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Posted 10/19/2020 9:31 PM (GMT -5)
I was thinking about all the confusing treatment choices facing newly diagnosed men. This is my imperfect attempt to list them. Let me know of any that I’ve missed😀

. Active surveillance (intense testing with curative intent)
. Watchful waiting (basic testing with palliative intent)

. Retropubic open radical prostate (open RP)
. Radical perineal prostatectomy (RPP)
. Laparoscopic radical prostatectomy
. robot assisted laparoscopic prostatectomy (RALP)
. Retzius-sparing robot assisted radical prostatectomy

. Intensity-modulated radiation therapy (IMRT)
. Stereotactic body (photon) radiation therapy (SBRT)
. Proton beam radiation therapy (PBRT)
. Stereotactic body (proton) radiation therapy (SBPRT)
. Volumetric modulated arc therapy (VMAT)
. Low dose brachytherapy (permanent seeds)
. High dose brachytherapy (temporary radiation inserts)

. Cryotherapy (freezing)
. High intensity focused ultrasound (HIFU)
. Focal laser ablation (FLA)
.Transutheral ultrasound ablation (TULSA-PRO)
. Irreversible electoporation (Nanoknife)

. Gold nanoparticles
. Vascular-targeted photodynamic therapy (VPT)
. Nanoparticle-directed laser ablation (AuroLase)
. Trans-urethral hyperthermia
. Lutetium 177 (Lu-PSMA-617)
. Peptide receptor radionuclide therapy (PRRT)

. Orchiectomy (castration)

. Hormone therapy (Androgen Deprivation Therapy)
. Chemotherapy
. Corticosteroids
. Immunotherapy
. Bipolar androgen therapy (BAT)

. Diets (WFPB, Gergen, Gerson, etc.)
. Assorted drugs and supplements (Metformin, statins, aspirin, atenolol, CBD oil, etc.)

Note 1. The 400,000 man SEER prostate cancer database shows that newly diagnosed men are choosing active surveillance, surgery, and radiation in equal numbers. There no longer is a “gold standard” treatment.

Note 2. Radiation choices range from one session for low dose brachytherapy to 44 sessions for protons. But, that is changing, as some major centers are offering IMRT in 28 sessions, and protons in as few as 5 sessions.

Note 3. Combination treatments are now common for unfavorable intermediate and higher cases. This can involve two types of radiation plus hormones, or surgery plus radiation and hormones. Surgery preceded and followed by hormones is now being tested in clinical trials.

Note 4. I have had to make judgement calls and not include close variations, not make two items for focal and full gland, and not include treatments still in animal or small human trials.
Posted 10/20/2020 9:28 AM (GMT -5)
Looks like a pretty complete list to me.
I would note, that Hormone Therapy, and Orchietomy would be primary therapy in newly diagnosed would be likely reserved only for those men diagnosed at an advanced stage. And Cryotherapy along with the other focal treatments, are maybe just a little bit out of the mainstream? (am i wrong).
Not very familiar with the group of treatments that start with Gold Nanoparticles
Posted 10/20/2020 9:38 AM (GMT -5)

ASAdvocate said...
I was thinking about all the confusing treatment choices facing newly diagnosed men. This is my imperfect attempt to list them. Let me know of any that I’ve missed😀

. Active surveillance (intense testing with curative intent)
. Watchful waiting (basic testing with palliative intent)

. Retropubic open radical prostate (open RP)
. Radical perineal prostatectomy (RPP)
. Laparoscopic radical prostatectomy
. robot assisted laparoscopic prostatectomy (RALP)
. Retzius-sparing robot assisted radical prostatectomy

. Intensity-modulated radiation therapy (IMRT)
. Stereotactic body (photon) radiation therapy (SBRT)
. Proton beam radiation therapy (PBRT)
. Stereotactic body (proton) radiation therapy (SBPRT)
. Volumetric modulated arc therapy (VMAT)
. Low dose brachytherapy (permanent seeds)
. High dose brachytherapy (temporary radiation inserts)

. Cryotherapy (freezing)
. High intensity focused ultrasound (HIFU)
. Focal laser ablation (FLA)
.Transutheral ultrasound ablation (TULSA-PRO)
. Irreversible electoporation (Nanoknife)

. Gold nanoparticles
. Vascular-targeted photodynamic therapy (VPT)
. Nanoparticle-directed laser ablation (AuroLase)
. Trans-urethral hyperthermia
. Lutetium 177 (Lu-PSMA-617)
. Peptide receptor radionuclide therapy (PRRT)

. Orchiectomy (castration)

. Hormone therapy (Androgen Deprivation Therapy)
. Chemotherapy
. Corticosteroids
. Immunotherapy
. Bipolar androgen therapy (BAT)

. Diets (WFPB, Gergen, Gerson, etc.)
. Assorted drugs and supplements (Metformin, statins, aspirin, atenolol, CBD oil, etc.)

Note 1. The 400,000 man SEER prostate cancer database shows that newly diagnosed men are choosing active surveillance, surgery, and radiation in equal numbers. There no longer is a “gold standard” treatment.

Note 2. Radiation choices range from one session for low dose brachytherapy to 44 sessions for protons. But, that is changing, as some major centers are offering IMRT in 28 sessions, and protons in as few as 5 sessions.

Note 3. Combination treatments are now common for unfavorable intermediate and higher cases. This can involve two types of radiation plus hormones, or surgery plus radiation and hormones. Surgery preceded and followed by hormones is now being tested in clinical trials.

Note 4. I have had to make judgement calls and not include close variations, not make two items for focal and full gland, and not include treatments still in animal or small human trials.

Active surveillance not a treatment and has no curative intent. AS is a decision not to treat and should not be on a list of treatments.

Post Edited (Duck2) : 10/20/2020 8:49:05 AM (GMT-6)

Posted 10/20/2020 10:14 AM (GMT -5)
AS is much more than a decision not to treat. But, I think a decision not to treat is more common than we might believe.
Posted 10/20/2020 11:11 AM (GMT -5)
And for Gleason 6, AS is the Gold Standard decision.
Posted 10/20/2020 11:45 AM (GMT -5)

alephnull said...
And for Gleason 6, AS is the Gold Standard decision.

I would qualify that as a blanket statement -- some G6 men do not meet the eligibility requirements for the AS programs of the major institutions.

Djin
Posted 10/20/2020 12:03 PM (GMT -5)
ASA - I think your attempt at helping may have just added to the confusion regarding choices, especially for newcomers. There is the basic issue of what insurance/Medicare will cover which is probably more important than treatment possibilities for the average patient when it comes to choices.

Watchful waiting is/was the predecessor of active surveillance which is essentially passive vs. proactive monitoring. Neither are intended to be curative in nature as Duck noted, just methods to determine if and when a curative approach needs to be employed for those who have relative benign cases of PCa. I think watchful waiting is also employed with older folks where the slow growing nature of PCa may never be the cause of death given age and other medical issues.

Otherwise, it is a nice list with a few I may have to lookup some day.
Posted 10/20/2020 12:17 PM (GMT -5)
As far as AS being a treatment, I know that can seem counter-intuitive, but the NCCN, ACS, and other major advisory bodies do consider it a “treatment”.

All of the listed treatments are approved and available, with two exceptions that are only offered in Europe at this time.

This is a work in progress. I first listed it on the Facebook groups and some other sites last month, so it’s had some feedback and additions.

I think there are 33 listed, but, let’s face it, that multitude only exists because there is no one perfect or certain treatment yet.
Maybe some day.
Posted 10/20/2020 12:38 PM (GMT -5)
Active surveillance is considered to be “curative” by its founders and the institutions who offer those programs,

That is because a stated goal of the programs is to defer interventional treatments until there is an upgrading of the risk, and to treat at that time. All the founders were surgeons. They were not convinced that all their patients needed immediate surgery.

I know, that was not clear to me either, until I read it in several descriptions.

Watchful waiting, on the other hand, is palliative, and any intervention is intended to reduce pain, not to cure.

At this time, if my pathology changed, I would have TULSA-PRO. That treatment did not exist when I was diagnosed.
Posted 10/20/2020 12:59 PM (GMT -5)
Good list, ASA. I think it will serve newcomers well. If they don't understand anything or are confused, relief is just a few clicks away, or a phone call to their urologist. Seems to me that we thrive (here on this forum that is) on more information rather than less.

I too would choose TULSA-PRO if I found out I needed treatment today.... although even after hearing Dr. Klotz's presentation this past Saturday I'm not sure whether it's currently recommended for my bilateral G6s. Not to mention finding, and paying for, a place that does it and does it well!
Posted 10/20/2020 1:18 PM (GMT -5)

2019Guy said...
......Not to mention finding, and paying for, a place that does it and does it well!

Always a danger when looking at the newest treatment, usually without long term results, or well researched side effects. IMHO, something to watch, not something to jump on.
Posted 10/20/2020 3:32 PM (GMT -5)
garyi, Certainly your caution is well understood.

In my case, Dr. Pavlovich of Johns Hopkins was one of the participants in the TACT clinical trial, so, he has been performing TULSA-PRO procedures since early 2018. He is now also the head of the AS program, so I have access to him. That access to a trained specialist probably don't apply for the great majority of men, yet.

In that clinical trial, while the criteria for success was reached, they still found significant lesions in 20 percent of the men. Since there was imagery of the patients before, during, and after the procedure, those cases were all analyzed. In most, there were calcium deposits between the heat source and the lesion(s). So, they now know to perform a TURP first, or reject those patients. In a few others, they found that the lesions were not blocked, but did not get enough heat for enough duration. That was attributed to the operator not noticing all the data on the screen.

So, that accounted for almost all the failure issues. Learn by experience. I would feel comfortable with that treatment. But, then again, not everyone thinks as I do.
Posted 10/20/2020 8:07 PM (GMT -5)
I noted focal cryotherapy was on the list. There was a time, in the early 1990's, that whole gland cryo was seen as The Next Great Thing, and many men had it as primary treatment. My Dad was one of them, at Cleveland Clinic, I think in 1993 or 1994.

In his case, his prostate shrank and died off to the point where it literally disappeared. However, he later developed metastases eventually in his spine and died in 2004. I don't think whole gland cryo is done much at all anymore.
Posted 10/20/2020 9:18 PM (GMT -5)
Cryotherapy is still used as a post-radiation salvage treatment. I was recruited for a cryotherapy clinical trial at Johns Hopkins in 2013, but turned it down.

It’s still being performed.
Posted 10/20/2020 10:34 PM (GMT -5)
I had a fried do Cryro at Cleveland in 2019 for G7
Posted 10/21/2020 4:51 AM (GMT -5)
Great list and good discussion. Information is king the more we know the better we can make decisions. The real problem in my experience is the bias of the doctor you see. They are mostly salesmen hawking their specialty. I have only met a few that are truly open minded.

Well done ASA! Denis
Posted 10/22/2020 2:47 PM (GMT -5)
ASA....I met Dr. Pavlovich when I was up at JH, and spoke to him several times. He is very generous with his time and knowledge, and doesn't mind thinking 'outside the box'. A fine choice to head up their AS program.

Has he relocated to the main campus, from the Bayview facility?

Gary
Posted 10/22/2020 3:36 PM (GMT -5)
Garyi,

I attended a community lecture on prostate cancer about 2010, where Dr. Pavlovich was the presenter. He was enthusiastic about the daVInci system, and showed us a video of the robot peeling the skin off of a grape, perfectly. It was clear to me that he was interested in innovation.

My AS contact, who is an NP, recently told me that they rolled the age for "protocol biopsies' back to 80. Not happy. Dr. Carter had told me I was finished with them. Apparently, there was an issue with one or more other patients, so they upped the age. Well, I am determined not to have any more MRI's with gadolinium contrast, or trans-rectal biopsies, and no anesthesia, either. I inquired if I could have an ExactVu micro-ultrasound biopsy using transperineal access. She wrote this all down, as if I was talking science fiction. Said that she would show it to Dr. Pavlovich, her boss.

A few days later, I get a message that, yes, He has the equipment, and wants to work with me.

Feeling good now. Got what I wanted. State of the art. Hope it doesn't find more cancer sad
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