I decided to treat my prostate cancer with radioactive seed implants ("Brachytherapy" / "BT"). I was a perfect candidate for either surgical removal ("Radical Prostatectomy" / "RP") or BT. I believed I would likely do very well either way. After a lot of study, I finally came to believe that for me:
(a) the long-term "cure" rate of either choice is similar, and
(b) BT side effects are likely to be less severe. The procedure was performed in Scottsdale Arizona by Dr. Gordon Grado on April 13, 2011.
I do not claim that everything I have written is 100% accurate, but I have done my best with what I have been able to understand. I welcome comments and input that result in improvements and greater accuracy.
Before you read on and perhaps begin to assume that what's good for me, must be good for everyone else who gets prostate cancer… that is not true - each person has their own unique age, health, PSA, Gleason score, biopsy results, cancer stage, opinions, and attitudes.
My Journey For Choosing A Treatment For My Prostate Cancer
Since the first two cancer doctors I met with were Urologists, it never occurred to me to consider anything other than surgery. They told me that the people who don't do surgery are "too fat, too old, or too scared". I was none of these. They told me that surgery is the "gold standard" and that surgery is the "most aggressive" way to treat my cancer. Who wouldn't want the "gold standard"? And isn't "most aggressive treatment" the same as "the best treatment"?
Then I stumbled across studies which said that some men who have surgery, still have a return of prostate cancer. How can you still have prostate cancer if you take out the prostate gland? And yet, these studies I found were saying that as many as 32% of the surgery patients were still dealing with the cancer later on. Some doctors later told me the percentage is, in their opinion, far higher. And then I learned of individual patients who saw their cancer return after surgery. [The Link Paul gave was to a thread on the US-TOO Inspire Forum an excellent resource which is open to members only.]
How could this be?
I was so confused, and so I continued to read and to study. I also decided to consult with Doctors who "did not have a dog in this fight". Fortunately I had a friend, Dr. Edwin Kingsley, who is a medical oncologist, who "didn't have a dog in this fight". He is clearly qualified to discuss this topic with me, but suggested and arranged a consultation with a Doc from his group - Dr. Nicholas Vogelsang, a renowned medical oncologist and cancer researcher. Dr. Vogelsang is the former Director of the University of Chicago Cancer Research Center.
Dr. Vogelsang told me about many options, and narrowed my options down to surgery and brachytherapy. He said I was a great candidate for both choices, but he also had a leaning toward the surgery. He went on to say that it was critical to select an experienced doctor. Whether it is Surgery or Brachytherapy - technique - and the "technician" - are critical. For Brachytherapy, he recommended Dr. Gordon Grado, who stopped counting how many procedures he had performed when the total exceeded 5,000 several years ago. For surgery, he recommended several well-known doctors practicing at major medical centers.
I scheduled consultations with a Surgeon who has performed more than 1,000 robotic prostatectomies, and with Dr. Gordon Grado who has performed more than 5,000 radiation seed implants (brachytherapy).
If you happen to have followed the link I listed for Dr. Grado above, you will see a "Patient Stories" link. Many men like me come to realize that choosing a treatment for prostate cancer is not like choosing a treatment for Strep throat. With Strep throat, the doctors are unanimous about what to do. [I'm not too sure that this is correct. My guess is that if you looked around, you might find a number of opinions for any medical condition. This is certainly true for my heart condition.] With Prostate Cancer the doctors are definitely not unanimous about what to do. Some men, (like me), travel up a "learning curve" that involves much study and research. Some men simply say, "Doctor, tell me what to do". A friend of mine chose surgery because he always knew if he got prostate cancer, he would have surgery just like Arnold Palmer did.
"A diagnosis of prostate cancer is scary enough. But just as scary is that nobody can tell a man the best way to treat it. This month, the Agency for Healthcare Research and Quality issued a sweeping review of prostate cancer treatments, including surgical removal, radiation, hormone therapy and so-called watchful waiting. Because none of these treatments emerged as superior, the agency came to the troubling conclusion that it could not recommend one over the others. 'This is the state of prostate cancer,' Mr. Kirk of Us Too said. 'There aren't any clear answers.' " - New York Times
Each year during my annual physical, the blood test identifies the PSA level. Here is my PSA history:
2009 6 months later 3.8
(Internist gave me a strong antibiotic for possible infection)
2010 6 months later 3.3
Feb 2011 4.1
April 2011 7.2
American Cancer Society Early Detection - what tests can detect prostate cancer?
In October 2010, my internist recommended that I have a biopsy. I had this done in November 2010. Five of the twelve biopsy cores turned out to be cancerous. In a way I was fortunate that the biopsy found the cancer on the first try. A biopsy samples 1/1000th of the prostate gland so it really is like looking for a needle in a haystack. Some men with prostate cancer have a biopsy which detects no cancer and they end up having multiple biopsies. I know of one man who had biopsies for 10 years before the biopsy found cancer. Seventy-percent of two of my biopsy cores were cancerous. Other cores were 60%, 40%, and 30% cancerous. All of the cancerous cores were from the LEFT side of my prostate gland and NONE of the cores from the RIGHT side were cancerous. This indicated that my cancer was moving right along. (A later C11 Acetate test, described below, indicated that MOST of the cancer in my prostate gland is in the RIGHT side of the prostate gland.) Because neither my Internist nor my Urologist could feel the cancer when they felt the prostate gland, (the good old "finger wave" up my butt - or, as they call it, a Digital Rectal Exam - DRE), my cancer was staged at Stage T1c
American Cancer Society Early Detection - what if the tests are not normal
Gleason Score & Second Lab Opinion
My cancer's Gleason score was 3+3=6. I had the slides sent to a different lab for a second opinion and they also came up with a Gleason score of 3+3=6. I later learned that getting a second lab opinion is highly recommended.
In between having two different labs give me their opinions, I also had a DNA test done to compare my DNA to the DNA on the biopsy slides to make sure they were mine! The DNA test came back as a match.
Partin Table Predictions
Knowing my PSA (3.1), my Gleason Score (3+3), and my Stage (T1c), I was able to look at the Partin Tables to be able to predict a few things about myself. [There is sometimes some confusion about the use of the word 'predict'. The Partin Tables and other nomograms - see The Palpable Prostate - give a range of notional probabilities and not individual predictions.] The Partin Tables, based on my particular statistics, predict there is a 88% chance the cancer is completely confined within the Prostate Gland. (When the cancer cells travel outside of the Prostate Gland, then the outlook is much more negative.) For me, the Partin tables also predict an 11% chance of extraprostatic extension, a 1% chance of seminal vesicle invasion, and a 0% chance of lymph node invasion. All of these percentages worsened when my PSA reached 4.1 in February 2011. When the cancer reaches the lymph nodes, the cancer has reached the last, and most serious stage - Stage 4.
One More Test - C11 Acetate Pet Scan
Remember the Partin Tables which tell me that the progression of my prostate cancer is "probably this" and "probably that"? Well, prostate treatment plans are based on those "probablies". That is the standard of care and that is how most everyone does it. It is unlikely that my cancer has escaped my prostate. The Partin Tables are quite good. But there are tests that attempt to find out more.
I have had heard about Color Doppler Ultrasound and ProstaScint. [Color Doppler scans, used by the limited number of experts are probably the best of available scans.] I have heard about the Combidex Scan that is no longer available in Holland [or in the USA after the FDA refused to authorise the use of this excellent scan]. I have heard about imaging studies using Iron Oxide and imaging using Feraheme, iron nano-particals contrast. [Feraheme scans have not (at May 2011) been approved by FDA but are being carried out at Sand Lake Imaging.] I really have not spent much time looking into these. There is a sampling of varied opinions about these things on an Inspire Discussion Group.
Dr. Grado told me of a test that can only be obtained at the present time at U of Kansas Medical Center is the C11 Acetate Pet Scan. They have perfected the complicated and lengthy task of making the radioactive 11 Carbon Acetate in their Cyclotron Facility.
I went to Kansas and had the C11 Acetate Pet Scan on April 4, 2011. The test indicates that all of my cancer cells are still contained within prostate gland, which is very good news.
(By the way, according to some sources, the C11 Acetate test is 85% sensitive, costs $3,000, and is not covered by Medicare. The ProstaScint test is 30% sensitive, costs $17,000, and is covered by Medicare. Another fine example of our tax dollars at work?) There is some expectation that the C11 Acetate Pet Scan may soon become approved by Medicare and the test will become recognized as part of "standard of care". My private insurance DID cover the C11 Acetate test.
The internet is replete with resources and information about prostate cancer. I spent a lot of time learning all I could online. There are many books to choose from. I read the following three books. [There is a RESOURCES page on this site which Lists and Links various books that have been found to be useful.]
Surviving Prostate Cancer Without Surgery by Bradley Hennefent M.D. 2005 (Hennefent): The author hates most Urologist surgeons and he hates the choice of surgery for treating prostate cancer. So reading his book takes a bit of "filtering". He describes many other options for treating prostate cancer. I was particularly interested in his assertion that prostate surgery has failed both of the only randomized controlled studies (the best kind of scientific study) that have ever been done - to compare surgery with doing nothing. I purchased each of these studies for myself. [One of the failings of this book is that none of the available therapies would meet the standards set by Hennefent for surgery.]
Guide To Surviving Prostate Cancer by Dr. Patrick Walsh 2nd Edition 2007 (Walsh)
Surgical removal of the prostate has been going on since 1904. Until about 1982, every man with a surgically-removed prostate gland was permanently impotent and many of those men also had severe problems with urinary control. Dr. Walsh is credited with improving surgical techniques which can remove more tissue, preserve sexual function and improve urinary control. Interestingly, he cites the same randomized controlled studies as Hennefent and reaches a different conclusion than Hennefent.
The Decision: Your Prostate Biopsy Shows Cancer. Now What? by Dr. John McHugh 2009 (McHugh) Dr. McHugh is a Urologist who surgically removes prostate glands ("Radical Prostatectomy" or "RP"). He was diagnosed with prostate cancer when he was 52 and after agonizing how to treat it (he eventually chose robotic surgical removal), he wrote a book about the decision process to help others with their decision. Though he tries hard to present all options in a balanced fashion, his surgical bias cannot be missed in the manner that he presents and describes options. [Dr McHugh has also produced some good 'cheat sheets' to help in the decision making process - see CHOICES and RESOURCES]
I subscribed to a few medical journals in order to purchase copies of published studies cited online or cited in the books listed above. I've since realized that dated studies might not necessarily be the best ones to use [This is a very important point. The long term older studies, especially the Scandinavian studies often commenced before the widespread use of PSA testing and the diagnoses then were very different from those that apply now. Gleason Grades have also migrated signficantly over the last ten years - a Gleason Score from 2001 may be very different from a Gleason Score in 2011].
Stage B Prostate Adenocarcinoma, Arch Surg - Vol 125, March 1990 (Mayo clinic study which describes 20% return of cancer after RP.)
The Incidence of Prostate Cancer Progression with Undetectable Serum Prostate Specific Antigen in a Series of 394 Radical Prostatectomies, The Journal of Urology, Volume 154, Issue 6, Pages 2128-2131, December 1995 (U of NW Chicago study which describes 34% return of cancer after RP.)
Prediction of Progression Following Radical Prostatectomy: A Multivariate Analysis of 721 Men with Long-term Follow-up, American Journal of Surgical Pathology: March 1996- Volume 20 - Issue 3 - pp 286-292 (Dr. Patrick Walsh Study which describes 23%, or 25%, or 32% return of cancer after RP - depending upon which of his study numbers your use.)
Five Year Follow-up after Radical Prostatectomy for Localized Prostate Cancer - a Study of the Impact of Different Tumor Variables on Progression, Scandinavian Journal of Urology and Nephrology, December 1994, Vol. 29, No 4, Pages 391-399 (Sweden University Hospital study which describes 31% return of cancer after RP.)
Prognostic significance of proliferation activity and neuroendocrine differentiation to predict treatment failure after radical prostatectomy Scandinavian Journal of Urology and Nephrology, 2007, Vol. 41, No. 5, Pages 375-381
My Consultations With Urologists
Surgery Bias: All three Urologists I met with recommended surgery. And I really believe that I would have been in very good hands with either of the surgeons I spoke with. Urologists have a surgery bias and Urologists are usually the first doctor to diagnose prostate cancer and the first doctor to recommend a treatment.
"Consciously or unconsciously, it has been noted that urologists often select for surgery those patients who are likely to do well regardless of treatment", comments (Dr.) Song, "referring the less-favorable patients for treatments such as radiation. It's akin to having the first pick of the litter." -Walsh: Chapter 10
Dr. Z performed my biopsy. He explained that the only right option for me would be surgery (RP). He explained the other options to be "Watchful Waiting" and Radiation. (I later learned that there are many other options.) I asked who, if surgery was a "no-brainer" for me, would choose radiation. He said the only people who choose radiation are those "who are too fat, too old, or too scared". I was none of these so I figured my big decision would be choosing a good surgeon - since Dr. Z does not do surgery. I met a man who had a fantastic outcome with Dr. B, the Director of Urology at a major medical facility. I scheduled a consult with Dr. B and really liked him. He trained at Johns Hopkins and is clearly good at what he does. Dr. B confirmed Dr. Z's opinion that radiation was not for me.
I also had a consult with Dr. A, at another major medical center, who has performed over 1,000 Da Vinci robotic prostatectomies. He is clearly at the top of his field. Not only did he say that radiation was not for me, he also believes that radiation is never the right choice for anybody with prostate cancer.
Future Cancer From Radiation? All three Urologists I met said that treating my prostate cancer with radiation created the risk of inviting a future radiation-related cancer into my life. They all mentioned possible cancer of the bladder or rectum. The McHugh book, (also a Urologist) also raises this as a possibility if a man chooses radiation instead of surgery. This appears to be a common informational item when surgeons advise prostate cancer patients about radiation.
I asked my friend Dr. Kingsley, Medical Oncologist, about this and he said that the chance of secondary malignancy from radiation is so small, that it is not relevant enough to influence a treatment decision between BT and RP. Another friend, Dr. D, a Radiation Oncologist, agreed with Dr. K.
I asked Dr. Grado, a Radiation Oncologist about this and he said if what the Urologists are saying is true, then why haven't any women gotten secondary cancer from all the radiation to their pelvis area for uterine or other cancers? [This seems not to be a sound scientific view. There are studies that demonstrate a very low probability of secondary cancers in men who have chosen radiation. Perhaps it would have been better to refer to such studies.]
I decided to dismiss the possibility of future radiation-related cancer as an influencing factor in my decision.
"The Radiologist Who Are Not In It For The Money Will Tell You To Do Surgery" Dr. B told me this. He offered to send me over to his radiologist, Dr L, who does Brachytherapy. He said that once they saw my young age (52) and other statistics, they would refuse to treat me with radiation and send me back to him for surgery. Turns out my friend Dr. D, a Radiation Oncologist is close friends with Dr. L. (Dr B, D, and L all are work within the same major medical group).
Dr. D asked Dr. L if he would refuse to treat a patient like me who is such an excellent candidate for surgery. Dr. L said that he treats patients of my age all the time, and that he would not turn me away. Dr. L said I was an excellent candidate for Brachytherapy and would do well with Brachytherapy.
Surgery Consultations Summary
I am an excellent candidate for surgery. I would very likely have an excellent outcome. And I would be in very good hands with either of the surgeons I met.
Surgery Vs Watchful Waiting [The term Watchful Waiting is somewhat archaic and has largely been replaced by the term Active Surveillance] - Did Surgery Really "Fail" A Randomized Controlled Study? Scientifically-speaking, randomized controlled studies are the best studies. According to Hennefent (pg 251), surgery has failed the only two randomized controlled studies which have compared the long-term results of Surgery vs Watchful Waiting. Of course this really got my attention. Two quotes from the Hennefent book and his sources follow.
"After an average follow-up period of 6.2 years, the authors concluded '… there was no significant difference between surgery and watchful waiting in terms of overall survival.' " New England Journal of Medicine. 2002: Sep 12;347(11):781-789
"...only 20 more men, out of the 347 who underwent prostate cancer surgery, were alive at 8.2 years than in the watchful waiting arm of the study. In fact, the authors of the study estimated the 10-year increase in survival for men who underwent surgery for prostate cancer to be only 5 percent after 10 years" New England Journal of Medicine 2005;352:1977-84
[There are later studies on this contentious subject. One such study was presented at the American Urological Association meeting in May 2011 and is discussed here. One of the conclusions based on the data in the PIVOT (Prostate Cancer Intervention Versus Observation Trial) study was: "Surgery did not reduce mortality more than observation in men with low PSA or low-risk prostate cancer."]
Walsh's book (Chapter 5) refers to same 2005 study cited above in the follow quote:
"The results, published in the New England Journal of Medicine, came faster than anyone expected, and they were dramatic: Within ten years, the scientists were able to show that radical prostatectomy reduced the progression of cancer to metastasis, reduced death from prostate cancer by 40 percent, and decreased death from all causes by 26 percent".
How in the world can Hennefent claim failure and a small 5% benefit and Walsh claim success and large 40% benefit- and BOTH refer to the SAME study? I purchased the studies to read them for myself.
First of all, the study had four endpoints. Hennefent is highlighting endpoint #4 (death from all causes) and Walsh is highlighting endpoint #1 (death from prostate cancer). I am still not completely sure how to reconcile these positive and negative portrayals of the same study. However, Walsh is selecting the study's report of "relative reduction" and Hennefent is selecting the study's "absolute reduction".
For example the study said 14.4% in the watchful waiting group died from prostate cancer and 8.6% of the surgery group died from prostate cancer. If you calculate the "relative change" from 14.4% to 8.6%, you get Walsh's "reduced death from prostate cancer by 40%". On the other hand, the study says death from all causes including prostate cancer was 32% for the Watchful-Waiting Group and 27% for the Surgery Group. The "absolute change" of 32% - 27% = 5% which is the low increase of survival that Hennefent criticizes.
The study does indeed say that in "absolute terms", the 5% is low - but Hennefent fails to mention that the study also goes on to say that "we expect the benefits of surgery will increase during longer periods of follow-up".
Since I am 52, one more thing that did jump out at me, was that the cumulative incidence of prostate cancer death for the subgroup of men under 65 was markedly higher than other defined subgroups. [It is not clear just which study is being referred to here, but it is likely to be the long term Scandinavian studies referred to above.]
I believe that Hennefent's portrayal of surgery as having failed the randomized controlled study leaves out too much of the study's results. [The point of looking at the 'all causes' of male deaths is that, because prostate cancer is the cause of very few deaths in men - a little over 2% of male deaths in the USA are from prostate cancer, a rate that has not changed for at least 30 years - surviving a prostate cancer diagnosis may not lead to a longer life.]
Surgery Vs Brachytherapy (Radiation Seed Implants)
The Spirit Trial To my knowledge there are no randomized clinical trials that have successfully compared Surgery and Brachytherapy. However, the failed SPIRIT randomized trial did end up providing an interesting quality-of-life comparison based on surveys from 168 patients. (After attending 47 education sessions, 102 chose BT and 66 chose RP).
"There is an increasing amount of data suggesting that quality of life after brachytherapy is (on average) better than quality of life after surgery. What is still not quite so clear - albeit very passionately debated - is whether there is any difference between the oncologic outcomes of these two types of first-line therapy for a highly defined group of patients with localized prostate cancer at 5 and 10 years after the initial treatment. It was this question, of course, that SPIRIT was originally intended to resolve when it was initiated in 2001." [This quote is from the moderator of of The "New" Prostate Cancer Infolink.]
Do Rp And Bt Have Similar Cancer "Cure" Rates? Well, that was what the SPIRIT randomized clinical trial, which failed miserably to enroll two thousand men, was all about. So that leaves us with just the studies done by the Urologists and the studies done by the Radiologists. But I did find it interesting that Walsh, the "father" of the modern prostatectomy, with a clear bias towards surgery, included the following in his book (Chapter 5):
"The bottom line", [Dr. Song] adds, "is that multiple studies have shown similar results for both brachytherapy and radical prostatectomy. National consensus panels such as the National Comprehensive Cancer Network, made up of experts in urology and radiation oncology, including doctors from Johns Hopkins, have stated that surgery and radiation should be considered effective therapies with somewhat different toxicity (side effect) profiles".
I came across other sources that made the same claim of equivalent cure rate outcomes between RP and BT. And this following link [This is a large PowerPoint File] shows Brachytherapy "cures" to be superior to Surgery "cures" [It may be worth getting another view by reading Comparing the Effectiveness of Therapies for Localized Prostate Cancer which is linked from CHOICES where there is other relevant mayerial.]
Who To Believe?
I've heard the "shots" that the Urologist take at the Radiologists and that I would be nuts to do Brachytherapy. I've heard the "shots" that the Radiologists take at the Urologist and that I would be nuts to do Surgery.
I finally have compared this to the manner in which municipal bond issues are sold. I always argued that competitive sale was usually the best. Others argued that negotiated sale was the best. I still think I was right in that the interest rate cost was usually a little bit lower with competitive sale. (Perhaps that lower interest rate cost could be compared to the lower side-effect "cost" of Brachytherapy.) In the end however, either way, the Issuer successfully sold their bonds and got their money.
Dr. K (Medical Oncologist). As I already mentioned, Dr. Kingsley referred me to Dr. Nicholas Vogelsang for a consultation and has also been helpful through subsequent emails and phone calls. Based on his own decades of experience, he believes that the long-term cancer-free success rates between surgery and BT is similar. Only after I had made my decision about choosing BT, did Dr. K tell me that if he were me, he would also choose BT.
Dr. D (Radiation Oncologist) A friend who also believes the long-term cancer-free success rates between surgery and seeds is similar. After I made my decision to choose BT, he said he would make the same decision for himself, but that I would do well with either RP or BT. He said that when he has a patient who has a "just get IT out of me" personality, he recommends surgery for that type of patient.
Dr. Vogelsang , a nationally-respected medical oncologist with "no dog in this fight" narrowed my many choices down to Brachytherapy (with Dr. Grado) and Surgery and leaned towards surgery for me.
Dr. Grado A Radiation Oncologist and former head of radiology at the Mayo Clinic's Scottsdale facility. My wife and I went to Phoenix (Scottsdale) and had a consultation with Dr. Grado. I will clearly be in very good hands with Dr. Grado and appreciate how important technique is when it comes to Brachytherapy. I asked Dr. Grado how many times he has done the procedure. He said he stopped counting several years ago at about 5,000. Dr. Grado was the first in the county to develop bi-plane ultra sound to see the seeds inside the prostate and fluoroscopy for perfect seed placement. This changed how everyone in the country did Brachytherapy. Dr. Grado is also responsible for the pushing enactment of the current requirement that doctors calculate differences between the plan before implantation and the actual results afterword. (They measure the radioactive dose and they examine the final placement of each of the approximately 100 seeds.) These differences must be reported to the patient and to the federal government - I think the Nuclear Regulatory Commission. Dr. Grado is not showy and is down to earth. When I have apologized for texting him and bugging him with follow-up questions, he insisted that I keep calling with my questions. One Saturday morning, I sent him a text and within a minute he was calling me from his office chastising me for being embarrassed about having more questions.
(Of course Dr. Grado says he completely disagrees with the premise for my Decision - below. He REALLY believes that surgery almost never gets all the cancer and that the "cure" rate with surgery could not possibly be similar or as good as seeds. OK, OK, I get it! Doctors like Dr. A and Dr. Grado are at the very top of their game and at the top of their field and they feel very passionate and certain about their positions.)
I have seen lengthy lists of side effects, and these all need to be considered. But the primary side effects relate to incontinence (urinary control), and impotence. [The comments that follow are Paul's personal views which are reasonably state. However, it should be borne in mind that there is very little good data on side effects - their prevalence or of the comparative rates of side effects between the various therapy options.]
Surgery Incontinence: Incontinence occurs in a fairly high percentage of patients. Total incontinence is uncommon, but a possibility. It can take up to 12 months for most men to regain urinary control. Long-term Stress Incontinence is common - leaking when you laugh or cough. According to one source, at least one-third of men require pads or diapers permanently.
Surgery Impotence: Even with the best surgical techniques, some nerve damage occurs. Nerve healing is highly age dependent. Impotence rate is high, especially among older men with hypertension. Complete loss of function is a possibility. For those who regain potency, it can take up to 2 years to regain pre-surgery sexual functioning.
I have spoken with men who have had 100% of the above-listed surgery side effect. I have also spoken with men who have had 0% of the above-listed surgery side effects.
Brachytherapy Incontinence: Incontinence is extremely rare. Other voiding symptoms, which are usually short-term, include urgency, frequency, burning, and obstruction. Total obstruction is a rare possibility (and usually temporary).
Brachytherapy Impotence: Impotence rate is significantly lower than prostatectomy. Some say that impotence rates rise, over 5 years, to levels less than surgery, but it is difficult to point only to Brachytherapy, as impotence causes are multi-factorial… age, weight, hypertension, etc.
The Premise For My Decision
I finally decided that I actually believed the conclusion that the chances of "cure" are similar - whether I chose Surgery or whether I chose Brachytherapy. I have decided to go with BT - because the treatment is likely to come with less-overwhelming quality-of-life side-effects.
More About Brachytherapy
When I started down this road, I never took seriously the possibility that I would choose Brachytherapy. As I compared surgery to brachytherapy, I was focused on the big picture of which one to choose. After I made my decision to treat my cancer with Brachytherapy, I focused more on that.
I learned that some people get only seeds, and this is called "monotherapy". But some people get several weeks of external radiation before seeds, and some people get both of those things, plus follow-up radiation.
I learned that there are primarily two types of radiation seeds used: Palladium (103pd) and Iodine (125i). I learned that some doctors claim that one type of seed is better than others. I also learned of a very reliable study by Ragde/Grado that concluded that seed type doesn't make a difference.
I found two centers - Dattoli Cancer Center and Brachytherapy Research Institute and ProstRcision who appear to routinely give a lot of radiation, even for patients like me - far more than what Dr. Grado or John's Hopkins would be willing to give me.
They do Brachytherapy and they give five weeks of external radiation. I called the Dattoli center for their free phone consultation and after looking at my statistics, they confirmed that they would recommend several weeks of external radiation both before and after Brachytherapy. (The Walsh book, Chapter 10, has this to say about so much radiation: "There is little justification for performing combination treatment in favorable, low-risk patients, since the results with brachytherapy alone are quite good. Retrospective comparisons have been published showing no differences between men treated with brachytherapy alone versus those treated with brachytherapy combined with external-beam radiation".)
I'm not a doctor. Who am I to believe?
I Did Come Across Other Brachytherapy Controversies:
I've heard about the radioactive seed companies who pay large sums of money to certain doctors to promote their particular brand of radioactive seeds.
For another example, there is the VA doctor who was found to be implanting seeds and MISSING the prostate gland. "Problems found at the Philadelphia hospital prompted a wider investigation of (13) V.A. facilities (with prostate treatment programs), leading to the temporary suspension of seed implants, called brachytherapy, at three other veterans hospitals."
The Nuclear Regulatory Commission describes their response at this link:
In another example, the Walsh Book points out that studies came out years ago claiming that brachytherapy alone was not as successful in men with intermediate-to-high risk cancer compared with the doubled-barreled approach of weeks of external-bream radiation PLUS seeds. He points out that this practice continues in some centers - such as the ones I listed above.
"Retrospective comparisons have been published showing no differences between men treated with brachytherapy alone versus those treated with brachytherapy combined with external-beam radiation. In some studies, Gleason scores and PSA levels appear to be similar in both groups. 'If this is the case,' asks [Dr.] Song, 'why did the physicians chose to give some patients both treatments and other patients brachytherapy alone?' "
"There is less controversy regarding the side effects associated with the two options. Results from several studies show that the combination treatment carries a higher incidence of erectile dysfunction and rectal and urinary side effects. Currently at Johns Hopkins, only men with one or more unfavorable characteristics are treated with both brachytherapy and external-bream radiation; men with Gleason scores of 6 or lower and other low-risk factors are offered brachytherapy alone. There is little justification for performing combination treatment in favorable, low-risk patients, since the results with brachytherapy alone are quite good."
Walsh - Chapter 10
My Post-Brachytherapy Experience
(This Section Of My Journal Will Be Updated Periodically)
Based on my test results, Dr. Grado recommended monotherapy (radiation seed implants - Brachytherapy). For patients like me, he has for years also preceded the radiation seed implants with two days of external radiation. He says this is to treat cancer cells that may escape during the seed implantation.
My April 2011 Monday - Tuesday -Wednesday schedule with Dr. Grado was similar to that described by one of his 2003 patients. (By the way, that patient's December 2010 PSA was 0.06)
Dr. Grado implanted 130 Iodine seeds on April 13, 2010. I was given prescriptions for a 5-day antibiotic, for pain, and for Flomax. I was told to the Flomax daily at least until my 3-month checkup with Dr. Grado.
Month 1 - Post Brachytherapy
The first night, I experienced burning, weak, and frequent urination. It was difficult to empty my bladder. Of course my "bum" area was sore and bruised from the rectal probe and from all the needle sticks. The next day, the urination had largely returned to normal.
I took Tylenol with codeine the first day, regular Tylenol the second day, and regular Tylenol as needed when my activity brought on an "achy" feeling - like after a 90-minute walk.
After the first several days, almost no problems with frequency or urgency or emptying or burning. Bowel movements mostly normal with occasional clear mucous. No erectile dysfunction but ejaculations (3) were decreasingly bloody and painful.
SIDE-EFFECTS AT 3 MONTHS POST-TREATMENT: While it is apparently more the norm to have some level of continuing frequency, weak stream, difficulty emptying, burning, and/or getting up at night to urinate – in my case, any such side effects disappeared rather quickly. Slight burning with urination lasted a couple of weeks. Frequency and getting up at night lasted a few days. Bowel movements have been pretty much normal except for an occasional clear mucous. Blood in the urine continued for a few weeks. Blood in semen continues at this time. No problems with sexual function but first few ejaculations were painful.
SIDE-EFFECTS AT 6-MONTHS POST-TREATMENT: At 3 months, I decreased the Flomax to every other day without any negative results. I stopped taking it entirely by the 6 month mark. Getting up several times a night to urinate has never been a symptom for me - either before or after Brachytherapy. DRE was normal. Somewhat-achey orgasms seem to be decreased if Viagra is taken beforehand. Plus the achey pain seems to be less and less as times goes on. Erections are improved with Viagra. Not sure whether decreased blood flow for erections is more related to the Brachytherapy or my below-normal Testosterone.
8 MONTHS AFTER TREATMENT - my PSA hit its Nadir of 0.5
12 MONTHS AFTER TREATMENT - my PSA was 0.6
18 MONTHS AFTER TREATMENT - my PSA was 0.7
24 MONTHS AFTER TREATMENT - My PSA was 0.8 and I was beginning to be concerned about a recurrence. My doctors recommended back-to-back PSA tests last July and August of 2013. Both PSAs came back at 0.8 and my doctors concluded that I had experienced the mysterious, but common, "PSA bounce".
TODAY - My PSA is 0.5
SIDE EFFECTS - At 16-18 months after treatment, I experienced severe pain in the anus, urination pain, and frequent loose bowels. The steroid foam/suppositories for anal pain didn't help much. Advil was more helpful. Doctor said this was a common side-effect at about 1 yr and would go away - which it did.
SUPPLEMENTS - While I realize there is no scientific proof about supplements, I've done some reason of materials by Meyers and Sholz and started the following in January 2013. I figured it couldn't hurt:
No Red Meat or Dairy – Lots of fruits and vegetables, chicken, fish
Vitamin D3 2000 IU day
Lycopene 10 mg with each meal
Omega 3 Fish oil 2000 mg twice a day
Selenium 200 MCGs
Vitamin E 200 IU day
Pomegranate Extract 200 Mg
Cialis 2.5 Mg
October 2014 Annual Blood Test gave me the good news of a PSA of 0.3
This is the lowest PSA level that I have ever had. Very happy with this news.
Just updating email address to email@example.com
48 months after treatment, happy to report that my PSA is 0.2
Doing great and happy to see my lowest PSA result ever (0.2). I've had normal testosterone in the low range for several years. I asked my incologist, Dr. Vogelsang about testosterone cream or shots. He said the following:
1. I don't need it because my Testosterone is still in the normal range.
2. Taking Testosterone won't feed the cancer because the Testosterone I am already producing would already be feeding the cancer and causing problems - if there were to be problems.
3. He handed me a study (TEAAM trial) that was primarily powered to determine effects of Testosterone on Atherosclerosis Progression. The secondary aim was to determine effects on sexual function. He said the sexual function results between the placebo group and testosterone group were pretty much the same.
4. He said there was not much gain, and not much risk
5. He said Testosterone causes the testicles to go to sleep and shrink - and long term use could cause permanently shrinkage of testicles.
6. He said no harm in 3-month trial.
7. He said to be prepared for the anxiety of the PSA going to as high as 1.0. I am currently at 0.2
Most recent PSA was 0.1. PSA has been 0.1 or < 0.1 since early 2015.
Doing very well.
Most recent PSA was 0.1. PSA has been 0.1 or < 0.1 since early 2016. (Prior post had a type and said "2015")
Doing very well. Testosterone cream did not absorb for me and had no effect on Testosterone levels. Did nothing for remainder of year. Going to try testosterone injections for 3 months to see if it has any effect on energy levels.
Paul's e-mail address is: firstname.lastname@example.org