My information, for whatever it is worth

[Guest guest]

Hi to everyone.

ly, I hate that I am in this group, because it means that I was

diagnosed with prostate cancer and am faced with all the

ramifications that this diagnosis entails. I don't know about you,

but I find this somewhat therapeutic to spell out my thoughts for all

to see. Therefore, these are my opinions, and my reasoning for the

approach I am taking for my treatment. I hope that this information

may be beneficial to someone.

I don't know about your diagnosis, so it is difficult to compare your

diagnose to mine. One thing that I have learned is that there are a

lot of different circumstances that each individual has to face in

regard to their own diagnosis and the associated decisions that they

make in regard to their treatments.

Here are my statistics, and the results from my pathology report on

Oct 31, 2007;

• Age – 53 (turned 54 in Nov 2007)

• PSA is 3.83

• Gleason's Grade - 3+3=6 (Gleason Score of 6)

• One biopsy core was diagnosed with carcinoma, which was less

than 10% of the tissue submitted.

• One other biopsy core had a " high grade parostatic

intraepithelil neoplasia " (atypical cells, otherwise called pre-

cancer cells).

• All other biopsies benign, or in other words, there was

neither cancer nor atypical cells.

From all that I have read, and from my consultation with my Urologist

and Surgeon, my understanding is that my prostate cancer is currently

a " low grade " and it has been diagnosed in an early stage.

My Approach to Treatment –

My approach to treatment, and decision for which treatment to use,

has primarily been made based upon what I believed to be the surest

method of curing the cancer. In other words, my primary motives were

not based on avoiding surgery, pain, or the possibility of

incontinence or impotency. Sure, I want to come away with the fewest

side effects, but again, I want the surest method of curing the

cancer, and remaining cancer free for the rest of my life.

I believe that at my age, I have a life expectancy of 20 plus years.

I want to have the best chance of living that long with the least

fear of reoccurrence, even if I have to live all that time with some

unpleasant side effects.

My thoughts are that with my early stage of cancer that the chances

are very good that the tumor is located totally within the prostate

gland. Therefore, having surgery is going to be the best method for

eradicating the cancer. I also think that using the newer robotic

surgery provides me with the best recovery options, as well as the

best chance to reduce the possibility of " long term " incontinence

and/or impotency.

For me, the Robotic-assisted Laparoscopic Radical Prostatectomy

provides me with a far less invasive procedure then the old Radical

Retropubic or Radical Perineal open surgery. Surgery provides the

most effective way for my doctor to view the actual site of the

cancer and allows him to do exactly what he feels is necessary to get

it all out. Also, the pathologist will examine the entire prostate

gland, once it is removed, and confirm the original biopsy results.

They will also be able to examine the surrounding tissue and my lymph

nodes and determine if the cancer has spread outside the prostate.

This will allow the best way for my doctor, or other specialists to

determine if additional treatments are necessary.

Expected Side Effects –

After the operation, I fully expect some short term leakage after

they remove the catheter, and probably this may continue for some

time. According to what I have studied, and from what my surgeon has

confirmed, my chances for long term incontinence issues are expected

to be about a 1% chance or less.

I also fully understand that after surgery, I will not have exactly

the same sexual experience as before the surgery. In my specific

case, I believe that the chances are very good that my surgeon will

be able to spare both nerve bundles, and I will continue to have a

near normal sexual life going forward.

My next few statements are meant to be totally honest about what I

expect to be different in regard to my sexual experiences after

surgery based upon my research, and based upon talking to other men

that have gone before me. If you are not comfortable with a graphic

discussion of sexual behavior, please just skip down to

the " Treatment Options " section.

The first impact is that I fully expect is that my erections MAY not

be as hard as they were before surgery, at least for the first few

week or months, and this will probably only be a short term effect.

Some people make it sound like if you have surgery, it is a given

that you will have long term impotency issues. I have talked to men

that have had both the open surgery as well as those that have had

the robotic surgery. Many men recover to have good erections, and

many times they are nearly, if not as fully as hard of an erection as

they had before the surgery. This has a lot to do with your age,

other health issues, if you are already experiencing any ED related

issues, as well as the experience and accuracy of the surgeon that

you chose. Regardless of how hard your erection is going to be, many

men say that they still have great orgasms even if they no longer

have an erection. Also, there are many treatments to help with the

quality of an erection if there are any difficulties.

Another expected impact is that I will no longer have ejaculate when

I climax. When they perform the prostatectomy, they also remove the

seminal vesicles, therefore, no more seamen. I also understand that

my orgasm may not be exactly the same as before, primarily because

there will no longer be a prostate. This means that during orgasm, I

will not feel the prostate contract to cause an ejaculation, nor have

the sensation of the ejaculation going through my penis and squirt

out the end. Just thinking about how that feels now, I have to think

that sexual relations will be somewhat different then it was before.

Regardless, many men say that their climax feels just as good as it

did before they had surgery and you get used to not having any

ejaculate come out.

Treatment Options –

As I have done my research in trying to make my decision, I have

gathered the following information from various places and have tried

to provide this documentation to help give others some basic

information to get familiar with the various treatment options.

There is a lot for you to think about when choosing the best way to

treat or manage the cancer. The treatment you choose for prostate

cancer should take into account:

• your age and how long you can expect to live

• any other serious health problems you may have

• the stage and grade of your cancer

• your feelings (and your doctor's opinion) about the need to

treat the cancer

• the chance that each type of treatment will cure your cancer

(or provide some other measure of benefit)

• your feelings about the side effects common with each

treatment

Below I have listed many of the treatments that are available for

treating your prostate cancer, along with expected side effects so

that you can read more about them. Specifically, in regard to my

case, here are my thoughts on active surveillance (watchful waiting,

or expectant management), EBRT, PBRT, Cryosurgery and even Hormone

Therapy. I don't believe that these are MY best long term options.

Even though some of them have had impressive results, there is no

evidence that they provide any better results in eradicating the

cancer. In fact, for me, I believe that I would have a higher

possibility of recidivism, and over a 20 plus year life expectancy,

they could even present a higher possibility of long term

incontinence and impotency.

I believe that the External Beam Radiation Therapy, and Proton Beam

Radiation Therapy, especially Brachytherapy, the treatment in which

tiny radioactive " seeds " are implanted in the prostate appear to be

treatments with promise, after the surgery option. These treatments

also have the potential for reduced impacts up front, and primarily

for the short term, which I mean over the next 5 years or so.

Regardless of the reduced up front, short term benefits, ALL the

radiation treatments either have as much risk, if not even a greater

risk, for impacts over the long run, which I mean as 5 years or more

after being treated. EBRT and Brachytherapy may have the same long

term impacts for incontinence and impertinence, but it will probably

start impacting you 3 to 5 years later and then those impacts could

even get worse from there. Even though PBRT has the potential to

kill the cancer that you have now, because the prostate remains, it

leaves the window fully wide open for the cancer to return down the

road. I was also made aware that if the cancer does return latter,

unfortunately, and as was confirmed to me by Loma Medical

Center, you are no longer a candidate for another round of PBRT.

Therefore, I would still need to consider another option for

treatment at that point.

I fully believe that for someone else, and especially for those men

that are much older then me, or possibly for men that have a more

advanced cancer then me, and possibly for some men that may have

other health risks beyond the prostate cancer, one of these radiation

treatments may even be the most preferred option for them.

Watchful Waiting (Expectant Management)

Because prostate cancer often grows very slowly, some men (especially

those who are older or who have other major health problems) may

never need treatment for their cancer. Instead, their doctor may

suggest an approach called " watchful waiting " (also called " expectant

management " ). This approach involves closely watching the cancer

(with PSA testing) without using treatment such as surgery or

radiation therapy. It is less often a choice if you are younger,

healthy, and have a fast-growing cancer. Some men choose watchful

waiting because, in their view, the side effects of strong treatments

outweigh the benefits. Others are willing to accept the possible side

effects of active treatments in order to try to destroy the cancer.

Surgery

The most common operation for prostate cancer is radical

prostatectomy.

Radical Prostatectomy

This surgery is done to try to cure the cancer. It is done most often

if it looks like the cancer has not spread outside the prostate. The

entire prostate gland and some tissue around it are removed.

Robotic-assisted Laparoscopic Radical Prostatectomy

An even newer approach is to do LRP remotely using a robotic

interface. The surgeon sits at a panel near the operating table and

controls robotic arms to perform the operation through several small

incisions in the patient's abdomen.

Risks and side effects of radical prostatectomy

The risks with this surgery are like those of any major surgery and

can include problems from the anesthesia, a small risk of heart

attack, stroke, blood clots in the legs, infection, and bleeding.

Your risk depends, in part, on your overall health, your age, and the

skill of your doctors. The main possible side effects of radical

prostatectomy are lack of bladder control (incontinence) and not

being able to get an erection (impotence). These side effects can

also happen with other kinds of treatment.

Radiation Therapy

Radiation therapy is treatment with high-energy rays (such as x-rays)

to kill or shrink cancer cells. The radiation may come from outside

the body (external radiation) or from radioactive materials placed

directly in the tumor (brachytherapy or internal radiation).

Radiation is sometimes used as the first treatment for low-grade

cancer that has not spread outside the prostate gland, or has spread

only to nearby tissue. It is also sometimes used if the cancer is not

completely removed or comes back (recurs) in the area of the prostate

after surgery. Cure rates for men treated with radiation seem to be

about the same as for men having surgery. If the cancer is more

advanced, radiation may be used to shrink the tumor and provide pain

relief.

External Beam Radiation Therapy (EBRT)

This treatment is much like getting a regular x-ray, but for a longer

time. Each treatment lasts only a few minutes. Men usually have 5

treatments per week in an outpatient center over a period of 7 to 9

weeks. The treatment itself is quick and painless. Today standard

EBRT is used much less often than in the past. Newer techniques allow

doctors to be more accurate in treating the prostate gland while

reducing the radiation exposure to nearby healthy tissues. These

techniques appear to offer better chances of increasing the success

rate and reducing side effects.

Proton Beam Radiation Therapy (PBRT)

Proton radiation treatment differs from standard radiation therapy.

If given in sufficient doses, conventional radiation therapy

techniques will control many cancers. Because of the physician's

inability to adequately conform the irradiation pattern to the

cancer, healthy tissues may be damaged with radiation. Consequently,

a less-than-desired dose frequently is used to reduce damage to

healthy tissues and avoid subsequent unacceptable side effects. The

characteristics of proton beam therapy enable the physician to

deliver full or higher doses while sparing surrounding healthy

tissues and organs. The side effects of proton therapy, though

identical to those of conventional x-ray, are greatly diminished,

because the proton beam is so well focused that damage to normal

tissues is reduced.

Possible Side Effects of External Beam Radiation Therapy

The possible side effects below relate to standard external radiation

therapy, which is now used much less often than in the past. The

risks of the newer treatment methods mentioned above are likely to be

lower.

Bowel problems: During and after treatment with external beam

radiation therapy, you may have diarrhea, sometimes with blood in the

stool, rectal leakage, and an irritated large intestine. Most of

these problems go away over time, but in rare cases normal bowel

function does not return after treatment ends.

Bladder problems: You might have trouble with having to urinate

often, a burning sensation while urinating, and blood in your urine.

Bladder problems persist in about 1 out of 3 patients, with the most

common problem being the need to urinate often.

Urinary incontinence: Although this side effect is less common than

after surgery, the chance of incontinence goes up each year for

several years after treatment.

Impotence: After several years, the impotence rate after radiation is

about the same as that of surgery. It usually does not occur right

after radiation therapy, but slowly develops over a year or more. As

with surgery, the older you are, the more likely it is you will

become impotent. Impotence may be helped by treatments such as those

listed in the section above, including erectile dysfunction

medicines.

Feeling tired: Radiation therapy may also cause fatigue that may not

disappear until a few months after treatment stops.

Lymphedema: Fluid buildup in the legs or genitals (described in the

surgery section of this document) is possible if the lymph nodes

receive radiation.

Brachytherapy (brake-ee-ther-uh-pee) (Internal Radiation)

In one approach (permanent or low dose brachytherapy), small

radioactive pellets (each about the size of a grain of rice) are

placed directly into the prostate. Sometimes these pellets are

referred to as " seeds. " Because they are so small, they cause little

discomfort and are often simply left in place after their radioactive

material is used up.

In another form of brachytherapy (temporary or high dose

brachytherapy), needles are used to place soft tubes (catheters) in

the prostate. A strong radioactive substance is placed in these

catheters for 5 to 15 minutes and then removed. You will stay in the

hospital for this treatment. Usually 3 brief treatments are given

over a couple of days. After the last treatment the catheters are

removed. Often this treatment is combined with external radiation,

given at a lower dose than it would be if used alone. For about a

week after this treatment you may have some pain in the area between

your scrotum and rectum, and your urine may be reddish-brown.

Possible Risks and Side Effects of Brachytherapy

If you have pellets that are left in place, they will give off small

amounts of radiation for several weeks. Even though the radiation

doesn't travel far, you may be told to stay away from pregnant women

and small children during this time. You may be asked to be careful

in other ways as well, such as wearing a condom during sex.

For about a week after the pellets are put in place, there may be

some pain in the area and a red-brown color to the urine. There is

also a small risk that some of the seeds might move (migrate) to

other parts of the body. Like external radiation treatment, this

approach can have side effects such as problems with the bladder and

bowel and impotence. But it may be that these occur at a lower rates.

Be sure to talk to your doctor if you have any of these side effects.

Often there are medicines or other methods to help.

Cryosurgery

This approach is sometimes used to treat prostate cancer by freezing

the cells with cold metal probes. It is used only for prostate cancer

that has not spread but may not be a good option for men with large

prostate glands. The probes are placed through incisions between the

anus and the scrotum. Cold gases are then passed through the probes,

which creates ice balls that destroy the prostate gland. Some type of

anesthesia is used during this procedure.

A catheter is also put in place (usually through the abdomen) so that

when the prostate swells (it usually does after this treatment) urine

does not stay trapped in the bladder. You will probably be in the

hospital for a day. The catheter is removed a couple of weeks later.

After the procedure, there will be some bruising and soreness of the

area where the probe was inserted. You may have some blood in the

urine for the first few days. Short-term swelling of the penis and

scrotum after cryosurgery is also common.

Possible Side Effects of Cryosurgery

There are benefits and drawbacks to cryosurgery. On the one hand,

because it is less invasive than radical surgery, there is less loss

of blood, a shorter hospital stay, shorter recovery time, and less

pain. But freezing can damage nerves near the prostate and cause

impotence and incontinence. These side effects may occur more often

than they do after radical prostatectomy. In addition, freezing may

damage the bladder and intestines. This can cause pain, a burning

sensation, and the need to empty the bladder and bowels often.

Compared to surgery or radiation treatment, doctors know much less

about how well the method works in the long run. For this reason,

most doctors do not include cryosurgery among the first options they

recommend for treating prostate cancer.

Hormone Therapy

The goal of hormone therapy (also called androgen deprivation) is to

lower the levels of the male hormones or androgens (an-dro-jens),

such as testosterone (tes-toss-ter-own). Androgens, which are made

mostly in the testicles, cause prostate cancer cells to grow.

Lowering androgen levels often makes prostate cancer shrink or grow

more slowly. Hormone therapy can control, but will not cure the

cancer. It is not a substitute for treatments aimed at a cure.

Hormone therapy is often used in the following situations:

• In men who do not have surgery or radiation as good treatment

options.

• For men whose cancer has spread to other parts of the body or

has come back after earlier treatment.

• It may be used along with radiation in men who are at high

risk of having the cancer return after treatment.

• Sometimes it is used before surgery or radiation to shrink

the cancer.

While hormone therapy does not cure the cancer, it can provide relief

from symptoms. Some doctors think that hormone therapy works better

if it is started as early as possible after the cancer has reached an

advanced stage. But not all doctors agree with this.

Because nearly all prostate cancers become resistant to this

treatment over time, some doctors use an on-again, off-again approach

(intermittent therapy). The drugs are given for a while, then

stopped, then started again. One advantage is that some men are able

to avoid the side effects (impotence, loss of sex drive, etc.) for a

time. Studies are now going on to see whether this new approach is

better or worse than giving the drugs constantly.

Types of Hormone Therapy

There are several methods used for hormone therapy. They involve

either surgery or the use of drugs to lower the amount of

testosterone or to block the body's ability to use androgens.

Orchiectomy (or-key-eck-tuh-me): Even though this is a type of

surgery (surgical castration), its main effect is as a form of

hormone therapy. In this operation, the surgeon removes the

testicles, where more than 90% of the androgens, mostly testosterone,

are made. While this is a fairly simple procedure and is not as

costly as some other options, it is permanent and many men have

trouble accepting this operation. Most men who have this surgery lose

the desire for sex and cannot have erections.

Orchiectomy can have serious side effects. These vary and depend on

the kind of treatment you are given. About 90% of men who have had

this operation have reduced or no sexual desire and impotence. Other

side effects could include:

• hot flashes (these often go away with time)

• breast tenderness

• growth of breast tissue

• weakening of the bones (osteoporosis)

• low red blood cell counts (anemia)

• lower mental sharpness

• loss of muscle mass

• weight gain

• tiredness (fatigue)

• lower levels of HDL ( " good " ) cholesterol

• depression

Many of these side effects can be treated. Osteoporosis can be a

major problem because men who have it are more likely to develop bone

fractures. If osteoporosis develops, it should be treated. Exercise

is a good way to reduce fatigue, weight gain, and the chance of loss

of bone and muscle mass. Depression can also be treated with

medicines and/or counseling.

LHRH analogs (luteinizing hormone-releasing analogs): These drugs

lower testosterone levels just as well as orchiectomy. LHRH analogs

(or agonists) are given as shots, either monthly or every 3, 4, 6, or

12 months. Even though this treatment costs more and means more

doctor visits, most men choose this method over surgery to remove the

testicles.

Side effects are like those from the surgery (see above). Also, when

LHRH analogs are the first given, the testosterone level goes up

briefly before going down to low levels. This is called " flare. " Men

whose cancer has spread to the bones may have bone pain during this

flare. To reduce flare, drugs called antiandrogens can be given for a

few weeks before starting treatment with LHRH analogs.

LHRH antagonists: A newer drug, abarelix (Plenaxis®) is an LHRH

antagonist. It lowers testosterone more quickly and does not cause a

flare. But a small number of men are allergic to the drug. For this

reason it is only used for men who cannot take other forms of hormone

therapy. The side effects are similar to those of orchiectomy or LHRH

agonists (see above).

Abarelix is given only in certain doctors' offices. It is given as a

shot every 2 weeks for the first month, then every 4 weeks. You will

need to stay in the office for 30 minutes after the shot to make sure

you do not have an allergic reaction.

Anti-androgens: These drugs block the body's ability to use any

androgens. Even after the testicles are removed or during LHRH

treatment, the adrenal glands still make a small amount of androgens.

Anti-androgens may be used along with orchiectomy or the LHRH analogs

to provide combined androgen blockade (CAB), or total blocking of all

androgens produced by the body. There is still debate about whether

CAB is better than using the other treatments alone.

Anti-androgens can cause diarrhea, nausea, liver problems, and

tiredness. They seem to cause fewer sexual side effects than other

hormone treatments.

Other drugs: At one time estrogens (female hormones) were used to

treat men with prostate cancer. Because of side effects, LHRH analogs

and anti-androgens are now used. But estrogen or some other drugs,

such as ketoconazole (Nizoral®), may be used if other hormone

treatments are no longer working.

Debates About Hormone Therapy

Many issues about hormone therapy are not yet resolved, such as the

best time to start and stop it and the best way to give it. Studies

looking at these issues are now going on. If you are thinking about

hormone therapy, ask your doctor to explain which treatments will be

used and what side effects you might expect to have.

Chemotherapy (Chemo)

Chemo is the use of drugs for treating cancer. The drugs are often

injected into a vein. Some can be swallowed in pill form. Once the

drugs enter the bloodstream, they spread throughout the body to reach

and destroy the cancer cells.

At one time, chemo was not thought to work very well in treating

prostate cancer, but this has changed in recent years. In the past

few years, new drugs have been shown to relieve symptoms from

prostate cancer in men with advanced disease.

Like hormone therapy, chemo is unlikely to result in a cure. This

treatment is not expected to destroy all the cancer cells, but it may

slow the cancer's growth and reduce symptoms, resulting in a better

quality of life.

There are a number of different chemo drugs. Often 2 or more are

given at the same time for better effect.

Side Effects of Chemo

While chemo drugs kill cancer cells, they also damage some normal

cells and this can lead to side effects. The side effects of chemo

depend on the type of drugs, the amount taken, and the length of

treatment. They could include:

• nausea and vomiting

• loss of appetite

• hair loss

• mouth sores

Because normal cells are also damaged, you may have low blood cell

counts. This can cause:

• increased risk of infection (from a shortage of white blood

cells)

• bleeding or bruising after minor cuts or injuries (from a

shortage of blood platelets)

• tiredness (from low red blood cell counts)

Also, each drug may have its own unique side effects.

Most side effects go away once treatment is over. If you have

problems with side effects, talk with your doctor or nurse about what

can be done. There is help for many chemo side effects. For example,

there are drugs to prevent or reduce nausea and vomiting. Other drugs

can be given to boost blood cell counts.

I hope that this information is useful. I hope that it may be of

some help toward getting you started down the road in considering

which options are available, and which treatments may fit better into

your set of circumstances.

I wish you the best of outcomes with your treatment, regardless of

which you chose.

Ted G.