ellysbelly-
Sorry I came late to this important discussion. I briefly scanned the previous posts so forgive me if I'm repeating stuff.
BTW, I'm a fellow data junkie, so the two of us will get along fine, and your Dad too when he gets over his cancer panic (it's a thing).
Decision-making timeFirst, on the time to make a decision - men who take less than 3 months fare no better than men who take more than 3 months. That's true if they eventually decide for radiation or surgery, and it's true for high-risk men:
Time from diagnosis to initiation of primary radiation therapy: does it effect outcomes?AgeI actually think men his age are undertreated. Survival with PC is so long these days that it's not necessarily true that something else will get him first. Surgery in
physiologically older men carries risks. They don't heal as well, have more SEs, and anesthesia can have lingering effects. Here's an article about
this:
Ageism in prostate cancer treatmentSurgeryAs for surgery, the surgeon with the most experience (in the world, I think) is Vipal Patel in Orlando.
Surgery in high risk men is problematic because those Gleason pattern 4s and 5s have a habit of escaping the prostate even when you can't detect the mets. Salvage radiation after surgery can be a nightmare, especially in older guys who don't have good tissue repair. Certainly if he were stage T3, surgery would be an awful idea. I'm beginning to think it's not a good idea for Gleason 8s and above. Radiation always treats a margin outside of the capsule whereas surgery stops at the capsule. Here's a recent study:
Better cancer control with radiation vs. surgery in high-risk patientsBrachyAs several have pointed out (MichaelT, Newton, JNF) the standard of care for high risk PC is a combination of IMRT, a brachy boost to the prostate, and ADT. It has proven to work better than IMRT alone (and certainly better than surgery alone) for cancer control. In Florida, he can get this done (with LDR brachy boost) by John Sylvester, who is one of the top LDR brachy guys.
I don't know any HDR brachy specialists in Florida. The two top guys in the US would be Alvaro Martinez in Detroit and Mitchell Kamrava (taking over for Jeff Demanes) at UCLA. An interesting possibility is HDR brachy as a
monotherapy for high risk patients. This offers the possibility of fewer SEs. Unlike LDR brachy, HDR can treat outside of the prostate. Here's an article:
HDRBT monotherapy in treatment of high-risk prostate cancerSBRTI should mention that SBRT (5 treatments) is now being used for high-risk men. Debra Freeman in Tampa is the top SBRT practitioner in Florida, but I don't think she offers it to high risk patients yet. One of the members here (Nomar Lupron) came out to LA from FL to have it done. Here's more info:
SBRT for high-risk prostate cancerThere is an excellent radiation oncologist in Fort Myers, Constantine Mantz. I think he's using a very precise machine called Tomotherapy, and he might recommend 25 or so treatments with that combined with an SBRT boost to the prostate:
SBRT boost radiation therapy in intermediate- and high-risk prostate cancerPhase II Trial of SBRT + or - IMRT in Treatment of Patients With Clinically Confined Prostate AdenocarcinomaIMRT, ProtonsAs for conventional IMRT - there are now several large clinical trials proving that shorter courses of radiation (hypofractionated) are equivalent in oncological control and toxicity. There is no reason to do it other than to line the pockets of ROs who charge by the treatment. And as you correctly said, there is no documented advantage to protons over IMRT (they would almost certainly mix the two for your father).
Have I overloaded you with data yet? If not, there's plenty more. Feel free to ask questions or email me.
- Allen