SBRT vs. Robot-assisted radical prostatectomy

Posted by dandl48 Dave @dandl48, Jun 11 11:47am

Well, my last visit to Mayo didn't go as well as I wanted. I'm 72 years old and I had an Ultrasound-guided transperineal prostate biopsy and the results came back positive for cancer with a Gleason score of 4-3=7 and the Grade Group of 3 which is a Risk Group of Intermediate Unfavorable. With these results active surveillance is out and it's either radiation or radical prostatectomy . If I choose radiation SBRT is available to me using protons for 5 treatments over a 10 day period. The downside of this treatment is I will have to have a 4 month Lupron injection before radiation and that if the cancer returns removal of the prostate would probably off the table. Choosing the radical prostatectomy which would be robot assisted, comes with its own problems, infection, incontinence and impotence. Decisions, decisions, I'm open for your input.

Thanks, Dave

Dave see my prior posts on this decision. I had exactly the same numbers as you and after agonizing review, chose DaVinci prostatectomy. I do not regret it. Any time you can cure cancer with surgery, you should do it. If you have been reading the recent posts on this site about the side effects of Lupron, radiation etc, you will know the situation. There are downsides from surgery but they are manageable. ED is certain but can be boosted with drugs; there is some leakage on coughing and I have some low level pain in the urethra (rare). But I am now 4 years post surgery with a PSA of zero and retain a healthy libido and function. One thing you should do is to have the Prolaris test done to determine the degree of aggressiveness of your cancer. Best of luck.

Liked by dandl48 Dave

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I was similar to you as well. Stage 3, 4+3=7 Gleason. Since it had spread (stage 3) it was deemed inoperable because I would still need radiation. I was told radiation on an area after an operation could be harmful. I went on Lupron then had High dose brachytherapy and 25 external beam. I was on Lupron for 24 months. If you stay active and communicate with your doctors – 4 months would not be too bad.

Liked by dandl48 Dave

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I'm pleased with your results, Horace, including the minimal side-effects. Like you, I was faced with the same agonizing decision — surgery or radiation. I spoke with several urologists, along with patients who had experienced both forms of treatment. Most were successful. The side-effects of surgery tended to be more pronounced in the near-term — incontinence, ED, etc., which in some people, continued to last more than 24 months after surgery. The impact of radiation on patients was dramatically less so, though the data suggests that the side-effects for radiation are more often seen in the long term, principally due to radiation effects beyond the prostrate itself. At 73 and with Gleeson scores that ranged from moderate to aggressive, I was stuck in the middle on making my treatment decision either way. The tipping point for me was a conversation I had with a young urological surgeon. Typically, surgeons will always lean toward recommending their skillset — cutting. And, like any good surgeon, he confidently predicted I would have successful prostate surgery based on his many operations. That said, he said that his father was my age, 73. He then said that if his father's cancer was the same as mine, he would recommend that he undergo radiation treatment. Why? Put simply, he said that at his father's age why risk the near term surgical side-effects that m I describe above and possibly continue to suffer from them for a longer period of time/end of his life? Moreover, the data indicates at 73 he will likely suffer another, separate medical event that may have serious consequences, making his life even more uncomfortable when dealing with surgical side-effects. Successful radiation treatment would assure a higher quality of life for the foreseeable future. Future consequences aren't inevitable. Remember, this advice is coming from a urological surgeon who has witnessed the side-effects of more than 1,000 surgeries/patients firsthand. This conversation was the tipping point for me. I opted for radiation. Put simply, it was a lifestyle choice based on my willingness to possibly pay now (surgery) or pay later (radiation). I successfully completed 28 days of radiation therapy in late May. It's an extraordinary benign experience. I will remain on ADT (lupron) though September. I anticipate the cancer will be well behind me by then and that only periodic check-ups will be needed. Survivability rate for this treatment protocol is in the 90th percentile. My choice is not an argument against surgery. I understand its virtues. I also understand why individuals may make the opposite choice of my mine. However, my experience may help your decision-making either way. Should you go with radiation, I would question the advisability of a high dose, 5 day treatment vs. a longer period at a lower dose. There is no good evidence that the high dose/5 day treatment is more effective. Challenge your MD for an answer. Finally, I suggest you visit the website for the Prostate Cancer Research Institute (PCRI). Excellent information and data, along with some great, short video opinions/insights. Good luck!

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I had a similar conversation with my urologist concerning my favorable immediate risk PCa. I directly asked him if I was his father would he recommend RP and he stated no, he would do radiation at my age (67). My Oncologist at Mayo said I would be a good candidate for SBRT/PBT (5 treatments) as an option.

Liked by dandl48 Dave

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@bruto1

I'm pleased with your results, Horace, including the minimal side-effects. Like you, I was faced with the same agonizing decision — surgery or radiation. I spoke with several urologists, along with patients who had experienced both forms of treatment. Most were successful. The side-effects of surgery tended to be more pronounced in the near-term — incontinence, ED, etc., which in some people, continued to last more than 24 months after surgery. The impact of radiation on patients was dramatically less so, though the data suggests that the side-effects for radiation are more often seen in the long term, principally due to radiation effects beyond the prostrate itself. At 73 and with Gleeson scores that ranged from moderate to aggressive, I was stuck in the middle on making my treatment decision either way. The tipping point for me was a conversation I had with a young urological surgeon. Typically, surgeons will always lean toward recommending their skillset — cutting. And, like any good surgeon, he confidently predicted I would have successful prostate surgery based on his many operations. That said, he said that his father was my age, 73. He then said that if his father's cancer was the same as mine, he would recommend that he undergo radiation treatment. Why? Put simply, he said that at his father's age why risk the near term surgical side-effects that m I describe above and possibly continue to suffer from them for a longer period of time/end of his life? Moreover, the data indicates at 73 he will likely suffer another, separate medical event that may have serious consequences, making his life even more uncomfortable when dealing with surgical side-effects. Successful radiation treatment would assure a higher quality of life for the foreseeable future. Future consequences aren't inevitable. Remember, this advice is coming from a urological surgeon who has witnessed the side-effects of more than 1,000 surgeries/patients firsthand. This conversation was the tipping point for me. I opted for radiation. Put simply, it was a lifestyle choice based on my willingness to possibly pay now (surgery) or pay later (radiation). I successfully completed 28 days of radiation therapy in late May. It's an extraordinary benign experience. I will remain on ADT (lupron) though September. I anticipate the cancer will be well behind me by then and that only periodic check-ups will be needed. Survivability rate for this treatment protocol is in the 90th percentile. My choice is not an argument against surgery. I understand its virtues. I also understand why individuals may make the opposite choice of my mine. However, my experience may help your decision-making either way. Should you go with radiation, I would question the advisability of a high dose, 5 day treatment vs. a longer period at a lower dose. There is no good evidence that the high dose/5 day treatment is more effective. Challenge your MD for an answer. Finally, I suggest you visit the website for the Prostate Cancer Research Institute (PCRI). Excellent information and data, along with some great, short video opinions/insights. Good luck!

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I understand your situation. I was 74 when I had the surgery in 2016 and in very good shape (work outs, walk the golf course, no other diseases etc) and so it turned out fine. I also have 4 friends who had similar numbers and opted for surgery and all came out very well. It is a personal choice. The relief to have the cancer gone is high and the worst was over recovering from the surgery in 2-3 weeks. I did not want to have the drug/radiation side effects and planned to have a long life. Hope it comes out well for you.

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@horace1818

Dave see my prior posts on this decision. I had exactly the same numbers as you and after agonizing review, chose DaVinci prostatectomy. I do not regret it. Any time you can cure cancer with surgery, you should do it. If you have been reading the recent posts on this site about the side effects of Lupron, radiation etc, you will know the situation. There are downsides from surgery but they are manageable. ED is certain but can be boosted with drugs; there is some leakage on coughing and I have some low level pain in the urethra (rare). But I am now 4 years post surgery with a PSA of zero and retain a healthy libido and function. One thing you should do is to have the Prolaris test done to determine the degree of aggressiveness of your cancer. Best of luck.

Jump to this post

@horace1818 Horace, Thanks for your input and advice. Sometimes I wish Mayo wouldn't give you options, Just say to me "You have cancer and we will get it out by doing xyz."

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@dmadi61

I was similar to you as well. Stage 3, 4+3=7 Gleason. Since it had spread (stage 3) it was deemed inoperable because I would still need radiation. I was told radiation on an area after an operation could be harmful. I went on Lupron then had High dose brachytherapy and 25 external beam. I was on Lupron for 24 months. If you stay active and communicate with your doctors – 4 months would not be too bad.

Jump to this post

@dmadi61 Thanks for your response. Hopefully my hasn't spread (the MD's feel it is contained to the prostate) The Lupron does concern me though.

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@bruto1

I'm pleased with your results, Horace, including the minimal side-effects. Like you, I was faced with the same agonizing decision — surgery or radiation. I spoke with several urologists, along with patients who had experienced both forms of treatment. Most were successful. The side-effects of surgery tended to be more pronounced in the near-term — incontinence, ED, etc., which in some people, continued to last more than 24 months after surgery. The impact of radiation on patients was dramatically less so, though the data suggests that the side-effects for radiation are more often seen in the long term, principally due to radiation effects beyond the prostrate itself. At 73 and with Gleeson scores that ranged from moderate to aggressive, I was stuck in the middle on making my treatment decision either way. The tipping point for me was a conversation I had with a young urological surgeon. Typically, surgeons will always lean toward recommending their skillset — cutting. And, like any good surgeon, he confidently predicted I would have successful prostate surgery based on his many operations. That said, he said that his father was my age, 73. He then said that if his father's cancer was the same as mine, he would recommend that he undergo radiation treatment. Why? Put simply, he said that at his father's age why risk the near term surgical side-effects that m I describe above and possibly continue to suffer from them for a longer period of time/end of his life? Moreover, the data indicates at 73 he will likely suffer another, separate medical event that may have serious consequences, making his life even more uncomfortable when dealing with surgical side-effects. Successful radiation treatment would assure a higher quality of life for the foreseeable future. Future consequences aren't inevitable. Remember, this advice is coming from a urological surgeon who has witnessed the side-effects of more than 1,000 surgeries/patients firsthand. This conversation was the tipping point for me. I opted for radiation. Put simply, it was a lifestyle choice based on my willingness to possibly pay now (surgery) or pay later (radiation). I successfully completed 28 days of radiation therapy in late May. It's an extraordinary benign experience. I will remain on ADT (lupron) though September. I anticipate the cancer will be well behind me by then and that only periodic check-ups will be needed. Survivability rate for this treatment protocol is in the 90th percentile. My choice is not an argument against surgery. I understand its virtues. I also understand why individuals may make the opposite choice of my mine. However, my experience may help your decision-making either way. Should you go with radiation, I would question the advisability of a high dose, 5 day treatment vs. a longer period at a lower dose. There is no good evidence that the high dose/5 day treatment is more effective. Challenge your MD for an answer. Finally, I suggest you visit the website for the Prostate Cancer Research Institute (PCRI). Excellent information and data, along with some great, short video opinions/insights. Good luck!

Jump to this post

@bruto1 Thanks for your detailed response. A question or two if you don't mind. Was the radiation done at Mayo? Did you have Lupron prior to radiation? Thanks for reporting your interaction with the surgeon. If I choose radiation, it is his response that swung me over to that.

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@dandl48

@horace1818 Horace, Thanks for your input and advice. Sometimes I wish Mayo wouldn't give you options, Just say to me "You have cancer and we will get it out by doing xyz."

Jump to this post

I understand your reaction but, please remember that neither Mayo nor any other physicians are responsible for decisions on your healthcare; you are. That is why they always explain the situation to you and then they wait for your decision on the options. This means that, in addition to Q&A with your physician, you need to analyze all other sources of information such as second opinions, your own research (there is an incredible amount of information available), experience of others, etc. etc. It is painstaking work and takes time but you need to do it and then you will be in a position to make the most informed decision based on your situation. Medicine is not a precise science since it deals with variable things: humans. Biology is not as precise as physics (except at the quantum level) and deals with statistics and probability! Everything in medicine has a risk/reward aspect to the decision. I wish there were an easier way to make these decisions.

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@bruto1

I'm pleased with your results, Horace, including the minimal side-effects. Like you, I was faced with the same agonizing decision — surgery or radiation. I spoke with several urologists, along with patients who had experienced both forms of treatment. Most were successful. The side-effects of surgery tended to be more pronounced in the near-term — incontinence, ED, etc., which in some people, continued to last more than 24 months after surgery. The impact of radiation on patients was dramatically less so, though the data suggests that the side-effects for radiation are more often seen in the long term, principally due to radiation effects beyond the prostrate itself. At 73 and with Gleeson scores that ranged from moderate to aggressive, I was stuck in the middle on making my treatment decision either way. The tipping point for me was a conversation I had with a young urological surgeon. Typically, surgeons will always lean toward recommending their skillset — cutting. And, like any good surgeon, he confidently predicted I would have successful prostate surgery based on his many operations. That said, he said that his father was my age, 73. He then said that if his father's cancer was the same as mine, he would recommend that he undergo radiation treatment. Why? Put simply, he said that at his father's age why risk the near term surgical side-effects that m I describe above and possibly continue to suffer from them for a longer period of time/end of his life? Moreover, the data indicates at 73 he will likely suffer another, separate medical event that may have serious consequences, making his life even more uncomfortable when dealing with surgical side-effects. Successful radiation treatment would assure a higher quality of life for the foreseeable future. Future consequences aren't inevitable. Remember, this advice is coming from a urological surgeon who has witnessed the side-effects of more than 1,000 surgeries/patients firsthand. This conversation was the tipping point for me. I opted for radiation. Put simply, it was a lifestyle choice based on my willingness to possibly pay now (surgery) or pay later (radiation). I successfully completed 28 days of radiation therapy in late May. It's an extraordinary benign experience. I will remain on ADT (lupron) though September. I anticipate the cancer will be well behind me by then and that only periodic check-ups will be needed. Survivability rate for this treatment protocol is in the 90th percentile. My choice is not an argument against surgery. I understand its virtues. I also understand why individuals may make the opposite choice of my mine. However, my experience may help your decision-making either way. Should you go with radiation, I would question the advisability of a high dose, 5 day treatment vs. a longer period at a lower dose. There is no good evidence that the high dose/5 day treatment is more effective. Challenge your MD for an answer. Finally, I suggest you visit the website for the Prostate Cancer Research Institute (PCRI). Excellent information and data, along with some great, short video opinions/insights. Good luck!

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@bruto1 This is a superb post. Thanks for taking the time to write it.

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@dandl48

@bruto1 Thanks for your detailed response. A question or two if you don't mind. Was the radiation done at Mayo? Did you have Lupron prior to radiation? Thanks for reporting your interaction with the surgeon. If I choose radiation, it is his response that swung me over to that.

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@dandl48 I was 75 when I had a similar discussion / consult with a PCa surgeon. It was the discussion with the surgeon that was decisive for my decision to do radiation. My Proton Beam radiation at Mayo was completed in March. It was the correct decision.

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@vernonkent

@dandl48 I was 75 when I had a similar discussion / consult with a PCa surgeon. It was the discussion with the surgeon that was decisive for my decision to do radiation. My Proton Beam radiation at Mayo was completed in March. It was the correct decision.

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@vernonkent you don't mind me asking, what did the surgeon say to you that convinced you to do radiation? Was it the 5, 20 or 40 treatments that you got?

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Sorry, I thought this was clear in my response. Looking at a combination of factors — age, progression of my cancer and likely side effects of each treatment option (surgery and radiation) — the urologist concluded that the opportunity for a normal lifestyle for the foreseeable future for me post-radiation treatment was greater than the choice of surgery. Put differently, if you could have 5-6 years of a healthy, normal lifestyle and cancer-free post radiation treatment, knowing that as you approach 80 you will likely be confronted with new medical issues — or even death — that will create a new set of health challenges, would this be a good option for you? Contrast this with the same aging scenario with surgery, where you may have a greater likelihood of side-effects (e.g., incontinence, ED, etc.) that are difficult to manage in the same timeframe, only to be faced with new medical issues. Again, I don't want to oversimplify things and I don't want to diminish the benefits of surgery, for which some individuals have little to no side effects. Note that there is data available the will provide you with the odds on various side-effects from surgery. Your urologist should be able to share this with you. The treatment choice is yours based on the considerations/trade-offs I outlined as have others. Sorry, no easy choices here. Research. Talk. Weigh the risk of each approach. Weigh what's important to you post treatment. And then make a decision from there.

Liked by cmartin65

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@dandl48

@vernonkent you don't mind me asking, what did the surgeon say to you that convinced you to do radiation? Was it the 5, 20 or 40 treatments that you got?

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My radiation oncologist seemed to bounce between 5 and 28 days, implying that the choice was mine. I probed on why the shorter treatment wouldn't be everyone's choice. Less time. Same effect — yes? Frankly, he wasn't able to provide a satisfactory answer. I was left with the impression that based on his hospital's experience, they were seeing little difference in the longer vs. shorter treatment options. Bottom line: The research and experience with the longer treatment span is extensive and proven. The shorter plan, while perhaps as effective and with no greater side-effects, is still being trialed in a fashion until they have definitive results.

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@dandl48

@dmadi61 Thanks for your response. Hopefully my hasn't spread (the MD's feel it is contained to the prostate) The Lupron does concern me though.

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Lupron is the most powerful drug I have ever taken. You will immediately feel the side-effects, the extent and intensity of which can vary from patient to patient. No fun for anyone. That said, it does immediately drop your testosterone, which is the food for your cancer cells. Probably good to start on this drug for 30-60 days prior to either radiation or surgical treatment. It also can shrink the tumor(s) on your prostate. Also, continuing on the lupron post-treatment is also advisable in my opinion for a short period time. Think of post treatment lupron as cleaning up any cancer cells that may be hiding in the corners of your prostate. Unlikely after treatment but better safe than sorry.

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