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Surgery or Radiation for G9-10?

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Posted 1/3/2019 7:23 AM (GMT -5)
Well said Jasper, and that has been my point all along. Good luck to you!
Posted 1/3/2019 1:42 PM (GMT -5)

jasperx10 said...

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.

Amen to that!!!!

This forum is better than an uninformative, insulting, and IMO totally incorrect remark, like that!
Posted 1/3/2019 2:09 PM (GMT -5)
well when you say something (questionable) expect it to be challenged, and that was a (misleading) comment. we all go into treatment to get cured and ED doesn't have to be a part of it, which is part of the "why" question.

I blame the denial and confusion on the prostate snatchers, who have done so much damage that there is a belief that PSA testing does more harm than good. it's not the testing. it's not the knowing that you have cancer. it's the prostate snatcher who's at fault.

Ed, I did some minor Rule 3 editing...trust I didn’t change the intent of your message. Jim

Post Edited By Moderator (Tudpock18) : 1/3/2019 2:14:34 PM (GMT-7)

Posted 1/3/2019 2:45 PM (GMT -5)
Happy New Year?

Everyone should make the best decision that's right for them. All of these new studies only really have value as another data point to those who have yet to make a treatment decision.

I'm a G9. I did my research, and then made my treatment choice. Period, over, done. It does no one any benefit to get on a soap box and say A is better than B as an absolute. If someone asks as to why I went with my treatment, I'm happy to explain the factors I considered and how I got to my decision. But I then tell them that this was the decision that was best for me at the time of the decision and only they can gather information for their situation and then make their own choice.

Thinking positive, assuming cure, and moving forward with my life.
Posted 1/3/2019 3:38 PM (GMT -5)
What is missing here is the side effect differential between radiation as a primary treatment and radiation following surgery, either adjuvant or salvage. The two radiations are not equal due to the significant anatomical changes that surgery causes. Radiation after surgery is inherently more damaging to vital organs than radiation as the primary treatment and thus will more often produce more significant negative side effects.

This very significant difference was explained to me by my urologist before we made treatment decisions. I doubt that many urologists explain the differences when they say ‘dont worry, if you are that rare man that surgery doesn’t cure, we can just follow up with a little radiation. No problem. Don’t worry-be happy”.
Posted 1/4/2019 4:11 AM (GMT -5)
In Pratoman's article, it was NOT comparing radiation as a primary treatment against surgery plus radiation. Rather, it was comparing a specific type of radiation BBT, which combines two types of radiation i.e., IMRT and Brachytherapy, against surgery plus IMRT. IMRT and Brachy together have a significantly higher risk of side effects than either IMRT or Brachy alone. I've seen studies where up to 25% of BBT patients had late-term gastrointestinal side effects. Furthermore, many BBT patients also have ADT, which adds yet another dimension of short-term side effects. Surgery plus IMRT certainly has a high risk of side effects, but so does BBT.

Point is, for G9/G10 patients, the best treatments are quite aggressive and both have pretty high risk of side effects. Whenever you combine treatments - surgery & IMRT or Brachy & IMRT you significantly increase the side effect risk.
Posted 1/4/2019 4:28 PM (GMT -5)
I don't usually speak highly of the surgical route, probably because my SEs have really left me less than thrilled. OK, it has done a fine job of keeping my G9 at bay so far, but RT could have done the same job, maybe even better, right? And probably with far less severe permanent SEs. Especially since my risk of needing RT later anyway was quite high.

But reading bbqdude' recent thread about his dad's experience reminds me that there is one RT SE that I tend to forget about:

bbqdude said...
My dad had prostate cancer somewhere around 15 years ago. They did brachy and some other radiation ( seems like about 9 weeks worth). They got rid of the cancer.

Last August he was diagnosed with bladder cancer, according the Washington U in St. Louis it was caused from the radiation. It was a special kind of cancer that chemo would have no effect on and he couldn't do any more radiation................

There was a guy who used to post here who told me more than once that concerns about secondary cancers caused by RT were over blown. But I'm not all that sure about that. It seems to me there are a few guys I have heard from at this forum who have experienced that, though I can't remember who right off. And certainly a few who came down with other cancers and were wondering if there was a relation. I also think about Purgatort's nightmare with RT, though if memory serves his was from a botched job.

Bottom line: either treatment is- IMO, might be wrong - to be avoided if at all possible. Of course for a bunch of us, that is not possible unless we are willing to have our PCs advance maybe even to the point of death. So for most of us, we have to pick some form of the poison. In order to avoid an even worse poison.
Posted 1/4/2019 8:25 PM (GMT -5)
JNF - I asked the RO I consulted with if radiation after surgery was shorter (less than 7-8 weeks) since there was no prostate to focus on. He said approximately the same number of treatments but at less radiation dose. Would this tend to mitigate side effects?
Posted 1/5/2019 9:23 AM (GMT -5)
Mumbo

Here is a thread on the subject explaining the issue:

https://www.healingwell.com/community/default.aspx?f=35&m=3301835

I looked at this and am glad I found that info to provide perspective.

I am G3+4 T2a and had a lot of cores on my right side 6/7 so choose HDR Boost, was concerned about EPE so went that route, about 11 months out, so far so good, very little acute effects, no bowel or urinary issues thus far.
Posted 1/5/2019 9:55 AM (GMT -5)
Mumbo - most of the guys I've spoken with having primary radiation had 44 treatments, while most who were having SRT or ART were getting 38 or 39. Seemed to be common numbers. Of course, dosing can be different.

BillyBob - as I understand, the late term SE's of radiation take YEARS to develop, so someone who has developed a secondary cancer from prostate radiation 5-10 years later probably won't be posting in a prostate group anymore. Other pelvic cancers are so commonplace that they would likely be asking questions in a colorectal (or whatever) forum and not think of prostate RT as a possible cause or perhaps unwilling to suggest it.
Posted 1/5/2019 10:43 AM (GMT -5)

RobLee said...
Mumbo - most of the guys I've spoken with having primary radiation had 44 treatments, while most who were having SRT or ART were getting 38 or 39. Seemed to be common numbers. Of course, dosing can be different.

BillyBob - as I understand, the late term SE's of radiation take YEARS to develop, so someone who has developed a secondary cancer from prostate radiation 5-10 years later probably won't be posting in a prostate group anymore. Other pelvic cancers are so commonplace that they would likely be asking questions in a colorectal (or whatever) forum and not think of prostate RT as a possible cause or perhaps unwilling to suggest it.

Good points. So does that mean it could be more common than we realize, since most who might have developed other cancers secondary to RT would not even post here?
Posted 1/5/2019 10:56 AM (GMT -5)
secondary cancers is tricky. For a couple of decades prior to PC, I've been screened as a colon cancer risk due to having polyps in my 30s.

so now, if I do get colon cancer will it be caused by my PC RT, or was it just dormant and would have happened anyway.

tricktsy ...
Posted 1/5/2019 11:10 AM (GMT -5)
The study that I posted to start this thread notwithstanding, it seems to me that there is one fact that no study will likely ever change.... that is that the decision on primary treatment should be driven by 1. Each patients individual situation, I.e. pathology, stage, etc, and 2. Personal priorities, ie side effects.
Posted 1/5/2019 11:32 AM (GMT -5)

Pratoman said...
... no study will likely ever change.... that is that the decision on primary treatment should be driven by 1. Each patients individual situation, I.e. pathology, stage, etc


Agreed, as well as personal circumstances, beyond pathology.

As for SE's, sometimes they happen, more often they do not. I tried to make that point earlier. Ended up with me blocking another user, though I hate to do that. Making a decision based on fear of possible side effects would prevent us from ever getting into an automobile. Choosing a treatment plan based on efficacy seems more rational.
Posted 1/5/2019 11:43 AM (GMT -5)
I think the rate of radiotherapy induced secondary cancers was ,0.16%, nothing I was going to worry about, if you believe these studies, in my decision tree, it was a low factor.

https://pcnrv.blogspot.com/search?q=secondary+cancer
Posted 1/5/2019 12:06 PM (GMT -5)
Turboz - Thanks for the link, saves time since there are so many.

As a retired engineer and having four arthoscopic surgeries under my belt, I completely understood the RALP surgery, the associated plumbing changes, and probable side effects. What I did not understand, I was easily able to learn about from the Web and various publications. Of course, there is nothing like experiencing the process to fully appreciate what is glossed over or painted with a rosy brush which is where this forum becomes so handy.

On the other hand, I have been warned about the accumulative effects of radiation and X-rays causing cancer most of my life and was concerned with more CT and bone scans being done in addition to the other scans in my lifetime although you have little choice when confronting cancer. With radiation therapy, you pretty much have to believe since it is very difficult to visualize the process from a mechanical standpoint and assess what it is doing to you as a by-product. I don't think there is much discussion when targeting a lethal brain tumor with radiation but when one shoots 40 blasts at a small area containing multiple organs that are all important to quality of life, the engineer in me tends to go for the the process I understand best, right or wrong.

My RO was great and came from Mayo so I quizzed him hard. He never dismissed surgery but explained the options I had from a radiation standpoint, side effects, etc. as being equivalent to the surgical option for me and the choice was mine. (Surprisingly, I asked about Mayo's proton beam therapy and he was not real keen on it for prostate treatment, too many moving body parts he said to utilize its precision so no better results in practice from what he observed.)

I have no position on this matter except as it pertains to my situation and agree with those who say learn about everything before you make your decision which is generally not necessary to do in a hurry and you can get second opinions on everything if you want to gain confidence. There is a certain "analysis paralysis" that creeps in for most people including myself since there is no optimum solution except for the simplest cases. Finally, you make a decision so you don't have to think about it anymore and get on with living.
Posted 1/5/2019 2:15 PM (GMT -5)
Interesting discussion. I'm 85 and was given little choice since surgery was off the table at the outset. I was advised to complete 45 session of radiation, combined with 2yrs. of ht for my g9 localized pc. I completed a total of 8100 cGY and have been on ht for 6 mos. so far, first firmagon, then lupron. For me radiation therapy was a piece of cake. No toxicity issues to speak of. But the ht was a different story. It crushed whatever libido I had left at my age, not to speak of the hot flashes, night sweats and chills--though my uro prescribed megastrol and the negative side effects stopped altogether. My psa is now down to 0.1 and all is back to normal. I gained no weight, feel no fatique and do all my usual chores. For me the radiation marathon was surprisingly easy to complete.
Posted 1/6/2019 1:21 PM (GMT -5)
Writeblock - Little off topic now but my Dad is 91, had Brachytherapy at age 76, then went on Lupron or equiv. a couple years ago and is now off of it. He said that the Lupron killed whatever was left of his sex drive but he really didn't care as he was 90 then. I don't recall much discussion about side effects but he hated the shots after a while. The only part I noticed over the last few years is he looks younger and his skin seems "clearer" than before. You would think he is in his young 80's when you first see him. His doctors said he will make 95 no problem.
Posted 1/7/2019 2:30 PM (GMT -5)
This thread is really timely for me. Thanks for starting it Pratoman.

For those of you in this thread who are saying radiation is the way to go, are there any scenarios at all where you feel surgery is the right way to go? I know if you have a medical condition that makes radiation to risky that could be one.

Also, second question - does anyone recall seeing someone in these forums who were G9/G10, had a prostatectomy and no other treatment and then were cancer free at least a few years later?
Posted 1/7/2019 3:00 PM (GMT -5)

bobmars said...
This thread is really timely for me. Thanks for starting it Pratoman.

For those of you in this thread who are saying radiation is the way to go, are there any scenarios at all where you feel surgery is the right way to go? I know if you have a medical condition that makes radiation to risky that could be one.

Also, second question - does anyone recall seeing someone in these forums who were G9/G10, had a prostatectomy and no other treatment and then were cancer free at least a few years later?

You might look back through the G9 Crew thread to look at signatures for treatment plans. A lot of them are in there, and you might find what you're looking for. If you do, they may have email addresses if you want to reach out directly. Here's the link:
The Gleason 9 (and 10) Crew - Welcome and how ya doin'? (Part 3, continued thread)
Posted 1/7/2019 7:57 PM (GMT -5)

bobmars said...
This thread is really timely for me. Thanks for starting it Pratoman.

For those of you in this thread who are saying radiation is the way to go, are there any scenarios at all where you feel surgery is the right way to go? I know if you have a medical condition that makes radiation to risky that could be one.

Also, second question - does anyone recall seeing someone in these forums who were G9/G10, had a prostatectomy and no other treatment and then were cancer free at least a few years later?

Well, that probably depends on what the exact definition of "cancer free" is. And this would be made more difficult due to our ability- or lack there of- to detect prostate cancer. And there is clinical cancer vs a slightly rising PSA or even high enough to be called BCR(Bio-Chemical Recurrence). Some also claim that slight, slow steady rises in PSA can be due to benign prostate tissue that was left behind. Others insist that doesn't happen. However, if the test is sensitive enough, goes down low enough ( like say < .006) you can find some PSA in the vast majority of folks even after surgery.

Since I was quite high risk, and since my post op pathology report was not nearly as rosy as I had hoped for, I have done way better than I was expecting, for an amazing(to me) 5 years now. ( another PSA test due shortly) But I certainly would not claim that I was cancer free. Something has been causing a mostly very slow, steady rise in my PSA, after staying < .01 for 18 months. Most likely it is a few cancer cells kicking around inside me. But I for sure have not yet had any clinically detectable spread yet.
Posted 1/7/2019 8:56 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

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

I don't know if this study has been cited here before, but it is from the same source as Prato's original link:

PracticeUpdate.com said...
The study authors concluded that men with LAPCa or RAPCa treated initially with RP plus XRT had both reduced risk of prostate cancer–specific death and improved overall survival relative to men who were treated with XRT plus ADT.


HOWEVER, it also notes that RP+RT has a higher incidence of incontinence and ED, which is something we already knew about ... However, RP plus XRT versus XRT plus ADT was associated with higher rates of erectile dysfunction (28% vs 20%; P = .0212) and urinary incontinence (49% vs 19%; P < .001).

So again, it comes down to do you want a higher probability of a cure, or are you more concerned about immediate side effects of treatments.
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