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Criteria for Surgery

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User
Posted 19 Feb 2023 at 14:37

I am wondering whether there is any set criteria for ruling out prostatectomy as an option in treatment or is it down to the individual Healthboard or MDT to decide. Reason I ask is that surgery was ruled out for me (Gleason 7 T3bN0M0 PSA 36 at diagnosis). A friend of mine was also ruled out (Gleason 7 T3aN0M0 PSA < 10 I think). We’re both 66.

Reason I am asking is that I’m sure I’ve read on here members that have had surgery with similar staging. I’ve also read that many members have required Salvage RT at a later date, not sure if it relates to staging though.

I’m not unhappy with my choice(or lack of it) for HT/RT, just trying to understand why?

User
Posted 31 Mar 2023 at 17:47

I was recently diagnosed last month with a T3b N1M0, Gleason 8,  PSA 20.59.  After my PSMA scan showed 3 lit up pelvic lymph nodes, and following many posts on this community forum, I thought for sure I was going to be pointed towards RT and HT.  Surprisingly, I have had 3 surgery with lymph node removal recommendations and 0 RT. The first was after a lengthy phone conversation with the Dr. who performed my fusion biopsy in Munich.  The second was with the head of the department of Urology in Regensburg Germany (They were highly recommended, perform around 450 Da Vinci prostate surgeries a year, and not so far away from my home in Austria). The last recommendation was from my local Urologist.  All of them seemed to consider my quality of life based on the activities I enjoy doing, my age (56) and fitness level.  

Quality of life of course is also important to me, but with my diagnosis pushing the fine line boundary of no return, I am more interested in staying alive. I did not try to push for one procedure over another.  I just wanted their honest opinion on what they felt would be best for me, with curative intent.  It does appear that back in my home country of the US, as well as here in Germany where I will be treated, that surgery is often recommended, even in locally advanced cases.  

My neighbour strangely also had a very similar diagnosis to mine (54 years old, Gleason 8, PSA 13, I don't know his tumor size for sure but think it was T3a ), without lymph node involvement.  I had not seen him for a while, so I was surprised when I did and he told me about his having surgery for PC (in Austria) a month prior.  He was just as surprised to here of my surprise.   

Surgery, RT? I wish I had a clear answer which way is best.  I think I have read about every study that was ever published and am just as confused now as I was in the beginning.  So for me, 150 mg Bicalutamide a day that started at the end of Feb, until I have my surgery on the 16th of May.  I do like knowing that I will have more options if and when the cancer shows its ugly self again.  I am not so excited that nerve sparing will most likely not be possible.  

To better days,

Robert

 

Edited by member 31 Mar 2023 at 17:50  | Reason: Not specified

User
Posted 20 Feb 2023 at 07:43

Surgery is not normally offered for T3b, and not for T3a of some types (depending on extent/location of cancer beyond capsule and the surgeon) if there's any other possible curative treatment option. Both T3b and PSA ≥ 20 make you high risk for recurrence (as would Gleason > 7).

For such a diagnosis, you really need a treatment that will mop up any micro-mets (mets too small to show up on a scan) outside the prostate, and RT/HT is capable of doing this.

Other reasons to refuse prostatectomy are if you've had some types of previous abdominal surgery, or BMI > 30, or if the anesthetist thinks you're a high risk (previous cardio/stroke), or over 75, or other comorbidities resulting in your expectation of good quality life < 10 years.

Edited by member 20 Feb 2023 at 07:45  | Reason: Not specified

User
Posted 20 Feb 2023 at 19:45

Originally Posted by: Online Community Member

Originally Posted by: Online Community Member
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

unfortunately whole pelvic RT appears to have been ruled out for me because there is too much risk of damaging other organs…the bowel and rectum I think. They had 2 attempts at coming up with a computer plan but both times the Onco wasn’t happy. Obviously my plumbing is in the wrong place, don’t really understand why but intend to ask that question to the Onco. So, I was sent for another MRI scan and see the Onco on Friday and hopefully will get a start date for treatment as it’s now been nearly a year since first diagnosis(PSA test)

It is widely known that Prostates grow with age, some to a greater extent than others, although they can be in a somewhat different position and actually move, relative to other organs, particularly depending for instance on how much urine is in the bladder and and water in the stomach.  It's inevitable that because the RT is directed along certain paths that some hits the rectum for instance but it is calculated so that this does not exceed certain amounts. So some men with unusual layout and organ position can pose a challenge. Prior to my RT I had 5 CT scans to take all of this into account in one week plus an MRI scan, so intent were they to minimise collateral damage.

Edited by member 21 Feb 2023 at 10:34  | Reason: spelling

Barry
User
Posted 19 Feb 2023 at 20:08

I had a virtually identical diagnosis to yours and I was offered the ectomy as an alternative to HT/RT. In fact the recommendation from the MDT was surgery. I opted for the surgery but you will see from my story it hasn't worked too well for me. The surgeon was fairly confident he could get it all out with open surgery but the prostate histology came back with a positive margin. It's now a case of fingers crossed that the SRT has done the trick.

User
Posted 19 Feb 2023 at 22:01
When I first joined this forum, nerve-sparing surgery was really only offered to men who were T1 / T2 N0M0 - operating at T3 was almost unheard of, except where the man was going into the op knowing that all nerves were to be removed. It does seem more recently that some surgeons will do it - however, the risk of poor outcomes is greater with a T3 and that makes their stats on the BAUS website look bad. Consequently, some surgeons cherry pick much more than others. John's urologist specialises in difficult cases so his stats on BAUS look not so great.

It isn't as straightforward "is he T2 or T3?" either; much depends on where the bulk of the cancer is sitting ( according to the scan).

For a man with a T2 N0M0 diagnosis, there is a 30% chance of recurrence regardless of whether he opts for surgery or radiotherapy. At T3, the chance of recurrence rises quite steeply for surgery but not for RT.

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

User
Posted 20 Feb 2023 at 16:09
My feeling is that the classification of Gleason, and Staging is a general one, so just because one man has a similar diagnosis in those terms, in reality there can be many variables that can mean Surgery might be considered a good option or not by the surgeon and patient. Then any personal contraindications of the individual, age and other considerations have to be taken into account. When I saw a surgeon representing the MDT he told me my case was borderline 3+4 and T3A and that he would remove my Prostate if I wanted but said he doubted he could remove all the cancer. (I think some surgeons conscious of their success stats would not have even offered that). He was clearly glad that I agreed to have RT the MDT recommended instead and personally introduced me to a nearby Oncologist. So there can be flexibility and not always hard and fast criteria. Of course, there does come a point where the cancer has widely spread well beyond where the surgeon can reach and it would not make sense for a surgeon to spend expensive and scarce time on doing a Prostatectomy where there was no prospect of this being helpful other than in exceptional circumstances.
Barry
User
Posted 20 Feb 2023 at 16:51
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

User
Posted 20 Feb 2023 at 17:41

Originally Posted by: Online Community Member
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

unfortunately whole pelvic RT appears to have been ruled out for me because there is too much risk of damaging other organs…the bowel and rectum I think. They had 2 attempts at coming up with a computer plan but both times the Onco wasn’t happy. Obviously my plumbing is in the wrong place, don’t really understand why but intend to ask that question to the Onco. So, I was sent for another MRI scan and see the Onco on Friday and hopefully will get a start date for treatment as it’s now been nearly a year since first diagnosis(PSA test)

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User
Posted 19 Feb 2023 at 20:08

I had a virtually identical diagnosis to yours and I was offered the ectomy as an alternative to HT/RT. In fact the recommendation from the MDT was surgery. I opted for the surgery but you will see from my story it hasn't worked too well for me. The surgeon was fairly confident he could get it all out with open surgery but the prostate histology came back with a positive margin. It's now a case of fingers crossed that the SRT has done the trick.

User
Posted 19 Feb 2023 at 22:01
When I first joined this forum, nerve-sparing surgery was really only offered to men who were T1 / T2 N0M0 - operating at T3 was almost unheard of, except where the man was going into the op knowing that all nerves were to be removed. It does seem more recently that some surgeons will do it - however, the risk of poor outcomes is greater with a T3 and that makes their stats on the BAUS website look bad. Consequently, some surgeons cherry pick much more than others. John's urologist specialises in difficult cases so his stats on BAUS look not so great.

It isn't as straightforward "is he T2 or T3?" either; much depends on where the bulk of the cancer is sitting ( according to the scan).

For a man with a T2 N0M0 diagnosis, there is a 30% chance of recurrence regardless of whether he opts for surgery or radiotherapy. At T3, the chance of recurrence rises quite steeply for surgery but not for RT.

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

User
Posted 20 Feb 2023 at 07:43

Surgery is not normally offered for T3b, and not for T3a of some types (depending on extent/location of cancer beyond capsule and the surgeon) if there's any other possible curative treatment option. Both T3b and PSA ≥ 20 make you high risk for recurrence (as would Gleason > 7).

For such a diagnosis, you really need a treatment that will mop up any micro-mets (mets too small to show up on a scan) outside the prostate, and RT/HT is capable of doing this.

Other reasons to refuse prostatectomy are if you've had some types of previous abdominal surgery, or BMI > 30, or if the anesthetist thinks you're a high risk (previous cardio/stroke), or over 75, or other comorbidities resulting in your expectation of good quality life < 10 years.

Edited by member 20 Feb 2023 at 07:45  | Reason: Not specified

User
Posted 20 Feb 2023 at 16:09
My feeling is that the classification of Gleason, and Staging is a general one, so just because one man has a similar diagnosis in those terms, in reality there can be many variables that can mean Surgery might be considered a good option or not by the surgeon and patient. Then any personal contraindications of the individual, age and other considerations have to be taken into account. When I saw a surgeon representing the MDT he told me my case was borderline 3+4 and T3A and that he would remove my Prostate if I wanted but said he doubted he could remove all the cancer. (I think some surgeons conscious of their success stats would not have even offered that). He was clearly glad that I agreed to have RT the MDT recommended instead and personally introduced me to a nearby Oncologist. So there can be flexibility and not always hard and fast criteria. Of course, there does come a point where the cancer has widely spread well beyond where the surgeon can reach and it would not make sense for a surgeon to spend expensive and scarce time on doing a Prostatectomy where there was no prospect of this being helpful other than in exceptional circumstances.
Barry
User
Posted 20 Feb 2023 at 16:51
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

User
Posted 20 Feb 2023 at 17:41

Originally Posted by: Online Community Member
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

unfortunately whole pelvic RT appears to have been ruled out for me because there is too much risk of damaging other organs…the bowel and rectum I think. They had 2 attempts at coming up with a computer plan but both times the Onco wasn’t happy. Obviously my plumbing is in the wrong place, don’t really understand why but intend to ask that question to the Onco. So, I was sent for another MRI scan and see the Onco on Friday and hopefully will get a start date for treatment as it’s now been nearly a year since first diagnosis(PSA test)

User
Posted 20 Feb 2023 at 19:45

Originally Posted by: Online Community Member

Originally Posted by: Online Community Member
In my situation my urologist said that he would operate if that was what I really wanted, but he strongly recommended that I follow the MDT's recommendation for RT, because it was likely that I had undetectable micromets outside the prostate. I followed the advice given and had "whole pelvis" RT which irradiated not only the prostate but all the surrounding lymph nodes. Four years later and so far, so good.

Best wishes,

Chris

unfortunately whole pelvic RT appears to have been ruled out for me because there is too much risk of damaging other organs…the bowel and rectum I think. They had 2 attempts at coming up with a computer plan but both times the Onco wasn’t happy. Obviously my plumbing is in the wrong place, don’t really understand why but intend to ask that question to the Onco. So, I was sent for another MRI scan and see the Onco on Friday and hopefully will get a start date for treatment as it’s now been nearly a year since first diagnosis(PSA test)

It is widely known that Prostates grow with age, some to a greater extent than others, although they can be in a somewhat different position and actually move, relative to other organs, particularly depending for instance on how much urine is in the bladder and and water in the stomach.  It's inevitable that because the RT is directed along certain paths that some hits the rectum for instance but it is calculated so that this does not exceed certain amounts. So some men with unusual layout and organ position can pose a challenge. Prior to my RT I had 5 CT scans to take all of this into account in one week plus an MRI scan, so intent were they to minimise collateral damage.

Edited by member 21 Feb 2023 at 10:34  | Reason: spelling

Barry
User
Posted 31 Mar 2023 at 17:47

I was recently diagnosed last month with a T3b N1M0, Gleason 8,  PSA 20.59.  After my PSMA scan showed 3 lit up pelvic lymph nodes, and following many posts on this community forum, I thought for sure I was going to be pointed towards RT and HT.  Surprisingly, I have had 3 surgery with lymph node removal recommendations and 0 RT. The first was after a lengthy phone conversation with the Dr. who performed my fusion biopsy in Munich.  The second was with the head of the department of Urology in Regensburg Germany (They were highly recommended, perform around 450 Da Vinci prostate surgeries a year, and not so far away from my home in Austria). The last recommendation was from my local Urologist.  All of them seemed to consider my quality of life based on the activities I enjoy doing, my age (56) and fitness level.  

Quality of life of course is also important to me, but with my diagnosis pushing the fine line boundary of no return, I am more interested in staying alive. I did not try to push for one procedure over another.  I just wanted their honest opinion on what they felt would be best for me, with curative intent.  It does appear that back in my home country of the US, as well as here in Germany where I will be treated, that surgery is often recommended, even in locally advanced cases.  

My neighbour strangely also had a very similar diagnosis to mine (54 years old, Gleason 8, PSA 13, I don't know his tumor size for sure but think it was T3a ), without lymph node involvement.  I had not seen him for a while, so I was surprised when I did and he told me about his having surgery for PC (in Austria) a month prior.  He was just as surprised to here of my surprise.   

Surgery, RT? I wish I had a clear answer which way is best.  I think I have read about every study that was ever published and am just as confused now as I was in the beginning.  So for me, 150 mg Bicalutamide a day that started at the end of Feb, until I have my surgery on the 16th of May.  I do like knowing that I will have more options if and when the cancer shows its ugly self again.  I am not so excited that nerve sparing will most likely not be possible.  

To better days,

Robert

 

Edited by member 31 Mar 2023 at 17:50  | Reason: Not specified

 
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