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Treatment options for locally advanced Gleason 9 cancer

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User
Posted 17 Nov 2020 at 18:07

Hi everyone

I'm 66 and generally quite fit and active.

I've been recently diagnosed with prostate cancer and am actively considering treatment options.

Gleason score 4+5
PSA 4.9 at time of diagnosis
T3aN0M0

Cancer is 1cm3 and prostate volume 66cm3.
Cancer is on one side of the prostate, with some indication of capsular involvement. (Initially the cancer was categorised as 2a, but at a Multi-Disciplinary Team meeting was raised to 3a because there was possibility of capsular involvement.)

I had a PSMA Ga68 scan which gave no indication of metastasis.

Have started on HT - 5 weeks on bicaludamide and first Zoladex injection on 9 Nov 2020 (to be continued for up to 3 years),

Considering three treatment options:
- Surgery
- HT plus external beam RT
- HT plus external beam RT plus HDR brachytherapy boost.

Brachytherapy not available at my local hospital and have been referred to Mt Vernon for consultation on this treatment.

Have three heart stents and had a carotid endarterectomy last year after a mini-stroke. Atrial fibrillation. Take a heavy duty blood thinner. For these reasons rather wary about having a four-hour operation, but haven't ruled it out.

From what I can gather, external beam RT plus HDR brachytherapy boost would give the best outcome for my case, but with risk of more side-effects.

Would v much appreciate comments/experience.

Thank you

 

 

Edited by member 19 Nov 2020 at 16:21  | Reason: Not specified

User
Posted 17 Nov 2020 at 18:47

Hi Max, sorry you are here. We have a fairly similar diagnosis, my psa was higher than yours though. You will see from my profile I had the HT and Brachy boost. I am inclined to think that will be the best treatment for you. Surgery is unlikely to get all the cancer, so you will almost certainly need RT anyway, and I can't see any point in having the side effects of both. One of our members ANDY62 had brachy boost at Mt vernon I'm sure he will post soon with some details. 

Dave

User
Posted 17 Nov 2020 at 21:17

Hi Max,

Sorry you join this club.

As Dave said, I had HT plus external beam RT plus HDR brachytherapy boost at Mount Vernon, 15 months ago now. Very pleased with the results so far, but obviously, it's too soon to be out of the woods yet.

This treatment seems to be a good combination of best outcomes for high risk patients, with not particularly bad risk of side effects. My short term side effects were all gone by 10 months (and mostly much sooner). I have one late onset side effect, rectal bleeding, but it's painless and minor, and no impact on quality of life whatsoever.

Very happy to talk if you wish.

I also run the Mount Vernon Prostate Cancer Support Group.

User
Posted 17 Nov 2020 at 21:17

Hi Max,

I was also a G9 case. Went for HDR brachy and radiotherapy and still very happy with that choice.

Last PSA 6 months after end of the hormone therapy stands at 0.1

See my profile for further details.

Jon

 

 

User
Posted 17 Nov 2020 at 23:21

If you opt for surgery, you are unlikely to be on the hormone treatment for 3 years - the 3 years assumes you are having RT and/or brachy.

With the existing heart problems and stent, it is worth checking with the surgeon about surgery. Most of what you read will assume that you are going to have keyhole or robotic RP but most men with heart problems need open surgery which is a bigger deal with a longer hospital stay and longer recovery period. Open surgery still has slightly better outcomes that the others in terms of continence, erectile function and margins and less time under general anaesthetic but means longer off work, greater risk of blood loss, etc.

Also, with capsular extension the chance of surgery 'getting it all' is reduced which means you are significantly more likely to need adjuvant or salvage RT / HT anyway. 

Edited by member 17 Nov 2020 at 23:23  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 18 Nov 2020 at 09:13
Keyhole RP requires the patient to be tipped head down / feet up on the operating table, which puts enormous pressure on the heart.

Radiotherapy is looking like a more attractive option in your case!

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 18 Nov 2020 at 11:39

Hi Max,

Did they say it was a 4 hour operation.  I was told it could be longer if you're heavy although I'm pretty thin and he said between 2 and 3.   It took just over 2.  A very fast 2hrs for me.  Before the op there was about 30 minutes being piped up in the prep/recovery room and then I was stored, asleep, afterwards for a few hours while they cleared a bed.

With your stents and possible spread RT might be better to pick up stray elements.   Although a 1cm3 lesion isn't so big.  I was told mine was 13mm diameter.  You might think a 1cm3 would be around 10mm square a bit bigger if it was round, say 12mm diameter.  Mine was all on one side and close to the apex edge. 

All the best,
Peter

 

Edited by member 18 Nov 2020 at 11:52  | Reason: Not specified

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User
Posted 17 Nov 2020 at 18:47

Hi Max, sorry you are here. We have a fairly similar diagnosis, my psa was higher than yours though. You will see from my profile I had the HT and Brachy boost. I am inclined to think that will be the best treatment for you. Surgery is unlikely to get all the cancer, so you will almost certainly need RT anyway, and I can't see any point in having the side effects of both. One of our members ANDY62 had brachy boost at Mt vernon I'm sure he will post soon with some details. 

Dave

User
Posted 17 Nov 2020 at 20:16
Thanks very much Dave. Glad things have worked well for you.

Max

User
Posted 17 Nov 2020 at 21:17

Hi Max,

Sorry you join this club.

As Dave said, I had HT plus external beam RT plus HDR brachytherapy boost at Mount Vernon, 15 months ago now. Very pleased with the results so far, but obviously, it's too soon to be out of the woods yet.

This treatment seems to be a good combination of best outcomes for high risk patients, with not particularly bad risk of side effects. My short term side effects were all gone by 10 months (and mostly much sooner). I have one late onset side effect, rectal bleeding, but it's painless and minor, and no impact on quality of life whatsoever.

Very happy to talk if you wish.

I also run the Mount Vernon Prostate Cancer Support Group.

User
Posted 17 Nov 2020 at 21:17

Hi Max,

I was also a G9 case. Went for HDR brachy and radiotherapy and still very happy with that choice.

Last PSA 6 months after end of the hormone therapy stands at 0.1

See my profile for further details.

Jon

 

 

User
Posted 17 Nov 2020 at 22:18

Hi Jon

Thanks very much for this. Found your profile / history helpful.

EBRT plus brachytherapy sounds like a good option. Look forward to discussing it with Mr Vernon.

Glad your outcome seems to be good.

Max

User
Posted 17 Nov 2020 at 22:28

Hi Andy

Many thanks for this. Helpful to read your history, which, as you say, mirrors my own.

Will be in touch - thank you.

Max

 

User
Posted 17 Nov 2020 at 23:21

If you opt for surgery, you are unlikely to be on the hormone treatment for 3 years - the 3 years assumes you are having RT and/or brachy.

With the existing heart problems and stent, it is worth checking with the surgeon about surgery. Most of what you read will assume that you are going to have keyhole or robotic RP but most men with heart problems need open surgery which is a bigger deal with a longer hospital stay and longer recovery period. Open surgery still has slightly better outcomes that the others in terms of continence, erectile function and margins and less time under general anaesthetic but means longer off work, greater risk of blood loss, etc.

Also, with capsular extension the chance of surgery 'getting it all' is reduced which means you are significantly more likely to need adjuvant or salvage RT / HT anyway. 

Edited by member 17 Nov 2020 at 23:23  | Reason: Not specified

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 18 Nov 2020 at 08:58

Thank you very much Lyn.

Point taken about hormone therapy.

I think in my case, although I have circulatory problems, surgeons would use keyhole surgery. They mentioned that there are still risks because I would need to stop taking anticoagulant for a while before surgery, and a long period under GA carries risks.

Thanks again.

Max

User
Posted 18 Nov 2020 at 09:13
Keyhole RP requires the patient to be tipped head down / feet up on the operating table, which puts enormous pressure on the heart.

Radiotherapy is looking like a more attractive option in your case!

"Life can only be understood backwards; but it must be lived forwards." Soren Kierkegaard

User
Posted 18 Nov 2020 at 09:45
The surgeons did mention the position for keyhole surgery. Yes, another reasons to be cautious about going down that route in my case.
User
Posted 18 Nov 2020 at 11:39

Hi Max,

Did they say it was a 4 hour operation.  I was told it could be longer if you're heavy although I'm pretty thin and he said between 2 and 3.   It took just over 2.  A very fast 2hrs for me.  Before the op there was about 30 minutes being piped up in the prep/recovery room and then I was stored, asleep, afterwards for a few hours while they cleared a bed.

With your stents and possible spread RT might be better to pick up stray elements.   Although a 1cm3 lesion isn't so big.  I was told mine was 13mm diameter.  You might think a 1cm3 would be around 10mm square a bit bigger if it was round, say 12mm diameter.  Mine was all on one side and close to the apex edge. 

All the best,
Peter

 

Edited by member 18 Nov 2020 at 11:52  | Reason: Not specified

User
Posted 18 Nov 2020 at 13:47
Thanks Peter for sharing your experience. It's good that your surgery was smooth and successful.

The surgeons did indicate it was likely to be a long operation in my case - up to 4 hours. I am carrying about 5kg extra weight, so this may have something to do with this.

Although surgeons are happy for me to opt for surgery, they are not presenting it as the first choice. With the possibility of capsule involvement, RT may do a more thorough job of getting rid of cancer cells.

Thanks again, and all best wishes.

Max

 
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