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44yr PSA180 Gleason9 non-metastatic. Surgery or Treatment?
Prostate Cancer | Last Active: Mar 16 9:03am | Replies (166)Comment receiving replies
In reply to @heavyphil, Memorial Sloan Kettering team in NYC and MD Anderson team in Houston, TX both slightly preferred proton radiation for my case. Mayo urology said surgery; Mayo radiation oncologist said photon radiation. Mayo concerned about cancer cells potentially invading the rectum since I have extracapsular extension near the rectum. Photon will pass through the prostate and “hit” the rectum to cover bases there. MSK in NYC and MD Anderson in Houston preferred proton due to pelvic lymph node involvement - I believe they are concerned about limiting bone marrow exposure due to proximity of pelvic lymph nodes to bone. I have asked them to clarify their specific lymph node concern. MD Anderson did present my case at tumor board - radiation with a SLIGHT preference toward proton (if insurance will cover) was recommendation + hormone cocktail previously mentioned. I had the same thought you raised about photon - it would seem more is better to get all the microscopic “floaters, ” right? Two of the three Centers of Excellence I consulted are leaning toward proton. It’s a tough call…I’m trying to learn as much as I can as quickly as I can. They all agreed the hormone cocktail should shrink the tumor some prior to radiation which will help proton precision. The hormone cocktail will also “sensitize” the cancer cells to radiation (making it more effective) so they want me on that for at least a couple months prior to starting therapy. Additional thoughts?
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4rs, I just posted a 10 paragraph response to your question and somehow it got lost so I will be brief.
That extra capsular extension close to the rectum should be a big cause of concern. I don’t think there is any MRI or CT scan computer generated algorithm that can shape a beam to be so accurate as to hit the prostate only and not the rectum.
I really believe that surgery is your best option - and this is coming from a guy who considered surgery as his LAST option when I was going through all this.
But I think you have to be pragmatic about your situation. You are very young and you have a higher grade cancer. The statistics would say that it has a good chance of coming back at some point in the future.
With that in mind, I would reserve a second chance to hit it. Surgery first - and then radiation as an option if you need it, is a sound plan. If you have radiation first - even proton radiation - salvage surgery is still extremely difficult.
I completed salvage radiation at Sloan Kettering in Commack about eight months ago. When I asked my radiation oncologist about a gel spacer he said that was not recommended because he wanted to treat any rogue cells that might be lurking near the rectum. You have an obvious mass lurking next to your rectum, and I think a careful dissection in the hands of a skilled robotic surgeon would offer you the best chance of removing the cancer and minimizing damage to your rectum. Surgical pathology will tell the true tale (hopefully!) if your surgical margins are clean; if not, immediate adjuvant radiation therapy would be done in 90 days.
Anyhow, just my personal opinion. I am telling you exactly what I would do if I were in your shoes today, knowing what I know ( and have learned) after 6 years of this freakin crap!
Phil