Radio Therapy or Surgery??

Steve,

in my case and I've seen and heard of it in others here, once my urologist knew that there was some level of breakout from the prostate, he wasn't willing to go ahead with a prostatectomy because there was a fair chance something would be left behind and in consequence he believed that RT was a better option. In retrospect I think it was a wise decision. I'm confident in saying that many urologists will take the same position, though I realize that some are willing to do surgery knowing that the cancer is not contained.

I know there's a tendency to think that once the prostate is out it will solve the problem and if the cancer is contained that's a fair call. If the cancer is not contained, with clear margins the story gets more complex and if it gets into the lymphatic system, it's on a railway line to the rest of your body where progress is unpredictable. In that case the prostate itself is not so much the issue as the spread, which is the real killer.

My own path ... G9, high risk locally advanced, T3bN1M0, cancer in 3 lymph nodes, RT and HT 2 years ago, now psa <.01 and no residual issues of any sort. If I'd been offered a choice I probably would have gone with a prostatectomy and follow up but in retrospect I'm more than happy I had to go RT/HT. Now, I take the position that it makes more sense to go through the process once, with a good chance of a "curative" treatment than to have to return for more scans, more treatment and possibly lifetime HT. I think we all tend to downplay the seriousness of PC, as a coping strategy, but it can be to our detriment when we're deciding on treatment options.

Steve, you're asking me why a prostatectomy followed by an RT clean-up is not as good as starting with RT and I don't know the answer, though I have read here in a number of threads that your first chance at treating cancer is your best chance and the probability of success reduces with subsequent treatments.

At this stage Mark is dealing with conflicting opinions from "consultants". Post scan results this might change and I hope that the consultants involved are representing both surgical and radiotherapy opinions.

Jules

Edited by member 30 Aug 2023 at 07:55  | Reason: Not specified

Both your staging and your Gleason are high risk. With this, micro-mets (mets too small to show on scans) in the area around the prostate, seminal vesicals, and lymph nodes must be a possibility too. I would be looking to hit it hard first time.

If your hospital offers HDR boost, I would ask if they think it's suitable. This is a radiotherapy combination where about half the dose is given using HDR brachytherapy to prostate and seminal vesicles, and the other half is given using external beam radiotherapy to same areas, but also including area around prostate and pelvic lymph nodes at a lower dose. This puts a higher dose into the prostate than can be achieved with external beam radiotherapy alone (prostates handle high doses well), but also aims to mop up any micro-mets in the most likely places, i.e. just around the prostate and in the pelvic lymph nodes (at a lower prophylactic dose). This will come with a period on hormone therapy too, probably at least 2 years. Although this hits the cancer hard, the side effect profile is not usually excessive.

I had this treatment although my diagnosis wasn't as high as yours. I'm very happy with the outcome, but there are no guarantees of course.

Edited by member 05 Sep 2023 at 19:05  | Reason: Not specified

Glad you've made your choice. You've taken a month to think about it and know the risks (at least as much as anyone can) so now go through the treatment and hopefully live happy ever after.

Keep us updated, people are more likely to hang around on here if they have problems. We would have a much more representative (and positive) view of prostate cancer if the 70% of successfully treated people stayed on the forum.

Sorry Mark, that's not what you wanted to hear.

I would push for a PSMA PET scan to try and find it, but your PSA is currently too low for that to have much chance of finding anything, so you will probably need to wait until it's risen some more. They might do some other scans in the mean time. Did you have a bone scan during diagnosis? If not, that's one you could have now.

So sorry to hear this Mark and I can understand why you’re feeling gutted. I suppose that’s the risk you take when surgery is kind of borderline. As I’ve said before,  in Scotland they wont do surgery if there’s any risk of spread which is why I wasn’t given that option, which I would have chosen if it had been….and then quite possibly I’d been where you are now. That’s not much help to you but theres  many on here who have had SRT and can advise you better than me and  I wish you all the best with any further treatment required. I’m sure you’ll cope well if SRT is required and hopefully the side effects will be minimal.

Derek

This thread covered a lot of treatments and reasoning behind them. I would start by working your way through it.

https://community.prostatecanceruk.org/posts/t26986-Can-t-understand-why-anyone-would-choose-surgery-over-Brachytherapy--I-must-be-missing-something

Hi Mark. It is undoubtedly difficult decision. I had a similar diagnosis to you (Gleason 4+3 & 4+4, T3bN0M0). I was given the options of surgery or RT/HT. I was unsuitable for Brachy. I chose surgery because the MDT favoured that option and I didn't fancy up to three years on HT. Also part of me wanted to be rid of the dammed thing as soon as humanly possible. Like you, I was warned the there was a strong possibility of SRT after surgery and that turned out to be the case.

Any regrets? Maybe some. I had extensive lymphodenectomy with the surgery which led to side effects I was not really prepared for. However one of the 36 lymph nodes removed turned out to be cancerous. On the plus side it does seem to have done the trick. I'm now 10 months post RT and my PSA remains undetectable.

Do make sure you get the opportunity to discuss the options with both the urologist and the oncologist. Also find out whether the surgery will be nerve sparing and whether there will be any lymph nodes removed. Not all surgeons favour it.

Having had RP myself along with a load of life threatening complications I still take comfort from knowing I don't have a prostate to worry about.

So RP is the radical option BUT post OP you would at least have the comfort (or not) of knowing the exact extent of your cancer in the prostate and seminal vesicles.

You would also post OP know with some certainty if they have got it all.

Hopefully the PSMA scan will help guide your treatment but with that 5 and T3B you should not be hanging about waiting for scans.

Mark, in the meantime you’d probably be put on HT. I was told I would be on it for life if it came back, but I’m not just going to accept that if it happens, I will be searching around for a second opinion.

Hope you get your scan result soon, things might become clearer then.

Derek

We’ve made some positive lifestyle changes too, this helps us focus on how to generally be healthier and keep feeling well. Life can still continue and be good even when living with cancer….you just have to believe it and try to enforce it. (I know it’s easy for me to say but I take this stance with rob) 

I honestly think you’ll feel better when you get the scan results. If you’re struggling maybe try and contact them to tell them this and hopefully they could get the results to you asap 🤞🏼

Keep strong, things will be ok x

Great news indeed Mark and I suspect you have already decided which treatment is best for you. I look forward to hearing what your decision is…once you’ve made it you will feel much better and can start to plan for the future.

all the best with your decision.

Derek

If you decide to go for RP make sure that the consultant has had a lot of experience. I don't know about other treatments but in my case, because I had private health insurance,  I was able to pick a top guy who had performed about 60 robotic procedures (that was a lot in in 2011). In my case the surgery turned out to be rather complex and difficult, lasting over 6 hours. However I did come through with very good outcome. That was 12 years ago. You are in a good position, whichever route you take; there is a lot more experienced consultants out there. Good luck.

Hi Mark

I was diagnosed last week, and after a lengthy conversation with my Urologist I am opting (I think) for surgery. She said there is "quite a lot" of cancer in there, even though it is luckily still contained, so I want it gone. We did discuss RT or Brachy, but I was told that after one lot of treatment via either route, it wouldn't be possible/advisable to repeat if it comes back. At least with surgery, if there is a future issue it can be attacked with RT etc.

I am aware of the side effects that can go with surgery, but at 59 I am willing to tolerate them in order to be rid of this thing (hopefully).

Just waiting for a meeting with the surgeon to discuss, so nothing concrete yet, but I can't see me changing my mind.

Good luck with whatever option you choose. I am sure we will be updating each other via this forum!

Take care. 

Ian.

I remember my confusion at the onset. The only difference was that, I did not have the benefit of this wonderful site, when I got my diagnosis. I booked a meeting with all the various consultants - my main concern was ED. However, I soon got to understand that each path carried a risk of ED and/or incontinence. I even went left of field and requested a session with the HiFU team @UCLH. I made it to that treatment by the skin of my teeth. I had do another MRI scan and a second biopsy just to check if I was a good candidate for HiFU. The choice in the end boiled down to HIFU or surgery. I even took myself off the surgery list. What made my mind up was the opinion of the HIFU consultant when I asked him what he would do if he were me, he did not mince his words he said, giving my age late 50's he would go with surgery. That was that!

Yes, urologists will usually advocate surgery which is understandable as it is the area they know best and favour where the patient is suitable. But in my case the surgeon told me he would operate if I wanted but his view and that of the MDT was it was unlikely that he could remove all the cancer so recommended I have RT instead. Oncologists are more familiar with RT and apart from taking cases like mine that the surgeons don't want, feel that one of the forms of RT is just as good an option as surgery, particularly as major advances have taken place in RT over the last 10 or so years. There was a prominent member of this forum and great character and researcher user name 'Athalays' (You can see his profile here)- https://community.prostatecanceruk.org/default.aspx?g=profile&u=2673 He expressed great confidence in his Oncologist who claimed whatever a surgeon could do, he could do just as well with RT.
So it's good that specialists have confidence in their area of expertise where there are not contra aspects. Certainly, there was a time when surgery was largely considered the 'Gold Standard'. My second opinion who was a radiation specialist told me this was his view in 2007. However, with great RT refinement in the intervening years, this view is now contestable. Other individual considerations now may be given more weight by patients in coming to a treatment decision.

Edited by member 07 Sep 2023 at 13:36  | Reason: to highlight link

It is, but my biopsy was G7 and I had the RARP and then the lab upgraded it to G9 T3bN0M0 - so it's a tricky one. Would my surgeon have proceeded with the RARP if they had know the state of the PCa beforehand?
Post RARP PSA was <0.01 so although it means I may still need RT later, initial results are promising. 

All the best for your treatment Mark. It should take the pressure off once you get going.

Jules

Mark - that's great news and very quick which is nice to hear in these troubled times of the NHS! If you need any advice on preparing for the surgery or what to expect afterwards then just ask - it's waaaayy less scary that you are probably imagining :)

Hello .My PSA did not  drop very much after my prostectomy so I had a  Pet scan that revealed spread to local lymph nodes .However recent scans show no cancer in the lymph nodes or anything else of concern .I am very  grateful to the team at the  Oncology section of our NHS trust for the wonderful treatment i have received .My initial diagnosis was in 2016 when I was also found to have superficial bladder cancer and after treatment I have been completely clear for 6 years now .I had my yearly cystoscopy checkup last month and am still completely clear .Enzalutimide for me has been a wonderful drug despite  the side effects which are manageable .

So had the RP which was a nervous experience.

Glad I’ve had it done now. Surgeon managed to save nerves on one side and most on other.

Continence is good so far.

Just need to wait on histology now. Hoping there is no node involvement and I have negative margins!

This waiting is very difficult..

best wishes to everyone

Mark

Glad it's done and remarkably fast for the NHS. Give yourself plenty of time for recovery. Waiting on test results will be your future from now on, worrying about them won't change them, so chill out.

So glad it’s done and you’re feeling ok Mark. Wishing you a full and speedy recovery.

I’m so sorry aswell that I’ve just seen your message from the 15th about my inbox. I’m just on holiday and left on the 15th so I missed it! I have deleted some messages now so please feel free to message anytime x

I don't think they will start or even consider HT/SRT at this stage - you need to get that first PSA result and that will guide them on any next stages that might be needed.

Good luck

Sorry to hear that Mark, I’m sure there are many on here who are more qualified to give you advic.

Hi all,

so latest PSA is 0.32 which is disappointing.

Was hoping for some time before I needed SRT. 

Not sure what I’ll be offered as waiting to see onco.

Any advice would be very welcomed.

im pretty gutted to be honest.

Hope everyone is doing ok.

rRegards

Mark 

Thanks for the reply Chris.

It is quite demoralising when this happens, especially so soon after surgery.

Im speaking to my onco about a PSMA scan which he is organising for me so will take it from there when it’s done.

its a scary time again too:. Just like when you are diagnosed!!

good luck with your PSA test. Let me know how you get on.

All the best

Mark