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Surgery or Radiation for G9-10?

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Posted 1/1/2019 10:22 AM (GMT -5)
I did not read the entire study but this might be of interest to newly diagnosed HIGH RISK MEN...

https://www.practiceupdate.com/c/76283/3/3/?elsca1=emc_enews_top-10&elsca2=email&elsca3=practiceupdate_uro&elsca4=urology&elsca5=newsletter&rid=mjg4mtq1njk3mdy0s0&lid=10332481


Somebody said...
Meaning It is plausible that treatment with MaxRP or MaxRT for men with Gleason score 9-10 prostate cancer provides equivalent survival outcomes.

Of course the question that many will ask, remains, “if I will likely need SRT/SRT anyway, why go through surgery?”
Posted 1/1/2019 10:28 AM (GMT -5)
I've learned a new term... "MaxRP", or what I've always called the "true" triple play (RP+HT+RT).

OTOH what guys on this board call triple play is MaxRT, or HT plus two forms of radiation.
Posted 1/2/2019 3:24 AM (GMT -5)
It's certainly interesting because the older research showed that Brachy Boost therapy had superior outcomes than all the other therapies for G9-G10 men. This research seems to contradict that by saying at surgery followed by radiation (when necessary) had similar survival outcomes. As a result, it isn't clear anymore that surgery is a poorer choice than radiation for high risk men.
Posted 1/2/2019 7:25 AM (GMT -5)
Choice of treatment is partly about ultimate effectiveness, and partly about the side effect profile. If different plans have similar outcomes (and be cautious about the inherent biases in every study), then the side effects could help guide one's choice. Most of us with these high risk cases seem to care mainly about effectiveness, and will generally accept a pretty heavy side effect profile.

Surgery and radiation have different constellations of side effects, with surgery+radiation being a hybrid of both. It's hard to know up front what kind of side effects you can live with. In my case, the surgeon said it would require a "wide excision", without possibility of "luxuries" such as nerve-sparing (one reason I ended up choosing RT+HT). When they talk about things like being continent, ask what they mean by that. Not leaking more than one pad per day is considered continent, for instance. The rate of ED is not well reported to surgeons either, so those stats tend to be "under called" too (according to some side-effect studies).

As we often note, everyone thinks their specialty is the best answer. Surgeons like surgery, radiation therapists like radiation therapy. That's not surprising, of course. Just something to keep in mind. Studies follow this trend too (There is an old expression, "He who pays the piper calls the tune."). When you see a study praising brachytherapy, check to see who did the study. Same with surgery.

Make no mistake, these doctors are in competition as service providers. I'm not implying anything nefarious, they do believe in what they do, so biases are simply inherent.
Posted 1/2/2019 8:55 AM (GMT -5)
My urologist/surgeon makes it very simple. Unless surgery has a very high probability of cure then it shouldn’t be used due to the more significant negative side effects inherent with surgery.

The monograms showed that I was 99% probability the cancer was outside the capsule thus greatly reducing the probability of a surgical cure. My uro and two other surgeons agreed that no surgery was best because they all talked of using adjuvant radiation which we wanted to avoid. I used HDRBT and IMRT as primary treatment.

I can’t fathom any way that surgery plus radiation would be any more effective for cancer control, but am positive would have left me with worse negative treatment side effects than I have experienced.
Posted 1/2/2019 10:34 AM (GMT -5)
This larger study with more recent treatments shows a clear superiority of EBRT + BBT over surgery.

https://jamanetwork.com/journals/jama/fullarticle/2673969
Posted 1/2/2019 10:34 AM (GMT -5)

Redwing57 said...
Most of us with these high risk cases seem to care mainly about effectiveness, and will generally accept a pretty heavy side effect profile... It's hard to know up front what kind of side effects you can live with. In my case, the surgeon said it would require a "wide excision", without possibility of "luxuries" such as nerve-sparing...


My MRI indicated that my PCa was contained but close to capsule wall. I knew the risks going in, but hoped the RP would get it all. My wife and I both emphasized the importance of cure over nerve sparing. Consequently when the surgeon found extensive local invasion he use a broad cut ("wide excision") and "removed a lot of tissue" in his words.

So I was told soon thereafter that adjuvant RT was highly recommended. That caused its own bundle of SE's to cope with. If an MRI could be so far off in diagnosing the extent of cancer involvement, I cannot imagine the fallout in the form of future BR if I had chosen primary RT based solely on external scans.

My current urologist (#4) who was not involved in the surgery said that high risk guys who had RP+HT+RT have the lowest rate of recurrence. I'm certainly hoping so. But of course, as has been noted, one must consider the source.
Posted 1/2/2019 11:34 AM (GMT -5)

RobLee said...


.......My current urologist (#4) who was not involved in the surgery said that high risk guys who had RP+HT+RT have the lowest rate of recurrence. I'm certainly hoping so. But of course, as has been noted, one must consider the source.

No kidding!

You pays your money, you takes your chances with PCa, and there's no guarantee you'll get the results you hope for. Not withstanding the multitude of nuanced and contradictory studies; physicians motivated by greed, ego, poorly documented results and little time or desire to stay current, and patients either with halo (I'm so smart) stories of their individual results, or disappointment (regrets???) about same.

While most PCa is slow moving, having it still sucks. Caveat Emptor, new guys!
Posted 1/2/2019 12:37 PM (GMT -5)
As I wrote, a year ago, to a brother, "A smart guy like you should realize by now the entire urology field is an exercise in uncertainty. The are no absolute answers!!"
Posted 1/2/2019 1:06 PM (GMT -5)

Pratoman said...
I did not read the entire study but this might be of interest to newly diagnosed HIGH RISK MEN...

https://www.practiceupdate.com/c/76283/3/3/?elsca1=emc_enews_top-10&elsca2=email&elsca3=practiceupdate_uro&elsca4=urology&elsca5=newsletter&rid=mjg4mtq1njk3mdy0s0&lid=10332481


Somebody said...
Meaning It is plausible that treatment with MaxRP or MaxRT for men with Gleason score 9-10 prostate cancer provides equivalent survival outcomes.

Of course the question that many will ask, remains, “if I will likely need SRT/SRT anyway, why go through surgery?”

..............................................................................................................................................................................................................................................................................................................................................................................

Another question I have asked myself from almost the moment I had surgery(maybe even before I made my choice)- if my odds of survival are at least equal with RT, why did I choose the treatment with the maximum and most immediate likely SEs? When I got my post op path with positive margin and +SV, I wondered why I had made that decision even more. I certainly can't complain about the out come so far(except for SEs), but I have often wondered what I was thinking. The fact is: considering the emotions happening once one gets the diagnosis, especially with a G9, it is just hard to think straight. Or, it was with me.
Posted 1/2/2019 1:46 PM (GMT -5)
The very legitimate question that always arises in these discussions is why do surgery if you’re pretty sure you’ll need SRT? Why not just do RT as primary tx? I agree with that very much. But, in my case I had big problems with urine flow prior to treatment. My RO indicated primary RT could make things even worse. I concluded the wide surgical cut would be worth the ED if I could pee again, and hopefully be cured.

Well, my flow improved for sure but I still have to pee frequently, including several times during sleep. Which has been disappointing because I thought it would turn out better.

Point is, primary RT isn’t always a given, and there can be reasons for the RP/RT route. But, the idea of choosing an RP because you can save the RT for later is usually BS, and poor advice in my view.
Posted 1/2/2019 3:07 PM (GMT -5)
Mattamx, you make a good point that those of us who chose radiation typically omit. That is that there are reasons, other than cure, ED and incontinence that may dictate treatment choice. Indeed, existing urinary problems with various causes may be exacerbated by some types of radiation. That's why it's important to look at all options and understand all reasonable possibilities when deciding on a treatment. What continues to make me crazy are the guys who continue to show up here and make decisions w/o reviewing their options and the consequences....

Jim
Posted 1/2/2019 3:44 PM (GMT -5)

mattamx said...
The very legitimate question that always arises in these discussions is why do surgery if you’re pretty sure you’ll need SRT? Why not just do RT as primary tx? I agree with that very much. But, in my case I had big problems with urine flow prior to treatment. My RO indicated primary RT could make things even worse. I concluded the wide surgical cut would be worth the ED if I could pee again, and hopefully be cured.

Well, my flow improved for sure but I still have to pee frequently, including several times during sleep. Which has been disappointing because I thought it would turn out better.

Point is, primary RT isn’t always a given, and there can be reasons for the RP/RT route. But, the idea of choosing an RP because you can save the RT for later is usually BS, and poor advice in my view.

That certainly seems a good rational for your choice for surgery, and there are no doubt others. I had mine at the time, even if I do often wonder what was I thinking. But I'm sorry to hear about your frequent bathroom trips. On an over all basis, I certainly would choose different if I had it all to do over again and knew what I know now(but who really does?) Even if I had gotten my hoped for "cure" - if I had been contained- couldn't RT have given me the same odds with better odds of taking care of anything that might have escaped? Of course, and most likely without the cursed SEs, or at least better and later.

However, if there has been one positive an wonderful thing about this otherwise life altering procedure, it has been the end of the prostatitis and BPH miseries. I have suffered with on and off prostatitis since age 30, and my prostate was 106 gms. I was routinely up every couple of hours to pee, but never really able to empty that dammed up bladder. But since the day the catheter came out, even though I woke up 110 years old in the sexual department, in the urination department I am 16. (not counting some minor spasms requiring a lightning fast Kegel a couple of times a day, not a very big deal) There are times when I am in the bed 8 straight hours without ever waking up to pee. Sometimes when I leave the house and I am gone 3 or 4 hours, or on a long car trip, when I get back home I pee but sometimes I don't even really have to go, I just go because it seems like I ought to. I don't mean to be bragging, but got to brag about something. But I'd trade all of that if I could be back the way I was before surgery, even with the troublesome prostate issues, if I could also dodge the G9 PC problem. which, with RT, I probably could. But I can hold it for hours and then pee like a racehorse. So there was some good that RT probably could not have accomplished.
Posted 1/2/2019 4:41 PM (GMT -5)
"Of course the question that many will ask, remains, “if I will likely need SRT/SRT anyway, why go through surgery?”"

best answer I can think of is if you want to maximize your chances of permanent side effects. you can call that MaxSE
Posted 1/2/2019 4:56 PM (GMT -5)
Myself and many others chose RP first because NOT EVERYBODY ends up incontinent and NOT EVERYBODY ends up with ED and NOT EVERYBODY will need SRT. There was a good likelihood that RP would be successful and a good reason to believe that there would be little in the way of long term side effects.
Posted 1/2/2019 5:01 PM (GMT -5)

RobLee said...
Myself and many others chose RP first because NOT EVERYBODY ends up incontinent and NOT EVERYBODY ends up with ED and NOT EVERYBODY will need SRT. There was a good likelihood that RP would be successful and a good reason to believe that there would be little in the way of long term side effects.

so you think most g9-10 won't need follow up treatrment?
Posted 1/2/2019 5:03 PM (GMT -5)
Given I had no reasonable choice, other than surgery, given my history with ulcerative colitis, the primary treatment choice was easy. In addition I wasn't keen on not knowing the precise pathology of my cancer, and waiting a lifetime for other radiation effects.

Concerns about what even the best aimed rads would do to my rectum and colon were well founded, as I've discovered after SRT. My radiation proctitis/colitis is MUCH worse than any of the side effects from surgery, which, for me, were very mild.

Once we have prostate cancer, side effects, recurrences, and 'new normal's' are a way of life. IMHO, the best we can hope for is lifetime remission, and to die in our sleep. There are no silver bullets.

This is what the Mayo Clinic says about potential radiation side effects.

<<<The type and severity of side effects you have with external beam radiation for prostate cancer may depend on the dose and on the amount of healthy tissue that's exposed to the radiation. Most side effects are temporary, can be controlled and generally improve over time once treatment has ended.

Newer technologies, such as intensity-modulated radiation therapy (IMRT) or proton beam, deliver the highest dose of radiation to the target while sparing surrounding healthy tissue. This helps minimize side effects of external beam radiation treatment.

Potential side effects of external beam radiation therapy for prostate cancer may include:

Frequent urination
Difficult or painful urination
Blood in the urine
Urinary leakage
Abdominal cramping
Diarrhea
Painful bowel movements
Rectal bleeding
Rectal leaking
Fatigue
Sexual dysfunction, including diminished erectile function or decrease in the volume of semen
Skin reactions (similar to a sunburn)
Secondary cancers in the region of the radiation
Dementia
Cardiovascular problems

Most of the side effects are mild and tolerable. Some side effects may develop months to years later. Serious late side effects are uncommon. Ask your doctor about potential side effects, both short- and long-term, that may occur during and after your treatment.>>>
Posted 1/2/2019 5:08 PM (GMT -5)

garyi said...
Given I had no reasonable choice, other than surgery, given my history with ulcerative colitis, the primary treatment choice was easy. In addition I wasn't keen on not knowing the precise pathology of my cancer, and waiting a lifetime for other radiation effects.

Concerns about what even the best aimed rads would do to my rectum and colon were well founded, as I've discovered after SRT. My radiation proctitis/colitis is MUCH worse than any of the side effects from surgery, which, for me, were very mild.

Once we have prostate cancer, side effects, recurrences, and 'new normal's' are a way of life. IMHO, the best we can hope for is lifetime remission, and to die in our sleep. There are no silver bullets.

This is what the Mayo Clinic says about potential radiation side effects.

<<<The type and severity of side effects you have with external beam radiation for prostate cancer may depend on the dose and on the amount of healthy tissue that's exposed to the radiation. Most side effects are temporary, can be controlled and generally improve over time once treatment has ended.

Newer technologies, such as intensity-modulated radiation therapy (IMRT) or proton beam, deliver the highest dose of radiation to the target while sparing surrounding healthy tissue. This helps minimize side effects of external beam radiation treatment.

Potential side effects of external beam radiation therapy for prostate cancer may include:

Frequent urination
Difficult or painful urination
Blood in the urine
Urinary leakage
Abdominal cramping
Diarrhea
Painful bowel movements
Rectal bleeding
Rectal leaking
Fatigue
Sexual dysfunction, including diminished erectile function or decrease in the volume of semen
Skin reactions (similar to a sunburn)
Secondary cancers in the region of the radiation
Dementia
Cardiovascular problems

Most of the side effects are mild and tolerable. Some side effects may develop months to years later. Serious late side effects are uncommon. Ask your doctor about potential side effects, both short- and long-term, that may occur during and after your treatment.>>>

your case is an unfortunate exception.

I get why guys want to "just get it out" and "have radiation as a back-up". we (four adults) went into my consultation thinking just that.
thankfully my uro talked me (us) out of it. thankfully he was not a prostate snatcher.
Posted 1/2/2019 5:25 PM (GMT -5)

F8 said...

your case is an unfortunate exception.

....or perhaps you were just a fortunate exception. No place for either prostate snatchers or prostate zappers. ;)

Have a wonderful and healthy New Year!
Posted 1/2/2019 5:53 PM (GMT -5)

garyi said...

F8 said...

your case is an unfortunate exception.

....or perhaps you were just a fortunate exception. No place for either prostate snatchers or prostate zappers. ;)

Have a wonderful and healthy New Year!

well I had 12 for 12 cores positive and a couple at 70%. I had a 60% chance of cancer being out of the capsule so a 60% chance of needing SRT. my doctor said with those odds and no prostate I would have a much better chance at permanent SEs. HNY man!
Posted 1/2/2019 7:26 PM (GMT -5)

ASAdvocate said...
This larger study with more recent treatments shows a clear superiority of EBRT + BBT over surgery.

https://jamanetwork.com/journals/jama/fullarticle/2673969

That was the older study by Kishan that Pratoman's link seems to contradict. There is no clear direction anymore if you don't consider ED.
Posted 1/3/2019 12:44 AM (GMT 0)

JNF said...
My urologist/surgeon makes it very simple. Unless surgery has a very high probability of cure then it shouldn’t be used due to the more significant negative side effects inherent with surgery.

I can’t fathom any way that surgery plus radiation would be any more effective for cancer control, but am positive would have left me with worse negative treatment side effects than I have experienced.

Pratoman's article says that surgery plus radiation is as effective as the best form of radiation for high risk - HDR BT. It's not that surgery plus radiation is any more effective. If you are G9/G10, then the chances of follow up radiation are > 50%, but not 100%. If you are lucky, you may be among the reasonably large group, say 40%, that don't need follow up radiation. If among the lucky few, you would trade trade the main surgery side effects (> 50% probability of ED) vs main HDR BT side effects (longer term rectal issues). Pratoman's study indicates that surgery is actually an option without compromising your survival since possible follow up radiation gives you the same survival as HDR BT. You just hope that you don't need it.
Posted 1/2/2019 9:04 PM (GMT -5)
I'll let you guys with the low PSA's and intermediate grade Gleasons fight this one out.

I cannot speak for the G9-10's, but I was solidly in the VHR group and MaxRP seems to have worked well, so far. Both Gary and I had conditions that once inside turned out to be much different than what an RO would have been treating based on scans. And as it turned out, yes, the SE's of RT have been more difficult to live with than the SE's of surgery.

So why did we not go straight with RT in the first place? Because killing the cancer was more important to us than was preserving our sexual prowess.
Posted 1/2/2019 9:28 PM (GMT -5)
"So why did we not go straight with RT in the first place? Because killing the cancer was more important to us than was preserving our sexual prowess."

well we have to cling to something even if it wafts of BS.
Posted 1/3/2019 2:10 AM (GMT -5)

F8 said...


well we have to cling to something even if it wafts of BS.

Chill out. These threads quickly become useless when dissenting opinions are attacked.

I'm not a g9/10 guy so can't comment there. But Looks like I'll be going the surgery+radiation path, though if my urologist can be believed on my last visit. So I can add my 2 bits there smile I figure SEs can't be predicted. I came out of surgery 100% continent. Just the odd drop after peeing. Not much ED but a long path of recovery there for other reasons.

I think the big risk with surgery is "how much" they take out. I'm only guessing here, but I would think they'd remove more for the G9/10 guys ?? risking some incontinence and ED. But I guess even that can vary depending whether the cancer is well contained. My surgeon said my continence and ED result would largely depend on what he found and whether he needed to be more aggressive in removing the cancer.
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