SBRT vs. Robot-assisted radical prostatectomy

Posted by dandl48 Dave @dandl48, Jun 11, 2020

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

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Hello Dave,
I am 69 years old and was diagnosed with PC in August of 2022 and had the Robotic surgery performed in October of 2022. Thankfully, 100% of the detectable cancer was removed as it was totally within my Prostate. The “nerve sparing” procedure was successful. My PSA on the day following my surgery was < 0.014 and has remained at that level through last week.

Making the decision to utilize radiation or surgery for initial treatment is ultimately a personal decision one makes after consulting with your group of physicians and specialists. Personal lifestyle circumstances along with any other comorbidity factors along with one’s own personal risk assessments come into play in the making of a patients final decision. There are other factors to be evaluated as well. Including the consideration of what can I do or what options do I have if my cancer returns.

This certainly came into play in my decision process.
The surgery first option allows you to utilize radiation treatments if needed at a later date as a result of a biochemical return of your cancer. Although the “Salvage Surgery” option can be used and is done by some patients. The vast majority of surgeons do not like to perform it for two main reasons.
Firstly, the dead tissue left after the initial radiation treatment protocol doesn’t react or heal well during and following the surgery,
Secondly, there can be and often are complications involved with the post surgical recovery process.

My personal decision for the surgery was made on a number of considerations.
1. If possible, I wanted 100% of my detectable cancer removed immediately.
2. I didn’t want to continue with the radiation process, regardless of the protocol or combination of protocols initially utilized knowing that cancer is still in my body. The uncertainty of how long it would take to remove all of the detectable cancer was a concern to me.
3. Although most patients experience episodes of Incontinence and ED immediately following surgery. Most patients recover to their pre surgical functionality within a 6, 12 or 24 month time frame. Of course, you are generally making significant improvement along the way.
4. Many patients still ultimately experience some level of Incontinence and ED along the way during their radiation treatments. It just occurs more slowly and over time versus the immediacy following the surgical option.
5. From a personal standpoint, I’ve been severely debilitated from CFS & FIBROMYALGIA for the past 30+ years. I have the comorbidity of HYPOGONADISM resulting in Low Testosterone dipping to levels of between 20-90 if I am not on my “TRT,” TESTOSTERONE REPLACEMENT THERAPY. The “TRT” has been invaluable and one of the few treatment options that significantly reduces the totally debilitating effects of my ongoing health related disabilities.
All men require an adequate amount of Testosterone in their body to help maintain overall good health and well-being. Maintain good muscle mass and bone density. Maintain a healthy libido and overall psychological wellbeing. As you can see, all of the above are very important.
6. Radiation usually involves the direct opposite employing
“ADT,” ANDROGEN DEPRIVATION THERAPY. Most men experience the loss of everything “TRT” provides me. Although not all men have HYPOGONADISM or require “TRT.”
As a result, I simply would become too physically weak in addition to suffering from all the other side effects I’ve mentioned above.
7. Due to the severity of my ongoing disabilities, it would be very difficult for me to get to the hospital consistently enough to follow whatever radiation protocol which would have been prescribed for me.
I still spend many days in bed and am home confined.
8. It’s also extremely critical to understand that ultimately, the success and eventual outcomes following your surgery almost totally and exclusively rely upon the performance by your surgeon.
In general, it’s recommended not to have any surgeon perform the “Robotic Radical Prostatectomy” on a patient unless they’ve performed at least 1,000 surgeries.
It’s also important to review what levels of success and statistical results they’ve achieved!

I’ve shared and explained all of the above to emphasize the fact that every PC Patient is usually faced with additional circumstances in their life that need to be considered while making their treatment decision.

After all of the above and more are considered. Usually the radiation or surgical option starts to emerge as the best and most appropriate choice for the patient to make.

I hope what I have shared with you will be of some benefit in your decision making process.

Best wishes and good luck with your personal journey.
GODSPEED

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I am biased as I had an RP. I was a 4+4 and had two of them. Good margins.

Options the same as yours.

I chose RP and yes those complications are real. I chose surgery because if I had radiation and there was a reoccurrence, then surgery is off the table.

Surgery was a success, clean pathology. Incontinence is improving and ED is not. Would I make the same choice again, sadly yes. Do I miss my sex life, yes. But I am healthy and life moves on.

I wish you the best in your journey.

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Great question. There isn’t one best solution. Keep reading this blog. I’m grateful for it.

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@dgbauto

I wanted and preferred the Orgovyx pills, but Medicare wanted a $900 a mth co-pay. Pretty much left me with the covered Eligard shot. Dr. claims the T levels return faster after Org dosage is stopped.

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Orgovyx was covered under Tier 5 (25% copay) of my Part D Medicare drug plan, and I paid the out of pocket. However I transitioned to catastrophic coverage (the precise calculation continues to evade me) after 5/6 months and the out of pocket cost dropped significantly.
Eligard/Lupron, as injectables, are covered more comprehensively under Medicare Part B.

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@gently

Did you check the orgovyx site for the co-pay cards? You may make too much money, but it is worth checking. I'm worried about the depression. This is depressing enough already.
Decipher will tell you if your tumor is resistant to anti-androgen treatment.
At least original Medicare pays for Proton. Where will you have the proton treatment?

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Local Hospital has the True Beam Rad machine, It seems to have multiple functions. Orgovyx web site only offered some potential discounts for commercial insured patients, not Medicare recipients.

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@dgbauto

I wanted and preferred the Orgovyx pills, but Medicare wanted a $900 a mth co-pay. Pretty much left me with the covered Eligard shot. Dr. claims the T levels return faster after Org dosage is stopped.

Jump to this post

Did you check the orgovyx site for the co-pay cards? You may make too much money, but it is worth checking. I'm worried about the depression. This is depressing enough already.
Decipher will tell you if your tumor is resistant to anti-androgen treatment.
At least original Medicare pays for Proton. Where will you have the proton treatment?

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@gently

Dave, in a similar position trying to decide, but definitely going for radiation. My only suggestion it to consider Orgovyx instead of Lupron. The only drawback also the advantage is that it is a pill so each day you'll be tempted to forget. But read about it because this is an inexperienced suggestion.
Proton 5 fraction looks like the best choice to me, but California Proton isn't presently offering the 5. And I wonder how the 5 fraction proton compares to 5 fraction photon. Especially since photon can be a MRI guided procedure. You must have researched Proton. How did you decide Proton vs Photon.
A second suggestion (ok I have two) is to have the Decipher genetic analysis of the tumor itself. It softened the blow of the biopsy results and may change your course. They use the biopsy material already drawn.
best wishes

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I wanted and preferred the Orgovyx pills, but Medicare wanted a $900 a mth co-pay. Pretty much left me with the covered Eligard shot. Dr. claims the T levels return faster after Org dosage is stopped.

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Dave, in a similar position trying to decide, but definitely going for radiation. My only suggestion it to consider Orgovyx instead of Lupron. The only drawback also the advantage is that it is a pill so each day you'll be tempted to forget. But read about it because this is an inexperienced suggestion.
Proton 5 fraction looks like the best choice to me, but California Proton isn't presently offering the 5. And I wonder how the 5 fraction proton compares to 5 fraction photon. Especially since photon can be a MRI guided procedure. You must have researched Proton. How did you decide Proton vs Photon.
A second suggestion (ok I have two) is to have the Decipher genetic analysis of the tumor itself. It softened the blow of the biopsy results and may change your course. They use the biopsy material already drawn.
best wishes

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Dave, I am 66 yrs old and have the exact same 4+3 =7 Unfavorable readings you have. PSA went back to 10 before starting new Eligard/ Rad regime. I also tried Hi-FU two and a half years ago, It did'nt work, took my PSA down from 14 to 8. More recent PET scan revealed cancer returned to treated areas and remained in missed or resilient areas. Now on Eligard 4 mth program with 28 radiation treatments beginning in a week or so. Eligard alone, PSA after 30 days is under 3. Testosterone level went from 409 to 2,5 Absolutely no libido, mild hot flashes are not too bad. Looking forward to TRU beam Rad machine getting rid of this....Hopefully

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@vshirley

I had Eligard injection and now geting ready for 5 day radiation.Eligard has side effects such as hot sweats more urination at night etc.

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Welcome, @vshirley. Are you getting proton beam radiation? How are you doing?

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