dx. with PC, originally I wanted to be "Seeded". But I too was a Gleason 7 (4+3) with a PSA above 12 and climbing. I was advised not only by surgeons to have surgery, but by the opinions of 3 radiation oncologists as well to have surgery. You are right , if through pathology after surgery you find out he was upgraded in Gleason, I think it would make your choice of surgery seem correct without a doubt.

David in SC
Posted 12/14/2009 4:46 PM (GMT -5)
Several months ago I was exactly where you and your father are now. At the time (October?), there was a long string of posts on this forum entitled "sitting on the fence" that addressed exactly what you are asking now.....how do you decide on surgery vs. BT? You may have to go through a number of pages to find it but I strongly recommend that you do.

I was initally leaning toward a radical surgery. After talking to my urologist, a second urologist, my radiologist and reading the actual experiences of the guys on this site (and particulary that string), I changed my mind and opted for BT (performed last Friday) to be followed by 25 treatments of IGRT in two months. While there are risks with any option you choose, I came to believe from reading the accounts on this site (and talking to others in person) that there were fewer "quality of life" issues with BT/Radiation than with either radical or robotic surgery. I can't prove that and may be wrong....but that's what I felt. That factored heavily into my decision and I am very comfortable with my choice.

That said, I totally understand the mindset of those who "just want it out"...had some of those same feelings myself in the begining. I have learned that a case of PC is almost like a snowflake....they are all different based on the individual's stats, age, physical condition, frame of mind, etc.etc.etc. There is probably no "exactly right" answer. You are doing the right thing by learning as much as you can, educating your dad and then going with  the option open to him that he is most comfortable with.

Best wishes on your journey....you will find a lot of support and information on this site.

________________

Age - 67 PSA - 4.5 Gleason 3+3 = 6  Ct and Bone scans - negative

BT performed on 12/11/09 - 84 seeds of Palladium 103  To be followed by 25 treatments of IGRT in February.

 No unexpected issues from the BT so far. All after-effects just as docs alerted me to expect (and members of this forum have reported).  

Posted 12/14/2009 4:52 PM (GMT -5)

Steve:

This subject never really gets exhausted on this forum as there are clearly (at least) two side to the story and we never seem to tire of debating it.

There was a recent thread, which I have shown below, where this got a fair amount of discussion.  The comments got a little chippy at times, but please ignore that and just look at some of the content that may help in your dad's decision making. 

Good luck,

Tudpock

 https://www.healingwell.com/community/default.aspx?f=35&p=2&m=1663949 

Posted 12/14/2009 6:44 PM (GMT -5)
Steve,

I find myself struggling with the same decision as my initial thoughts were surgery or seeds. My stats make all treatments available, but there are several factors leading me towards surgery: the desire to have the cancer out of me, my age and the options available should surgery fail. I do have a strong feeling that the cancer has to go so that means removal. I'm younger and my prime thought is surviving a loooooong time. I think I could either with surgery or seeds, but the thought of potentially removing a treatment option (salavage radiation) worries me since I'll still be young if surgery doesn't work.
Posted 12/14/2009 6:49 PM (GMT -5)
Steve,
I will give you a completely biased view of Brachytherapy. This bias was not easily reached as it entailed hundreds of hours of research, talking to surgery and Brachy patients and reading hundreds of posts on forums like this. This bias was reinforced by my own experience.

The following studies regarding cure rates are peer reviewed.
Prostate Cancer Foundation of Chicago, 2009: 9137 patients, 11 year follow up: Low risk 96%; intermediate 84%, High 75%
Cleveland Clinic; 11 years; low 96% intermediate 84% high 71%
MSK, 1829 patients, 5 years; "Reoccurrance rates are similar with surgery, Brachytherapy and External Beam"
Journal Of Urology, 173, 2005 12 years, 1449 patients. 89% low, 78% intermediate, 63% high; overall 93% disease free survival.
Seattle Prostate Institute; 10 years: metastic free survival 97%; local control 97%
Prostate Cancer Study Group, 2009: Brachytherapy or Brachy with IMRT. Biochemical Free after 10 years higher than all other treatment forms.
ICER. Dec 2008; "Brachytherapy is the most cost effective method of treating prostate cancer"
At worse Brachytherapy has similar cure rates as surgery at all risk levels and data indicates it is slightly better than surgery.
Tud's post will point out the differences in side affects, but here are a few things to consider:
Brachy incontinence rate is about 1%; Surgery has severe incontinence at 2 years of 10% and the chance of being leak free at 2 years is only 28%. You will be incontinent for at least a few months in the best of situations.
I arrived for my seed implant at 9am and by 12 I was having lunch in a resturant and played golf the next day. Try that after surgery. You won't even be off the table by then and will have to spend at least 2 to 4 days in the hospital and have a several week recovery.
I have no side affects, never had ED or any incontinence from day 1 and never had to fool around with a catheter.
Yes, I'm biased, how could I not be.
JohnT
Posted 12/14/2009 7:18 PM (GMT -5)
Just to balance out the Brachy discussions, it is not a guaranteed cure either. Here is a copy of
Hopeful in MD's signature which tells his story.

Age 70.
Dx Dec 07. PSA 8.4. DRE confirmed tumor. Three of six positive. Gleason: 6 (3+3). Seeds Iodine 125 Jan 08. PSA's 3.9, 1.7. Rising PSA's: 2.3, 3.4, 3.9, indicating seeds not working. April 09 began HT with Lupron 30 MG ea. 4 mos. Side effects hot flashes, severe fatigue until mid-July. Jun 09 - Onco DRE negative for nodules - hooray!!! Aug 09 - PSA 0.5!!! Lupron working! Aug. 21 - 2nd Lupron shot. Aug. 31 - hyperbaric oxygen for rectal bleeding (radiation proctitis). 40 sessions as of Nov. 9. Nov. 5 sigmoid exam - gastro "oxygen not working." Hyperbaric doc "they are" confirmed by Nov pics compared to Sep. Will continue treatments up to 60, the max nr for one course of treatments.
ful in MD's signature

Most of our Brachy posts on this site are successful ones, but, if the PC has escaped the capsule beyond the reach of the radiation, it also can fail.

Goodlife
Posted 12/14/2009 7:20 PM (GMT -5)
To JohnT and Tudpock:

Both you guys have a good record with your Seeding Experience, and I love it when one or usually both of you give a positive counterpoint to your method of treatment. Tud, that posting you have repeated several times for the new men asking is always an excellent source I think. Looks like we have picked up a couple more men chosing your path recently, that is good to see.

Sitting here after a failed "good surgery" and having just gone through that painful (for me) salvage radiation for 2 months, and still sitting here 13 months later with a catheter in place, makes me wonder about how great surgery turned out for me, lol, laughing at myself.

Not really second guessing, but one never knows how things are going to turn out for them.

I am glad you guys that broke the mold and went for "seeding" are doing so well.

David in SC
Posted 12/14/2009 8:24 PM (GMT -5)
Goodlife,

It is a bit unfair and untrue to suggest that you need to balance JT's or my brachytherapy posts by pointing out that brachytherapy is "...not a guaranteed cure...".  Neither John nor I have EVER even come close to suggesting that.  What I believe we both have done is try to provide some perspective on an option that we think men should consider.  What both of us have pointed out is that brachytherapy is a well researched treatment whose cure rate is equal to surgery and whose side effects are considerably less onerous.  Feel free to dispute that if you can but do not mischaracterize our posts.

And, as I have freely admitted, I am an advocate for this treatment for most of the same reasons JT described.

Tudpock

P.S.  David, after all you have gone through, I can understand why you might "wonder" about your decisions.  But, based on everything you knew at the time, I'm sure your decision was fine...you just happened to be so very unlucky with your results...

Posted 12/14/2009 9:04 PM (GMT -5)
Tud,

That certainly wasn't directed at either of you personally. 

But in all fairness, you and John are the Brachy poster boys here, and thank God, you are both doing well.  (Hopefully Joey will stay around for another voice ).  We have hundreds of surgery guys here, and along with that a fair number of guys needing radiation followup.

If someone were to take a snapshot of the HW posts today, he/she could be led to believe that we surgery guys are certainly experiencing more problems than the Brachy guys.  I'm not even saying that is untrue, but, we do need to keep before us that neither approach is perfected yet, in spite of the seeding institute's arrangement of fancy graphs.

Higher risk PC's like mine are not eliglible for Brachy in many radiologists practices.  Therefore surgeons and/or IGRT have to take us and all the potential for bad stats that go along with it.

Goodlife

Posted 12/14/2009 9:50 PM (GMT -5)
I have to jump in here,
What both Tud and I have posted are the NORMAL and EXCEPTED cure rates and side affects for Brachytherapy. It is unfair to pick out one individual who has experienced severe problem with Brachy just as it would be to pick out a person who has had severe complications from surgery or external beam. Yes, these do exist in all treatments, and no treatment is 100% effective, but we must be careful and present the norm not the exception. Any individual may do better or worse than the norm; I definately think I'm on the better side.
Data also shows that Brachy and or Brachy with IMRT is very effective on high risk PC, so I don't know where the idea that it is not good for high risk patients came from.
JT
Posted 12/15/2009 1:53 PM (GMT -5)

John,

I am not sure we can say if the Brachy didn't work, that they are severe side effects.  Obviously, the PC was already ouside the capsule.  That is the read I get from reading that signature, nothing else.

That was my whole point, and not to make any negative statement about Brachy.

In my case, my radiologist stated I did not qualify for Brachy.  I believe David in SC states the same.  Could we have have found a second or third opinion and found someone to do it?  most likely.  But what I am saying is, that many radiologists have that opinion, that aggressive PC's are not Brachy candidates.  I also realize that Brachy with IMRT is becoming more popular.  The ball game changes in this world fairly rapidly these days.

Again, my whole goal is to keep all the facts in front of us.  Like I said, some of the new guys may or may not have seen all the cards on the table as they make their decision.  I attempt to inject no bias into what I say, but I guess when my signature is read, an assumption is made I am saying cut, cut, cut.

Goodlife

Posted 12/15/2009 4:09 PM (GMT -5)
Goodlife, you are most accurate. I went to my previous Oncologist after I was dx with PC. My own mind was made up about seeding, they do a lot of here locally, and I thought it would be that simple. Due to my rapid PSA velocity pre-surgery and my actual final PSA, the oncologist believed that surgery would be a better first pass treatment. Two other rad. oncologists agreed at the time, as well as the Uro/Surgeon that I ended up hooking up with. Could I have forced the seeding as my treatment? Not sure, never thought about that before, I had a total of 4 professionals telling me to have surgery, so it seemed logical to follow their advice.

This is why I have a fond interest here in following good seed ventures like John and Tud's. Perhaps a little jealous.
Posted 12/15/2009 4:16 PM (GMT -5)
Goodlife,
I'll never question your intentions as I think they are honest and noble. What I do question is that there are a lot of myths floating around and most come from educated doctors. No wonder patients are confused and getting misled.
A couple of Myths:
1. Brachy is not good for high risk patients. Not true, it has a cure rate better or equal to surgery especially if the tumor and prostate is small. It does not work well alone on large prostates and large tumor volume PC, but can be combined with IMRT for a very effective cure of high risk PC, expeciall where there is a question of margins.
2. There is no salvage treatment after radiation, but if I have surgery I can have radiation. There are several very god salvage techniques for failed Brachytherapy, 1. you can be reseeded with a different isotope. 2. you can have HRD Brachy. 3. you can have cryosurgery. 4 You can have HIFU and 5. you can have surgery, but know it is very difficult and will result in complications. Positive outcomes from salvage after radiation is 30%; exactly what salvage RT after surgery is.
3. If I have surgery then I will know my pathology and if my Gleason is higher. OK so what, most positive margins don't result in a reoccurrance so you are in the same boat, you wait for a psa rise.
The surgery may discover seminal vescile invasion and or progresson into an organ. Then it's too late. A color doppler before hand will spot most invasions. It's nice to have pathology, but you can get 80% there without having an massive invasive procedure to discover it. It's always better to know stuff like seminal vesicile invasion and extra capsular extension BEFORE you do anything not after.
sorry to vent.
JT
Posted 12/15/2009 5:02 PM (GMT -5)
John,

Vent on. (just kidding)

I really hope you realize how good I and many men feel here that Brachy is a positive treatment with excellent results, and particularly that it is working for you.

I also hope you realize that when we (us surgery guys) explain why we chose surgery, or were strongly encouraged to have surgery, it is in no way an affront to Brachy, or any other option. I have heard some fairly confrontational statements from the Brachy side that stops just short of calling the surgery guys ignorant and stupid for electing to have an option that causes pain, incntinence, and ED, and generally I let them slide. I also know that you guys are still a little early in the side effect cycle to know what the final outcome will be, but again, I hope and pray that you guys will have no side effects.

All that being said, all of the guys on this site need to just give facts on why we did what we did, and by the way, reading your post again today on your 10 year journey is enough to make any one want to vent. It is when we start implying that someone's choice was ill thought out, or just plain wrong, we probably lose our effectiveness in helping each other. Not saying you did this, but some posters on this side come very very close.

These are such hard choices. Sometimes our choices are illogical. Sometimes based on faulty information, but once made, they are pretty final.

Thanks again John for your important contributions to this site. I just continue to try to assist guys such as this thread to make good decisions, and when I think I see a one sided discussion, i jump in.

My best to all the guys here .

Goodlife
Posted 12/15/2009 5:10 PM (GMT -5)

Goodlife, I will certainly take you at your word about the direction of your post.  What I understood, and perhaps I was mistaken, was a suggestion that John and I were touting brachytherapy as a treatment that offered "guaranteed cure", which neither of us have ever done.  What I think both of us have continued to do is provide some understanding about this option, the fact that the cure rate matches surgery and that the side effects tend to be considerably less severe than surgery.  I think John has also done an excellent job in debunking many of the myths about surgery and brachytherapy that tend to be espoused by uro-surgeons and oft repeated on this forum by surgery patients. 

In fact, during my decision making process, I was encouraged by more than one very reputable surgeon to choose surgery with a strong implication that, if it failed, radiation would be a curative back up.  As I have sinced learned via this forum, the "curative back up" only cures at a 30% rate and that is no better than post-brachytherapy options. 

Your point is well taken that both John and I are early in the post-treatment process, though I am now a year out.  However, in some respects, our personal success with this treatment is irrelevant.  The point is not what we personally experience, the point is what generally and usually happens with patients who choose this path.  Hopefully I have been clear about that...

Tudpock

Posted 12/15/2009 5:48 PM (GMT -5)
Tud, I knew all along about the 30% salvage radiation card after my surgery, but I never in a million years expected my surgery to fail in 6 months. I dumbly thought that I might have 5-15 years before any chance of reaccurance. But boy, was I ever wrong. Now I am hoping I can be in that 30% group, but with my velocity issues, I don't think I am really fooling myself.
Posted 12/15/2009 6:22 PM (GMT -5)
Goodlife,
I have no problems with anyone choosing surgery; it is a good option for a lot of men for a lot of reasons. What I do mind is someone choosing surgery based on mis information or for borderline cases not going the extra step to get a more accurate staging before making a decision.
The psychological issue of "just getting it out " is a very compelling one; the long term studies especially in the case of younger patients is also compelling. The reasons for wanting a 2nd chance with radiation or needing the pathology are not very good reasons in my opinion, yet are constantly given as the main reason for choosing surgery.
JT
Posted 12/15/2009 7:20 PM (GMT -5)

David, I hope and pray that you are in the 30%, my friend.  After all that you have been thru with this horrible disease, you deserve it!!!

Tud

Posted 12/15/2009 8:19 PM (GMT -5)
John and Tud,

I really do understand you guys. And again, I am really pleased with your results. We have no disagreements between us.

I am as pleased with my surgery as you are with your Brachy. In hindsight, after seeing my pathology, probably Brachy with IMRT would have worked as well as surgery. And surgery would have worked for you guys, but you guys have the advantage of no side effects. Once I get through the ED, I will also be able to say that.

I hereby solemnly promise to not throw rocks at the Brachy Boys, if you guys do the same. I am here for one purpose, to help guys through this jungle.

So, lets go out and help em !

Goodlife
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