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New Member - Still Shocked - Radiation or DaVinci

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Posted 9/10/2011 4:09 PM (GMT -5)
I am a new member of this exclusive club. I was diagnosed 10 days ago with PCa I am 70 years old, healthy and active and still working (part-time) and traveling. Wrestling with the decision of Robotic Da Vinci (at City of Hope or UC Irvine) or HDR or EBRT or a combination of HDR and EBRT. I have appointments this week at UCLA (Radiation route) and UC Irvine (DaVinci route) and in October at City of Hope. My appointments are with (hopefully) very experienced doctors and facilities. Done lots of reading and research but not further along in the decision.

My statistics are:
Age 70 healthy
PSA 1.2 (prior two years were 1/09=1.3, 4/10=1.19). In other words, no change
DRE= Dr felt a nodule and did biopsy
10 out of 12 cores were benign
One core left side base Gleason 3+3 (5%)
One core left side lateral base Gleason 3+4 (50%)
Partin Score 82+14+2+2
Did not get staging
Prostate enlarged to 57grams (suffered from this for years and using Flomax)

I just had CT scan and full body bone scans. Don't have results yet. My urologist said that he did not recommend surgery due to age with more possible complications and after-effects. He recommends EBTR with one shot of HT before EBTR and one shot afterwards. He also told me that with surgery, I would most likely not be able to work or travel for a very very long time (if ever). Questions:

1. How relevant is the age issue for a healthy and active 70 year old?
2. I still work and travel quite a bit overseas. What would be the impact of surgery versus radiation?
3. How did those of you in my age bracket (65+) make the decision?

Sorry for posing all this questions on my first post. Reading the posts, felt that there is a lot of collective wisdom here. Thank you very much for listening.
Posted 9/10/2011 5:28 PM (GMT -5)
I was 65 when I had my DaVinci surgery and tolerated it very well.  They looked very closely at my heart function, even going so far as a nuclear stress test (which I passed with no problems).  Obviously, the physicians you're talking to know a lot more health details about you than can be shared here on HW, so maybe there's something there that is a concern, but short of that it's hard to understand the doctor's comments about your not being able to work or travel for a very long time after surgery....robotic or open. 

Your prostate may be at the upper limits of size for brachytherapy, but given what I've read in your comment, that's a course of treatment I would have to seriously consider at age 70.

On the other hand, a friend of mine in his 70's just had radiation and is doing great.  No HT involved at this point.

Maybe others here will have better insight into all this than I do, but if you're as fit as you seem to be, 70 doesn't seem too old for open or robotic surgery.  Good luck with a difficult decision.

 

Posted 9/10/2011 6:21 PM (GMT -5)
Welcome to HW.

I would say that with your low PSA, your age, only 2 positive cores, you might also consider Active Survelliance. With the slow growth rate of PC, and the ability to monitor it for the next year, you can avoid any major treatment until you see what it is doing.

If I could have, I would have had Brachytherapy.

Good Luck. Don't rush into any decision. You have time. Keep on traveling and enjoying life.
Posted 9/10/2011 6:26 PM (GMT -5)
KRM,

If your prostate is beyond a certain size, even for external beam radiation most radiation oncologists will treat you first with HT to try to reduce the size of the prostate. I know that when I consulted for proton beam therapy my oncologist told me 40cc was her "cutoff point" and any prostate above that she would like to see reduced via HT. Mine was 28cc and so I was ok.

There are many radiation options. I am doing proton therapy, a form of External Beam Radiation. There are also several varieties of IMRT and IGRT including "Tomo," "CyberKnife" and "Calypso." These are all photon radiation devices that are designed to limit side effects on healthy tissue. There is also Brachytherapy, including both low dose and high dose (HDR).

I highly recommend you study all of these options and then make the best choice for your situation. Most of the guys on this board have had some form of surgery. You can generally find someone, however, who has had whatever form of treatment you are considering. It doesn't hurt to talk to folks who have actually undergone whatever treatment you are considering.

I do believe that you would find radiation easier to handle than surgery, and less likely to disrupt your travel overseas. I am 61 and I chose proton radiation. Most "experts" will say that at 70 you should strongly consider radiation. You know your own health. Ultimately the choice is yours, so be as fully informed as you can.

Steve
Posted 9/10/2011 7:23 PM (GMT -5)
Dr Walsh the most prominant surgeon in the US will not operate on anyone over 70 because the complications outweigh the benefits. I would also consider AS at that age because for anyone over 65 with low or low intermediate grade PC, treatment does not add to overall survival. In order to shrink the prostate for either radiation or Brachy I would use Casodex and not Lupron. It does a better job with about 20% of the side effects and about 20% of the cost. My prostate went from 60mm to 32 mm in two months using Casodex and proscar. Brachy is also a good choice with much less side effects and complications than surgery and equal or better cancer control. If you are in LA I would also consider getting a second opinion on your staging from Dr Mark Scholz in Marina Del Rey, Prostate Oncologists Specialists. A second opinion from Dr Scholz indicated my initial staging was totally wrong and the recommended treatment would have been a disaster for me.
JohnT
Posted 9/10/2011 7:51 PM (GMT -5)
HDR could be a good option. The HDR pioneer is at UCLA, Dr Jeffrey Demanes. Check his website at www.cetmc.com. HDR can handle large prostates much better than permanent seeds or IMRT. Demanes uses a flexible template to place the catheters that allows much better conformity with large prostates then other methods. I had HDR and am very pleased. At 70 most great surgeons suggest something other than surgery. Also look at using Avodart to shrink the prostate as it is normal to see about 30% reduction in a few months.
Posted 9/10/2011 7:53 PM (GMT -5)
Hello and welcome to HW,

With your one Gleason 7 core, being 50%, I wouldn't personally go for AS, there may or may not be more Gleason 7 present if your entire prostate were examined. A healthy 70 year old could probably find a surgeon who would do it, but there would be more risk involved, and like all of us surgery guys (I had open surgery), you will be spinning the gambling wheel as far as severity of incontinence and ED. On the surface, and I certainly have no medical training, looks like your could be a very good candidate for either conventional RT or Seed RT. That's my take.

Keep investigating your options, as you are currently doing, get as many opinions as you need, then like the rest of us, you will come to your own decsion, the one that is not only right for you, but one you can live with.

Please keep us posted of your journey into the world of PC.

Good luck,

David in SC
Posted 9/10/2011 7:59 PM (GMT -5)
KRM,

You describe my life at age 56 - good health - my job involved 200+ days of international travel per year to all parts of the globe. I would leave for Norway with a pack of meds that included malaria pills because no set of tickets was even used as planned. That part ended with my DaVinci surgery. In my situation, I had to travel on short notice, and stand for hours in front of groups of businessmen and students. The persistent incontinence I suffered for the first 5 months left me effectively unable to travel, much less drive more than 100 miles, and certainly unable to present a vibrant and active image for my company. Then along came RT (IGRT with Calypso markers), which added all the known common side  effects, but those were more due to a lifetime of colo-rectal issues.

I have not been on an airplane in almost two years - I'll be flying up to our GFMPH weekend - first flight since surgery. I pity the flight attendants.

I still work, but I don't get to do the things that gave me enjoyment in my job.

There is no way that I can even speculate your results, but mine hit and exceeded every negative point they said might happen, "but 98% do fine". OK, 98% of the guys out there did better than me. Bravo for them, and I am really happy for their progress.

So, if I had not done adjuvant RT, I would likely have regained my continence, and been able to travel again about 7 months out from surgery. However. my rising PSA proves that there was justification for it.

If I had done only RT as a primary treatment, I would have some issues, but most would associate to prior damage from other cancer and surgeries. Most of the men I met during my RT were much older, and most did great (I asked the wives who were there waiting - we all know men will never admit having issues). Much better than I did. The problem there was that I am very advanced, and primary RT was not really a valid option (9 of 12 cores positive, mostly G 4+4, post-op G4+5). For you, it seems to be completely valid. Seeds also seem a very valid option.

So, why / why not surgery? Consider the side effects and the benefits. Likewise RT. Make a list. Read Walsh's and Scardino's books. Don't make my error of discounting the side effects. I should say I do not regret my decision, as I think it was proven correct medically, but I underestimated the possibility of NOT being in the 98%.

Each of us has to decide, and the doctors are of little help. Then we move ahead.

 

Posted 9/10/2011 8:15 PM (GMT -5)
WOW. Never expected all this support and suggestions. Thanks for all the suggestions so far. I agree that AS is not for me. I am the type of person that extinguishes a match with a fire hose. What David is saying about surgery is also what I am afraid of. Hopefully, the appointments I have scheduled will also shed some light. Also agree with John T. I would like to know for sure what my biopsy score is and what is the staging. My urologist tells me that the results of the biopsy are accurate because they were reviewed by two pathologists, although from the same office. Hopefully the places where I have appointments will review the slides and form their own opinions to compare.

HDR with Dr. Demanes is what I am considering as alternative to DaVinci robotic. However, I share the concerns of not knowing the extent of my cancer and knowing that it is removed. However, quality of life is important to me like all of you, hence worried about incontinence, blood clots, impotency, etc, of surgery. Dr. Ahlering UC Irvine has pioneered an enhancement to Da Vinci with cooling of the tissues that supposedly reduces after surgery issues. Lots to think about. Thanks. I'll report back. Have appointments Monday (my urologist to review bone scan and CT scan), Tuesday (HDR option) and Wednesday (DaVinci Robotic option).
Posted 9/11/2011 7:25 AM (GMT -5)
 

Welcome to our club and at same time sorry that you are here. You are definitely in a gray area at 70 about surgery and what treatments to pursue. I agree with Purgatory about not using AS with your 50% G7 on the one lobe. My post surgery pathology showed my tumor which was 100% organ confined was 60% of my prostate involved at G7 on both sides. With my sudden rise over 18 months in PSA to 5.25 and the tumor size my URO told me after surgery that his best guess was my PC would have not been organ confined in 2 years and could have been life threatening in 5 years if untreated. AS was not an option for me. My Prostate  size was 69 gms in the pathology but all of my DRE's never showed I had an enlarged prostate nor did I have any symptoms of the enlargement.

There are a couple of recent members here in California who have had the Davinci surgery  with the cooling procedure and hopefully they will comment back to you about their experiences. You could also start another thread asking for anyone who had the procedure to comment.

Good luck and remember the only correct treatment decision is the one you will make as you are the one who will live with that decision.

Terry the Water Guy

Posted 9/11/2011 1:37 PM (GMT -5)
Thank you Terry and thank you Moderator. Good suggestion Terry on checking experiences with the Cooling enhanced DaVinci at UCI. I'll do that.

Moderator: I am really sorry to hear what you went through It is an eye opener for me. We tend to look at success stats of 98% and think that we are within the 98% without thinking that we may be in the other 2% (pray not). I am probably driving myself crazy (like most of the "members" trying to come up with the most effective less risky alternative. It may not be there and all I may be able to do is make an educated guess. You are right, doctors are not very helpful on this.
Posted 9/11/2011 2:53 PM (GMT -5)
krm001,
I was diagnosed at the age of 67 and had Davinci surgery. I tolerated the surgery very well. I started walking few days after surgery and started playing golf 2 months after. I was incontinent for 3-4 months. The only negative remaining effect is permanent ED due to the removal of both nerve bundles.
If it wasn't for my high Gleason, I might have chosen to avoid surgery. With your low numbers you have a lot ofoptions.
Posted 9/11/2011 3:05 PM (GMT -5)

That is very encouraging Ed C.  Keep on the same path to full recovery.  Starting to evaluate my options by scheduling appointments with both DaVinci surgeon and HDR/radiology center.  I will post progress.

Posted 9/11/2011 3:37 PM (GMT -5)

I had just turned 70 when I was diagnosed with PC. Had the open RRP and was in the hospital for 3 days. ED back to 90% of 'normal' after about 12-18 month. Fully continent after about 10 weeks. The only reason that I didn't opt for any radiation treatment was that I already had some urinary difficulty and radiation would have made that worse. Unfortunately I had a recurrence 2 years after the RRP, but tolerated SRT fairly well. Now, about 5 years after my diagnoses, I'm pretty much back to normal with only an slight, occasional anal discomfort.

Unfortunately we are all a bit different and perhaps I was one of the more lucky ones.

Sorry if I added more confusion to your procedure selection process.

Wishing you all the best in the next step of your journey.

Mag

Posted 9/11/2011 3:49 PM (GMT -5)
Thank you. Your situation was pretty much like mine. With enlarged prostate, I am on Flomax. I have to find out if this needs to be trated before potential RT to avoid worsening the condition. This coming week should be enlightening (to say the least) with my appointments.
Posted 9/11/2011 3:54 PM (GMT -5)
I am 64 when diagnosed with PC.  I am a 3+3 in one sample.  I did the active surveillance for 4 months until PSA jumped again to an 11.1.  I am doing external radiation.  I do have a large prostrate, but was not a concern for ER.  I am now half way thru with ever little side effects.  I do have some problem with gas, bloating, and constipation that I think is unrelated.

Like someone else said " Don't jump into anything.  there is time to decide.

Posted 9/12/2011 5:22 AM (GMT -5)
Here's one you haven't heard about: (besides A.S./W.W.) Michigan guy I know is into year 16 now with his PCa journey, no radiation and no surgery, he did the Dr. Leibowitz protocol of ADT3 drugs for 13 months, quit and then stay on proscar for maintenance.
So far he is total elated and plenty of normalcy of functions and living, he has had rebiopsies many times since and recently a color doppler exam by Dr. Lee and biopsies of the suspecious 'red' areas shown on that exam.....'no PCa found thus far'.

So, is Rick insane for not jumping into surgery, radiation, cryo and other major invasive treatments? I have his phone number and email address, it is the real deal story. He had the guts way back to consider doing this and going against all those freakin experts!!!!
Posted 9/12/2011 3:09 PM (GMT -5)
Just returned from my urologist. CT scan and bone scans are negative. No cells. He gave me the prostate statistics. Volume 56.4, Transurethral lenght 4.8cc. Stage T2a. Off to the HDR radiologist tomorrow and UC Irvine (DaVinci) on Wednesday. Wer will see if my vision gets clearer afterwards.
Posted 9/14/2011 12:03 PM (GMT -5)
UPDATE

Yesterday I met with Dr. Demanes at UCLA to get an opinion on HDR.  First, he is an incredible doctor and human being.  I though that this would be a quick consultation.  He spent 2 1/2 hours with me rechecking everything, doing another ultrasound, and explaining from a-z and options.  He restaged me as T2a with a Partin of 70% confined.  The nodule he felt is on the right side apex, but the two bad biopsy cores are in the left side base and lateral base.  He felt that I was a candidate for HDR Monotherapy, but wants to do an MRI and also a treatment to reduce the size of my prostate prior to HDR treatment.  I continue to evaluate options.  Will do more updates.

Posted 9/14/2011 3:02 PM (GMT -5)
I can appreciate your concern about the age factor. I recieved my PCa dx early May,2011. My uro, based on the results of my biopsy, bone scan and CT of my pelvic area, assured me that I did not have to rush into anything. He said I am a " young " 73 and could consider a number of options from AS to surgery. I refused to consider AS. The thought of living with PCa was off the table as far as I was concerned. I could envision having panic attacks at every ache and pain. He suggested that I consult with a radiation oncologist which I did.

During the consultation I asked if I went with radiation and it failed did I still have the surgical option? He said probably not, but I might be able to find a surgeon that would try it. So much for radiation.

To make a long story short, I sent my biopsy slides to a highly regarded cancer hospital not far from me for a second opinion,they agreed with the findings and I made the decision to have DaVinci Prostatectomy.

On 8/1/2011 I had the surgery. Everything went well thank God. The worst part was getting rid of the gas they pump your stomach up with to give them more space in there to work.

Today, I am almost 6 weeks on the other side. I am 90% continent, still can`t fart with out dribbling. ED, forget it!

Your numbers are similar to mine, you have time to explore all your options.

Best of luck in your journey

Posted 9/14/2011 3:33 PM (GMT -5)
 

Snake,

3 months out from surgery and I still can't fart without dribbling a little. I now have to pass gas while sitting on the throne, makes the wife happy, but just another of life's pleasures gone thanks to PC. If you can't clear a room out what good is a fart? nono

Terry

Posted 9/14/2011 7:55 PM (GMT -5)
I am here again with another update. I went to see a DaVinci Well know expert that uses the Cooling enhanced DaVinci (personally done 1100 surgeries). He felt that in my case he could do the nerve sparing DaVinci and said that the after surgery effects have been highly reduced with the cooling of the organs and tissue before and during surgery. He did not believe that radiation would be as effective as the surgery long term. Decision time.
Posted 9/14/2011 8:30 PM (GMT -5)
If you live in SoCal and decide to go the Da Vinci route, in addition to Dr. Ahlering of UCI and the City of Hope, you might want to look into Hoag Hospital's Dr. Yoshida. He was a City of Hope trained robotic surgeon, did over 1000+ robotic surgery since 2002 and has a large group of very happy and thankful patients.
Posted 9/15/2011 2:53 PM (GMT -5)
Thanks.  Still have one to go a City of Hope.
Posted 9/15/2011 3:12 PM (GMT -5)
krm,
If you see Tim Wilson at CoH tell him Tony Crispino in Vegas says hi.

Just an FYI, Tim was my surgeon. Nearly five years later I am fully functional. Tim called my wife during surgery to let her know that he saw some issues but that I was doing well. The issues he saw he and I had a long talk about.

Three years later I saw him at an AUA conference and he agreed to come out to Vegas and speak to our UsTOO group. He was awesome. In February this year I picked him up at the airport at 3:30 and we had dinner and went to the meeting and I scrambled him back to the airport so that he could be in surgery the next morning. I also saw him as he was the speaker for surgery at last weeks PCRI conference with his partner Mark Kawachi. These guys are well known and very good.

I have also heard great things about Ahlering...you have some great options in front of you...

Tony
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