Surgery vs EBRT

Hello Lionhawk,

Welcome to the forum. Sorry you find yourself here (nobody wants to) but glad you found us.

With a substantial Gleason 9 cancer you will want to seek some sort of treatment fairly soon but it will still be worth you time to get some second opinions before you commit. You will want to consult the most experienced surgeon you can. The experience of the surgeon make a huge difference in the outcome of surgery, especially in high risk disease. Similarly you will want to seek out very experienced radiation oncologists to discuss brachy and EBRT. It will also be a good idea to consult with a medical oncologist who specializes in prostate cancer -- a doctor who is an expert on treating prostate cancer with drugs. A man with Gleason 9 cancer shouldn't have a doctor -- he has a medical team. It's worth travelling to talk to the best. If you tell us generally where you live we can probably suggest some doctors you can talk to.

One thing to remember with your Gleason 9 cancer is that you will probably wind up treating your cancer several different ways. Combination therapies tend to get better results than any one therapy alone. Surgery plus hormone therapy gives very good results but with considerable risk of side effects. Brachytherapy plus hormone therapy plus external beam radiation is a popular combination treatment that gives similar disease control and may have fewer side effects than surgery. A very experienced IMRT (external beam) practitioner can get similar results if he is using the latest machines and techniques and, again, if he includes a course of neo-adjuvant hormone therapy to make the radiation more effective.

What these combination treatments all seem to have in common is the hormone therapy part to suppress the production and effects of testosterone which seems to help the cancer cells recover from treatment. A treatment given to a man with no testosterone during the treatment and the recovery is significantly more likely to yeild a long term remission. (Doctors seldom use the word "cure" with Gleason 9 patients.)

Once you have had your initial consultation with your medical team , especially with the medical oncologist who will usually act as the quarterback, you should get hooked up with some hormone therapy to keep the cancer bottled up while you make your decision and get everything scheduled.

Good luck. Tell us where in the country you live and keep us posted on your progress.

Lionhawk,

Welcome - sorry about the high risk diagnosis.

Long term results as measured by PSA recurrence-free survival (bRFS) are not at all similar in therapies for high risk disease in the modern era (since PSA testing). Combo therapy with brachy (HDR or LDR) and EBRT has results that far exceed RP. RP with 2-5 years of immediate hormone therapy (ADT) may be an equally effective alternative, but few surgeons offer it, as far as I know.

At Memorial Sloan Kettering, they compared the results of high risk men receiving ultra-high dose (86 Gy) EBRT to those receiving HDR brachy+EBRT combo therapy. The 5 year PSA relapse-free survival for combo therapy was 93% vs 71% for the ultra-high dose EBRT.

You can see how much adding immediate long-term ADT seems to improve the results of surgery by looking at these two studies:

Surgery at Johns Hopkins - 68% bRFS at 10 years
Surgery with 2 years of ADT - 92.5% at 5 years

Surgery affords the possibility of removing many of the pelvic lymph nodes to check for, and perhaps eliminate spread there.

Combo radiation therapy gives a very high potentially curative dose of radiation inside the prostate that even the highest possible dose of EBRT alone cannot provide. In addition, it treats the prostate bed as well, which surgery cannot. The variables of combo radiation include whether or not to treat the pelvic lymph nodes (which may not be necessary with your low PSA) and whether to start with a couple of months of ADT and possibly continue for some time afterwards (which may not be necessary if HDR brachy is used).

In terms of side effects, you are almost assured of permanent impotence from non-nerve sparing surgery, especially with adjuvant ADT, while your odds of potency preservation after the combo radiation are much better. Continence is also more of an issue with surgery. There may be some irritative urinary and rectal side effects to the combo therapy, but they typically are transient.

In terms of salvage, failed surgery would be followed by EBRT, which increases its side effects markedly. Failed combo radiation would most likely be followed by salvage brachy or cryo, also with increased side effects. There are only a few surgeons adept at salvage surgery.

I hope you are seeking treatment at a tertiary care facility. You may want to talk to your doctor about getting some ADT now to hold the cancer in check while you explore alternatives.

- Allen

Lion
If you decide on RP The surgeon makes the decision regarding sparing nerves based on what he sees or feels (with open RP) not the patient. I had gl9 also and had open RP at JH and both nerves were spared. I elected RP because I wanted it over and out. I had no complications but I'm now facing more treatment. When I asked my local Uro if he thought I had made a mistake having surgery he said no because leaving a prostate in with Gleason 9 tumors causes terrible urinary tract problems.
Best of luck.
Bob

Lionhawk, here is a link to a thread we have that's devoted to Gleason 9 cases, intended to help provide some focused support to those facing this diagnosis. I've added you to the "roster' there. Check it out, there are quite few there and most are carrying along rather well. You'll see from many of the posts what decision the individuals made and perhaps some of the stats that supported them.
www.healingwell.com/community/default.aspx?f=35&m=2863652&g=2863652#m2863652

Sadly, there is no clear cut guide to which way is better, surgery or radiation. You find many rather strongly stated opinions, many studies that can be pretty difficult to interpret (one has to look very closely at the patients in the studies, definitions, radiation treatment levels and methods, that sort of thing). Studies are always subject to biases, often hard to identify and compensate for. Surgeons like surgery and studies support it. Radiologists like radiation, and studies support it. Brachytherapists like brachytherapy and studies support it. Find out who published a study - if "Brachytherapy" magazine publishes a positive article about brachytherapy, one must weigh their objectivity. Not to belabor it, but I hope you get the point.

There are many things in your specific case to consider including your Gleason score, staging, extra factors like PNI and so on.

Have you had any imaging studies (like 3T MRI) to give a clearer look at whether it is still contained in the prostate or not? If it's not well contained, even aggressive surgery is likely to require follow up radiation.

My oncologic urologist said he would do surgery if I wanted it, but didn't think that *in my case* it would likely be curative. My 3T MRI rather clearly showed extracapsular extension and involvement of the neurovascular bundles. Along with the PNI on the biopsy report, the risk of the cancer not being contained was significant. He would have to do a wide excision without "luxury things" like nerve sparing (which I take to mean instant and permanent ED with possibly significant incontinence). He could barely make eye contact while we were reviewing all the data. He also said he would refer me to a radiologic oncologist (RO) if I wanted to explore RT. I said I did want to, and he was visibly relieved.

My RO was reasonably confident of successful treatment, though due to a nearly 40% risk of lymph node involvement we treated them too. I had IGRT by IMRT on a Varian Trilogy with RapidArc. Minimal side effects to date. Along with that I have hormone therapy that enhances the effectiveness of the radiation, and will be ongoing for 3 years. This combination has pretty good results in many studies.

For a balanced perspective on combo brachy/EBRT therapy, my RO was not in favor of adding brachytherapy to my IGRT plan. My facility has the ability to do this, but their position is that the IGRT they perform is as effective without adding the side effect risk of brachytherapy too. The biggest risk factor apparently is urinary strictures. The effectiveness of external beam radiation has changed immensely over the years, with the current highly sophisticated image-guided 3D conformal techniques providing great accuracy and control. Older studies use older methods, and may or may not be applicable to what can be done today.

There's also a rather technical aspect of RT based on something called the alpha/beta ratio of the tissue sensitivity to radiation. There are studies showing the higher dose rate possible with HDR is more effective for prostate cancer than the lower dose rate of external beam. It is a dose rate higher than can be achieved safely with external beam by any method. If prostate cancer is uniquely sensitive to high dose rate, then that would favor HDR brachy.

This discussion is controversial, and I'm going to ask about it again when I see my RO in May. It keeps coming up on this forum, and I'd like to have some more data to post here about it. I've seen post here that the only reasonable course for high risk cases is HDR brachy with IGRT and HT. This may or may not be true; I suggest you discuss it in depth with your RO. Print the studies Tall Allen quoted, and bring them to your RO for his position on them. He'll surely know of them.

Lionhawk,

As you've figured out by now there are a lot of options -- a lot of ways to skin that cat -- even for a guy with "high risk" cancer like you and me. And speaking of "skin", as a young guy you have a lot of that in the game. If you can get past this cancer thing -- and you probably can -- you will have a long time to live with the side effects.

We will, of course, support you whatever you decide but do make sure before you sign on for any treatment you have talked to as many doctors about your prostate cancer as you did car salesmen when you bought your last car.

Lion
I went to a surgeon who refused to do nerve sparing DaVinci with my gl9 so I went to Johns Hopkins who did it. A good surgeon will at least try it and that's why I had open RP so he could feel the nerves which DaVinci does not allow.
Bob