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Old 10-04-2012, 07:51 AM   #61
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Mr Speed; you make a compelling arguement, however I disagree. For an older man who is not a good surgical candidate due to other health complications, you would be correct. Also, for a man who already has metastatic disease, surgery might not be called for.

But for a younger man with high volume cancer, the opportunity to "de-bulk" the body of the cancer should not be passed. In my case for example, I presented with a gleason 4+5=9, but no indications of metastasis. I was a youngish 57, and surgery made sense for me. By doing the surgery, I have maintained the radiation "bullet" if I might need it in the future.

In other words, salvage radiation is still available to me if needed. Very few surgeons would touch a patient who had prior radiation. Tissues that have been radiated pose real problems for a surgeon.

However for most cancers, a radiation doc will want to apply his skill, and a surgeon loves to cut. It's often about the $, and the patient must often decide on their own.

Have a blessed day.

B
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Old 10-04-2012, 09:02 AM   #62
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Quote:
Originally Posted by bentley View Post
Mr Speed; you make a compelling arguement, however I disagree. For an older man who is not a good surgical candidate due to other health complications, you would be correct. Also, for a man who already has metastatic disease, surgery might not be called for.

But for a younger man with high volume cancer, the opportunity to "de-bulk" the body of the cancer should not be passed. In my case for example, I presented with a gleason 4+5=9, but no indications of metastasis. I was a youngish 57, and surgery made sense for me. By doing the surgery, I have maintained the radiation "bullet" if I might need it in the future.

In other words, salvage radiation is still available to me if needed. Very few surgeons would touch a patient who had prior radiation. Tissues that have been radiated pose real problems for a surgeon.

However for most cancers, a radiation doc will want to apply his skill, and a surgeon loves to cut. It's often about the $, and the patient must often decide on their own.

Have a blessed day.

B
Bentley, prostate cancer treatment selection should be highly invidvidualizeded based on many patient specific variables, including tolerance for treatment specific side effect profiles. I am glad your choice worked out for you and you made a good decision.

With all due respect, however, the "best" treatment is hotly debated. High volume(bulk), high grade disease does not tend to do well with either radiation or surgery. Low volume, high grade disease is most likely cured with either. Salvage radiation does not work very often in high grade cancers that fail surgery, because they fail outside the prostate and not in the prostate bed.

With no prospective, randomized comparisons of treatment modlities in PCA, I would refer you to analysis recently published in the British Journal of Urology that reviewed all the peer-reviewed prostate cancer treatment articles published between 2000-2010, that had at least 5 years of f/u and 100 pts, and looked at treatment outcomes broken down by low, intermediate and high risk groups. Across all risk groups, pts who had surgery faired about the same as those who got external radiation, however the brachytherapy+/- external radiation groups stood out as having better outcomes, especially in the high risk group.

Comparative analysis of prostate-specific antigen fr... [BJU Int. 2012] - PubMed - NCBI
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Old 10-08-2012, 07:14 PM   #63
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Question: Given the current state of treatment options, is there any one treatment that provides the highest level of resolution with the lowest level of negative complications?

I've read a lot of the last week and I keep reading that Surgery does this but it has this potential complications. Same thing with radation. Same thing with freezing and homone therapy. If it came down to having to do something how in the world does one sort all of this out?

Question: If one were to select watchful waiting how do they judge if the time for watchful waiting needs to end and the time to do something has arrived? I would be concerned that one would wait too long and allow the cancer to spread.
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Old 10-08-2012, 08:10 PM   #64
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There is no single clear cut answer to your question. Trust me when I say that I have sat down and cried out of pure frustration over this very issue. My analytical engineering mind was driven crazy because I couldn't answer the questions, and neither could my dr's.

I can only suggest that you find a urologist that you trust and who has a good track record and let him do his job. There is one caveat to this though. Educate yourself. Buy Patrick Walsh's book "Guide to Surviving Prostate Cancer", and understand what your Gleason score, psa, pni, etc... means in context to your health.

Check out Chronic Illness Community, Support, and Resources - HealingWell.com. There is a great group of guys on the prostate cancer forum. Years of wisdom dealing with PCa.

God Bless
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Old 10-08-2012, 08:40 PM   #65
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Any one treatment modality can have horrible, quality of life altering complications, or be very easy. The answer to what is the best treatment is like all answers in medicine: "it depends". It depends on pre-existing urinary, bowel, sexual function, age, comobrdities, body habitus, prostate size and shape, stage, grade, extensiveness of disease, psa, what is important to the patient, mentality of the patient, work status, travel issues, among many other variables. One example and strong indication for surgery would be the patient who just has to "get it out of my body." Someone with that mindset would almost never be happy unless it was cut out, and therefore should get surgery. The other key is to explore all options at a comprehensive cancer center-- do not just accept the biases of the first doctor you see, which would almost always be the urologist that does your biopsy. The first sign that you are dealing with a doctor that is FOS is if s/he says you don't need another opinion and only gives you one option. Also, experience counts also in your treating physician. All treatments have only a small risk of horrible, permanent complications in experienced hands.
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Old 10-08-2012, 08:59 PM   #66
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Moondoggy, I started this thread. In August i had a Bx, 3 out 14 cores, all G6. My Urologist suggested Watchful Waiting. Went to see a surgeon, he said WW is definitely an option, but he also said that it is just delaying an inevitable. Both Uros said I have plenty of time to decide. I am defaulting to WW until my first PSA which is coming in early Nov. Bentley made a great suggestion. I have also spent countless hours researching and reading but realized that there is no Best, each case is different. For low risk PCa, more and more Uros are suggesting WW. I am 58 yrs old, yet both Uros are willing to suggest WW. Healingwell is a great site. Also USTOO website is quite good. Its monthly hotsheet keeps you informed of new development.
Assuming you you are low risk, take a little time to learn more about all the treatment options. I was very interested in Proton therapy, but can't seem to find longterm study by a third party. All patients seem to praise this treatment as the best in terms of very little side effects. I am still researching.
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Old 10-08-2012, 09:00 PM   #67
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Quote:
Originally Posted by Moondoggy
Question: If one were to select watchful waiting how do they judge if the time for watchful waiting needs to end and the time to do something has arrived? I would be concerned that one would wait too long and allow the cancer to spread.
You also go for yearly biopsy and psa. This has been my choice for the last six years, and it has been supported by urologist.
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Old 10-08-2012, 09:03 PM   #68
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Lightspeed, thanks for chiming in again, well said. It is very frustrating. I am not panicking yet, it has not sunk in. May be I am too dumb to appreciate the seriousness of this didease.
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Old 10-09-2012, 09:35 AM   #69
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This article about new blood test has just been posted on Healing Well by JohnKeats.

Scientists find blood signatures for aggressive prostate cancer | Reuters

Don't think it is available yet, but perhaps biopsy may not be needed in the future.

mp
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Old 10-09-2012, 09:57 AM   #70
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Nice article. It will be nice to have better tests, and better targeted gene therapies. It will make everything we do now seem barbaric.
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My 2 cents
Old 10-10-2012, 04:41 PM   #71
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My 2 cents

Hi Disappointed,

I was diagnosed with low grade prostate cancer in 2009 and after going through an extensive analysis of treatments decided on Active Surveillance (AS). AS is different than watchful waiting although many people use them interchangeably.

You can find out everything you ever wanted to know about active surveillance by viewing the archived webcasts from last Decemberís NIH consensus meeting at

NIH Role of Active Surveillance in the Management of Men With Localized Prostate Cancer Conference

If you are already familiar with this site then I apologize for being repetitious.

You can select the day that you are interested in by scrolling down and looking at the agenda. Once in the webcast you can then position to the presentation that you are interested in. For example, if you want to view the presentation at 2:10 pm on day 1 (Monday) delivered by Laurence Klotz (which I recommend) you can position the video to approximately 274 minutes. Following the Klotz presentation, there is a question and answer discussion that I think many people may find valuable. The question and answer discussions follow each of the 4 major areas addressed by the conference and I found them very informative.

Another presentation that I highly recommend is the results of the PIVOT study on day 2 at 10:10 AM by Timothy Wilt. You can position this video to approximately 93 minutes. PIVOT is the first US randomized study comparing radical prostatectomy versus observation/watchful waiting for localized prostate cancer. There are also podcasts of the presentations on the same web page as aforementioned (you need to scroll down) that are broken down into multiple segments. You can also read the final draft statement of the consensus meeting if you wish but I found that the videos and the subsequent discussions provided greater insights into the state of active surveillance.

As I read your prior posts I have some general observations that helped me and may help you. I would recommend that you always get your PSA test using the same assay at the same lab. The link

Two PSA Test Standards Are Causing Problems in Screening for Prostate Cancer from Dr William Catalona discusses the importance of using the same test standard.

Larger prostates will produce higher PSA values and therefore many institutions use the concept of PSA density (PSA value/Prostate Volume) of <.15 as entrance into their active surveillance programs. For example, if your prostate volume is 40 cubic centimeters or 40 grams (if expressed in weight rather than volume) and your PSA is 3.35 then your PSA density is 3.35/40 = .08 . Your prostate volume is determined by an ultrasound examination. About 50% of men over the age of 50 will have BPH (an enlarged prostate) and therefore a higher PSA value may not indicate cancer progression but rather BPH. Some men with very large prostates (>100g) can have PSA values greater than 10 without having prostate cancer.

Based on your interest in City of Hope I am assuming you would be open to going to Ventura California. Therefore, rather than basing your treatment decision solely on your Nov PSA, I would recommend that you consider seeing Dr Duke Bahn who can perform a color Doppler ultrasound on your prostate that will provide you with additional information such as if the cancer localized, missing cores that may not have been detected with your initial biopsy, etc. In addition, should you choose to continue with active surveillance then you may want to have a Color Doppler ultrasound performed on a regular basis to assess growth and aggressiveness. For more info see Prostate Institute of America.

I would recommend that you consider diet and lifestyle changes as part of your prostate cancer treatment. The good news is that a heart healthy diet/lifestyle program is also good for your prostate. The attached study by Dr Dean Ornish and others is a classic one on the benefits of this approach.

http://www.ornishspectrum.com/wp-con...ate_Cancer.pdf

I have also found an excellent nutrition guide from UCSF at http://urology.ucsf.edu/patientguide...n_Prostate.pdf

Lastly, I would recommend that when you are ready you consider changing your moniker from Disappointed to something more positive. When I was diagnosed with prostate cancer I read many books and articles about people who had prostate cancer and after getting over the initial shock and treatment felt it was the best thing that ever happened to them. It changed their relationships with family and friends, gave them a greater appreciation of life, focused on living in the presence.

Hope this helps and let me know if I can be of any assistance.
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Old 10-11-2012, 12:43 PM   #72
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Quote:
Originally Posted by Parallel View Post
Hi Disappointed,

I was diagnosed with low grade prostate cancer in 2009 and after going through an extensive analysis of treatments decided on Active Surveillance (AS). AS is different than watchful waiting although many people use them interchangeably.

You can find out everything you ever wanted to know about active surveillance by viewing the archived webcasts from last Decemberís NIH consensus meeting at

NIH Role of Active Surveillance in the Management of Men With Localized Prostate Cancer Conference

If you are already familiar with this site then I apologize for being repetitious.

You can select the day that you are interested in by scrolling down and looking at the agenda. Once in the webcast you can then position to the presentation that you are interested in. For example, if you want to view the presentation at 2:10 pm on day 1 (Monday) delivered by Laurence Klotz (which I recommend) you can position the video to approximately 274 minutes. Following the Klotz presentation, there is a question and answer discussion that I think many people may find valuable. The question and answer discussions follow each of the 4 major areas addressed by the conference and I found them very informative.

Another presentation that I highly recommend is the results of the PIVOT study on day 2 at 10:10 AM by Timothy Wilt. You can position this video to approximately 93 minutes. PIVOT is the first US randomized study comparing radical prostatectomy versus observation/watchful waiting for localized prostate cancer. There are also podcasts of the presentations on the same web page as aforementioned (you need to scroll down) that are broken down into multiple segments. You can also read the final draft statement of the consensus meeting if you wish but I found that the videos and the subsequent discussions provided greater insights into the state of active surveillance.

As I read your prior posts I have some general observations that helped me and may help you. I would recommend that you always get your PSA test using the same assay at the same lab. The link

Two PSA Test Standards Are Causing Problems in Screening for Prostate Cancer from Dr William Catalona discusses the importance of using the same test standard.

Larger prostates will produce higher PSA values and therefore many institutions use the concept of PSA density (PSA value/Prostate Volume) of <.15 as entrance into their active surveillance programs. For example, if your prostate volume is 40 cubic centimeters or 40 grams (if expressed in weight rather than volume) and your PSA is 3.35 then your PSA density is 3.35/40 = .08 . Your prostate volume is determined by an ultrasound examination. About 50% of men over the age of 50 will have BPH (an enlarged prostate) and therefore a higher PSA value may not indicate cancer progression but rather BPH. Some men with very large prostates (>100g) can have PSA values greater than 10 without having prostate cancer.

Based on your interest in City of Hope I am assuming you would be open to going to Ventura California. Therefore, rather than basing your treatment decision solely on your Nov PSA, I would recommend that you consider seeing Dr Duke Bahn who can perform a color Doppler ultrasound on your prostate that will provide you with additional information such as if the cancer localized, missing cores that may not have been detected with your initial biopsy, etc. In addition, should you choose to continue with active surveillance then you may want to have a Color Doppler ultrasound performed on a regular basis to assess growth and aggressiveness. For more info see Prostate Institute of America.

I would recommend that you consider diet and lifestyle changes as part of your prostate cancer treatment. The good news is that a heart healthy diet/lifestyle program is also good for your prostate. The attached study by Dr Dean Ornish and others is a classic one on the benefits of this approach.

http://www.ornishspectrum.com/wp-con...ate_Cancer.pdf

I have also found an excellent nutrition guide from UCSF at http://urology.ucsf.edu/patientguide...n_Prostate.pdf

Lastly, I would recommend that when you are ready you consider changing your moniker from Disappointed to something more positive. When I was diagnosed with prostate cancer I read many books and articles about people who had prostate cancer and after getting over the initial shock and treatment felt it was the best thing that ever happened to them. It changed their relationships with family and friends, gave them a greater appreciation of life, focused on living in the presence.

Hope this helps and let me know if I can be of any assistance.

Great Post, many many thanks, Parallel. I will go through all the videos etc. I am still very insterested in AS (it is more of a default option at this time). My main Uro is Dr. Ukimura at USC, he also practices Color Doppler + Elastography Ulrasound. He may or may not be as good as Dr. Bahn. I went with Dr. Ukimura based on his article published in one of the journals that I found at the time. He also suggested DRE and Ultrasound every six months (or annually - need to look at my note). He suggested Bx every two years, I am a little uncomfortable going that long without a Bx but I am not looking forward to the procedure. I think he also suggested MRI (my Bx was MRI fused, CDEUs).

Please staty in touch. It is comforting to have somebody to share and talk with while going through this AS.

On a different note, my company will be sold next year, I am planning to retire when it is sold. However, this event may influent my choice of treatment due to the health insurance issue, it may force me to take the active treatment route. While I can afford the active treatments (surgery, Proton, etc.) on my own, I am very concerned about the ongoing or unexpected future problems.

mP
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Old 10-12-2012, 06:11 PM   #73
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Well, I thought all of you should know that I had a PSA test before having my biopsy on Wednesday and had no real ill effects from the biopsy. This afternoon (Friday) the doctor called and said my PSA was 1.3 up from 0.5 of last year but still normal and the biopsy results were all negative (no cancer). The doctor said the increased in my PSA could be related to an infection of the prostate he thinks I was having when I went in for my initial appointment and/or the DRE that he performed last week. Anyway, he said as a precaution we would do a follow up PSA and another DRE in 6 month to insure that things are remaining normal. Not that things can't change but I'm thankful that at least for now I'm one of the lucky ones and hopefully things will stay that way. Thanks to everyone that provided input when I was freaking out. It was VERY much appreciated.
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Old 10-14-2012, 10:40 AM   #74
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I would not be too concerned about taking a biopsy in 2 years. Currently there is no standard protocol for frequency of repeat biopsies. Since your physician is doing regular ultrasounds (preferably every 6 months) he should be able to detect any tumor progression and if so can schedule a biopsy earlier than 2 years.

In my case, I had a second biopsy that was negative at 15 months and have not had a third biopsy in over two years. Many physicians are concerned about the increased infection rate for prostate biopsies. See attached url

Prostate Exam Deaths From

You might also be interested in the attached research showing that dogs are better at detecting prostate cancer than a psa test.

http://www.urosource.com/fileadmin/E...olas_Cornu.pdf

Maybe the future is prostate cancer sniffing dogs for initial diagnosis, genetic testing to determine cancer aggressiveness, MRI's for ongoing AS and then we can eliminate biopsies and psa tests.
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Old 10-15-2012, 09:14 AM   #75
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Quote:
Originally Posted by Parallel View Post
I would not be too concerned about taking a biopsy in 2 years. Currently there is no standard protocol for frequency of repeat biopsies. Since your physician is doing regular ultrasounds (preferably every 6 months) he should be able to detect any tumor progression and if so can schedule a biopsy earlier than 2 years.

In my case, I had a second biopsy that was negative at 15 months and have not had a third biopsy in over two years. Many physicians are concerned about the increased infection rate for prostate biopsies. See attached url

Prostate Exam Deaths From

You might also be interested in the attached research showing that dogs are better at detecting prostate cancer than a psa test.

http://www.urosource.com/fileadmin/E...olas_Cornu.pdf

Maybe the future is prostate cancer sniffing dogs for initial diagnosis, genetic testing to determine cancer aggressiveness, MRI's for ongoing AS and then we can eliminate biopsies and psa tests.
It would be great if Bx is replaced by other forms of detection.

Thanks again for all the info.

mP
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