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How relevant is age in diagnosis?
Raynman40409 posted:
I have, in the last two weeks, been diagnosed with PCa. 49 years old, Gleason 3+4, T2C, PSA 4.7, generally good health. Besides talking to my urologist my wife and I have also met with a radiation oncologist who is telling me that between radiation therapies and surgery, the 5-year survival rate is about the same. I have narrowed my choices to IMRT, radical prostatectomy or Cyberknife. Unfortunately, Cyberknife radiation therapy has very little supporting data for men around my age, most data reflects rates for men in their 60's. Anyone have any advice?
Raynman40409 responded:
I should also note that the cancer was confirmed on my 2nd biopsy. The first procediure in Feb 2011 was indeterminate by a lab in Nashville and was forwarded on to Johns Hopkins. Their result was benign, though suggestive of adenocarcinoma and another biopsy was indicated. A second biopsy, a saturation biopsy was performed in mid-May 2011 and of twenty cores removed, 7 of those were positive for adenocarcinoma over on average 60-80% of 5 of the cores. Six of the cores were from the right lobe. The only positive core on the left was 5% over the length of the core. DRE disclosed a nodule on the right lobe. CT's of the pelvis & abdomen with and without contrast were unremarkable, bone scan was also unremarkable.
Fairwind replied to Raynman40409's response:
Age is VERY relevant..At 49, you want the best chance at a CURE..Normally, you can expect to live 30 or 40 more years. That's a long time for organs damaged by radiation to hold up. There is ONE form of radiation treatment, Brachytherapy combined with IGRT for a total dose of around 150Gy..That procedure delivers the highest 10 year free from progression rate..The BEST surgeons, the real prostate pros who have done 500 or more prostatectomies and are currently doing at least one or two a week can give you your best shot at a cure and still leave you the option of radiation should they fail..Cyberknife is an unknown and what is known is not particularly good..The five big fractions have a high risk of doing severe damage to nearby organs.. The 35Gy total dose has not been proven to be effective against PC..

There is no easy way out of this...The side-effects can be terrible and there is no guarantee of a cure...You said something about a 5 year survival rate being the same with either surgery or radiation...You can expect to live far longer than that..Even the men with high-grade Gleason 9 cancer do better than that with proper treatment..

There are several good books dealing with PC..Dr. Patrick Walsh, a Johns-Hopkins surgeon wrote one of the best, "A Guide To Surviving Prostate Cancer."..If you have not read it, you should..Also, there is a lot of talk about how much better daVinci surgery is...While it is indeed less invasive and the recovery time is shorter, the older docs who still do open surgery achieve a better rate of "clean margins" according to a recent study..One thing for sure, success with surgery depends on the skill of the surgeon, be it open or robotic..If you decide on surgery, choose your surgeon carefully..Same with radiation....The best of luck to you..
Raynman40409 replied to Fairwind's response:
Thanks for the advice, you have been very helpful. One point you make had completely passed me by, and that is what you said about irradiated organs holding up for another 30 or 40 years, should I be blessed with such longevity. I have also read Dr Walsh's book, there is a lot of good information there.

Taking into consideration the extensive homework I have done, the other physicians I have spoken with (I'm a respiratory therapist, so I have access to a number of doctors I can talk to "off the record"). All of this has shown me the wonderful options out there, but the bottom line is that I have treatable cancer and my age will dictate treatment. That is why I am choosing open radical prostatectomy. I feel the cure is worth the risk and the post-op pathology is the only way to assess the true extent of my cancer. I have been told if I choose radiation, and the PCa comes back, surgery is automatically off the table. The surgeon I am dealing with is very experienced with this and I feel comfortable with his skill.

Dr Jonathan Epstein of Johns Hopkins, who is mentioned in Dr Walsh's book, was just one of the pathologists who interpreted my biopsies and goes on record saying that RP is the best treatment for younger men. Therefore, as I mentioned before, I feel surgery is my best treatment option.

Thanks again for your help and advice.
az4peaks2 replied to Raynman40409's response:
Hi Raynman, - Being 49, which is relatively young for Prostate Cancer (PCa), is a very important factor in your treatment choice considerations, whatever choice you eventually make. What the Radiation Oncologist said about 5 year survival rates being similar is correct, BUT at 49 years of age, that is only 1/6th of your remaining life expectancy of 29.4 years. THAT is how long you want to remain Cancer free.
It also provides a prolonged opportunity for PCa to recur, IF it is not cured by your Primary treatment.
Your Gleason SCORE has a Gleason GRADE 4 component, which is considered an aggressive G-GRADE, although because it is the Secondary grade rather than the Primary grade, it is the more favorable of the 2 most common Gleason 7 SCORES. Still, it is statistically, more subject to recurrence than the more favorable (3 3)=6, but LESS SO than IF the more aggressive (4 3)=7 Gleason SCORE had been present.

Traditionally, most PCa experts would recommend surgery for a man of your age and I believe that is still the case.. The major advantage in choosing the surgical route, for one so relatively young is that it provides a post-surgery Pathology Report which is, by far, the most accurate assessment of the extent and status of your PCa at the time of treatment. Since a substantial number of post-surgery PCa Gleason Scores are upgraded, as is the pathologic Staging, it is only logical that a substantial number of clinical Gleason's and clinical Staging's in those receiving other forms of treatment are also incorrect.. However, these are not identified as such because nothing but, less accurate clinical findings are all that is available to them.
I see now, that you have decided on Radical Prostatectomy as your treatment of choice. It certainly is a viable decision and as long as you feel it is an INFORMED one, you should move forward with confidence, since NO ONE can ever know what the result of any alternate decision would have been. decision. Good luck and God bless! - (aka) az4peaks
Raynman40409 replied to az4peaks2's response:
Thanks for your input, John. What began as a very scary time for me has now become less scary and more performance/cure driven. I have been learning more about this every day (More than I ever wished to know on the subject) and based on information, data, statistics and just plain old good advice from others who have dealt with this have all been instrumental in my decision to have the surgery. I have come to realize that the post-op path report is every bit as important as the cure itself. Sure, I have an excellent chance of surviving beyond 5 years with just about all the options available, but the next 24.4 years beyond that are important as well. Fairwind said this in his reply to my post in a way that woke me up, so to speak.

A Gleason score component of 4 is of great concern to me and this, all tied together with all I have learned is what helped me to reach my decision. Thanks again for your time and advice, it is greatly appreciated.
carjimgor replied to Raynman40409's response:
Hello Raynman, I was diagnosed with PCa 49 years old PSA 7.3. I choose Radical Prostatectomy in 2003, the patological report showed Glason 3 4, T2c. No problems with the surgery, no incontinence, no problems with ED.
PSA from 2003 to 2009 PSA less than 0.1 but since 2010 PSA was increasing slowly, in april 2011 was 0.23. I was recomended radiation, I have started 35 IMRT sesions from 23 May.
Raynman40409 replied to carjimgor's response:
Thanks much for your reply. What you have described is just one of the many hypothetical scenarios I have tried to imagine that may or may not happen to me. This is just one of the reasons I have opted for surgery. I feel if I have radiation now at my age, then there is a greater chance of the cancer returning. However, with surgery I have a better chance of being cured and remaining cured. At a later date, I may require salvage radiation as you are having to do, and that is something I have to keep in mind. With the exception of your higher PSA at diagnosis, it appears we were both diagnosed with fairly comparable stages of PCa and the fact that you had no problems with the surgery is reassuring to me that I am making the right decision and that I may be as lucky.

Thanks again for your input, you have been very helpful to me.
Gottano replied to Raynman40409's response:
Hi Raynman,
At 59 I was diagnosed with PC (Gleason 3 4) and PSA of 5.2, with a "ridge" felt on DRE. I was given the same arguments you heard about a chance for cure and using radiation as a fall back therapy if the cancer returned. Two years after radical prostatectomy (robot assisted laparoscopic), PSA is barely detectable at 0.01. The ridge turned out to be an extraprostatic extension of the tumor, cancer had invaded one seminal vesicle and my Gleason score was increased to 9. In hindsight, I wasn't a good candidate for RP. At age 49 you will have a long time to live with the effects of radical prostatectomy. If you're committed to having the surgery, I wish you the best; but if you're still wondering about other possibilities I suggest reading Surviving Prostate Cancer Without Surgery, by Dr. Bradley Hennenfent. the book gives a good overview (footnoted and referenced) of non-surgical options for treating prostate cancer (more current than Walsh's book) along with his reasons for opposing surgery. If you don't accept that view, you might still find some questions in it for your surgeon/urologist. Good luck.
Raynman40409 replied to Gottano's response:
Hello, Gottano. Thank you for your response. I appreciate everyone here who has given me solid input and good, sound advice based on experience. Your case has some similarities to mine (Gleason score, similar PSA, palpable abnormality) and you feel, in hindsight, that you were a poor candidate for RP at the time. You didn't give any details why you feel this way now and I can't help but ask, why would you have done things differently? Did you have complications at the time of surgery? Did you have any lasting effects of the surgery, such as incontinence or ED? These are all concerns that I have. Yes, I have committed to a decision to have surgery, but I am still open to hearing others arguments, whether for or against. My CT and bone scan seem to indicate that the cancer is contained within the capsule, but, I feel the only definitive answer at this point is to have the surgery, get the pathology report, begin monitoring my PSA and hope & pray for clean margins. Since my urologist felt a nodule on one side, I have to wonder if there might be some involvement with a seminal vessicle. That, along with my age, are just part of the driving forces behind me to have this done surgically. No matter what the treatment, all of it is a crap shoot, of sorts, and I'm betting on the surgery. That is, unless someone can convince me otherwise. Therefore, I would really like to know more of what your thoughts are. Until I sign in to the hospital and am rendered unconcious from the sedation, I still have the discretion of backing out of this decision and opting for something else. All that being said, though, right now I feel surgery is right for me. Thanks, and good luck to you, too.
Gottano replied to Raynman40409's response:
Hi Raynman. It's funny how you finished with the "discretion of backing out...". I remember laying on a gurney waiting to be taken in to the operating room and thinking "What am I doing here?" I had no pain, no symptoms and I was about to let someone cut out my prostate. It wasn't just nerves about surgery. I'd had major surgery more than once before and I had confidence in the surgeon. The operation went great and I went home the next day. Back to work in a few weeks and incontinence wasn't a problem after a couple months. I had (still do) hopes that ED would be less of a problem as time went on. Still, RP has resulted in a significant change in my life and it cannot be undone. As for not being a good candidate for RP, that was one of the follow-up opinions I got after the pathology report showed that I a particularly aggressive cancer. One (of the many second opinions) said that the extent of growth outside the prostate and seminal vesicle invasion could/should have been determined prior to surgery, indicating a poor chance of success using surgery as primary treatment. Apparently, with my pathology report from surgery, the "standard of care" called for immediate radiation and hormone therapy. The consensus was that I could expect recurrence within 5-10 years and aggressive adjuvant therapy could (20percent increase) extend the time to biochemical failure by as much as 12 months. I wasn't up for it (frankly, I didn't believe them and I was more interested in overall survival). I finally found an oncologist who recommended an unconventional approach - confident that the PC could be managed without further drastic treatment (radiation). Who knows? Perhaps you'll do well with RP. I sincerely hope so. And I also hope that the side effects from your treatment are minor and something you can live with. After talking with surgeons, radiologists and medical oncologists, I keep thinking about the old story of the man whose only tool was a hammer - every problem looked like a nail. Best of luck to you.
Raynman40409 replied to Gottano's response:
Hello, Gottano.
..."I remember laying on a gurney waiting to be taken in to the operating room and thinking "What am I doing here?" I had no pain, no symptoms and I was about to let someone cut out my prostate." That is, in some ways, how I have been feeling after getting past the initial shock of my diagnosis. But, I know I'm not going to wish this away. There is way too much clinical evidence supporting the fact that I am a younger man with PCa. I'm hoping that side effects from surgery will be minimal, but, those are issues my wife and I have begun to discuss, albeit very delicately and are willing to address further if and when the need to arises or not (no pun intended). Being that I, like most other men, have always seen myself as the prototypical dominant alpha male that is ten feet tall and bullettproof, I am humbled into realizing that PCa is my kryptonite. It has shown me that I'm only human. During my lifetime I have been an athlete, soldier, father/husband/son and general workaholic. So, sometimes, it is really hard for me to convince myself there is a problem. I have always taken the view that there are no problems in life, merely situations to be resolved. But I know this is a potentially life-threatening problem that must be dealt with. That (along with my age, Gleason score, tumor characteristics, statistics and data from several studies, as well as opinions of my physicians, etc.) has lead me to look to surgery as my most reasonable answer for primary treatment in my case. A lot of it is so I can get the post-op pathology report that will better quantify the extent of my cancer. To me, the choice for radiation of any kind as primary has too many unknowns I may or may not have to face in the coming decade(s). I initially went into this thinking radiation would be the way to go vs surgery. I did not even want to entertain the thoughts of someone "gutting me like a fish", so to speak. If, in the coming years my PSA begins to rise, then I still have salvage radiation to fall back on. As you stated, Who knows? Perhaps I'll do well with RP. I'm certainly hoping that that will be the case, as I sincerely hope is the case for every other man who is having to deal with this. I keep reminding myself that when caught early and appropriate treatment is initiated, this cancer has a very high cure rate. But, it's still cancer. One thing I can remember reading was about a man diagnosed with PCa several years ago and was told he had three choices-impotence, incontinence or death. Pick two. Thankfully, none of the three are nearly as worrisome as they once were.

For possible future reference, what is the unconventional approach you alluded to? I would like to know, just in case.
I wish you the best of luck, and God bless.
Gottano replied to Raynman40409's response:
Hi Raynman,
I'm not advocating one approach over another, just voicing my personal second thoughts about surgery. Hope it goes well for you - it sounds like you're well-informed and tough enough to take whatever results come your way. Also sounds like you've got family support (it's essential to discuss with your wife, as you probably already know). Unconventional approach is triple androgen blockade for 13 months followed by finasteride maintenance. However, for those of us whose first treatment (surgery or radiation), the follow-up is customized to the patient. In my case, I'm on finasteride "maintenance" with some off-label uses of drugs with some evidence of slowing progression of PC. Changed my diet as well (cut added sugar, reduced dairy and meat). Still trying to reduce stress and get regular exercise. Actually feel pretty good with all that and so far, PSA is at the limit (0.01). Take care.
ChadSJ replied to Gottano's response:
Hi Raynman,
I'm 43 years old. Went to my family doctor with pelvis discomform, was treated for a prostate infection with sulfer anti biotics. Had a psa test of 11. Family doc said the psa test was too soon after DRE, and cause of the elevated psa.
The pelvic discomfort went away after taking the antibiotics. On a follow up psa in May, psa test was 7.5. a biopsy showed 1 of 12 cores posative 5%, with a 3 3=6 Gleason. This week I visited a surgeon for consult on a robotic procedure. I feel the surgeon is experienced. He definately thinks surgery is right.
I also had a consult with a radiation doctor. I was very surprised that he recommended watchful waiting. He gave me paperwork with guidelines for watchful waiting, that are usually reserved for persons over 65 years old. I'm 43. He mentioned being able to keep my current lifestyle and erection as long as possable before having surgery and side effects. My young children are more impostant than an erection, so I don't go along with his opinion.
I will probably go with surgery, and am leaning toward open surgery. I was in a big rush to have a treatment and get it behind me. The initial shock is over, and am comfortable waiting a few months, if my doctors agree. Having surgery in the winter would be more convient for me. But cure is the most important.
I get a lot on mixed messages about what a cure is. Most tell me 10 years cancer free. But none seem to say a lifetime cancer free.
Good luck. My few weeks of research tell me surgery is a god option for a younger man.
ChadSJ replied to ChadSJ's response:
On anouther note,
Initially when I went to my family doctor with pelvic discomfort, he found an abnormality on DRE, but said prostate was small and pliably. Said it was an infection and often treats infections for several months. He is an older doctor from the old school.
After finding the cancer in a biopsy, 1 of 12 at 5%, Gleason 6 and psa 7.5. The urologist thinks there may be more cancer than the 1 of 12 biopsy would lead us to beleive, due to the psa of 7.5. he said psa of 2 would be more typical of a 1 of 12 biopsy.

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