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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[QUOTE=able5;3419466]What does your professional team say about changing your treatment path to something more agressive (surgery, radiation, HIFU, proton beam, etc.)?

You ask an excellent question, and here's a short answer and a longer answer from my viewpoint. (As I'm reviewing this before clicking the Submit Reply button, it looks really long. So if you get all the way to the end, give yourself a gold star! :cool: )

The short answer is that local therapy was and is almost certainly not capable of curing my case of prostate cancer. :( That's because the combination of case characteristics point emphatically to so called distant "microscopic metastasis" that cannot be detected by scans or other means. That means there would likely be some viable cancer that was out of the reach of any of the local or regional therapies, like surgery, HIFU, cryo, seeds, proton beam or even more widely aimed IMRT. One high risk characteristic is usually not so bad, though my baseline PSA of 113.6 is almost a door slammer all by itself. Even two high risk characteristics, or sometimes more are okay if the overall combination does not look forbidding. In my case, I had a combination of unfavorable characteristics that did look forbidding, and I was even rejected when I requested surgery back when I didn't know much. :( Many research studies back this up, pointing to poor outcomes when local and even regional therapies have been tried. The other side of the coin is that with a challenging case and it's need for a very thorough approach with local therapy, such as extensive pelvic radiation, there is a good chance of a lingering burden of substantial side effects from local therapy. You asked specifically what my professional team thought about these therapies, and essentially they feel this way about a shot at cure: highly unlikely for surgery, and a far lower than 50% chance for radiation, probably well under 25%, which would probably apply to the other approaches as well.

The longer answer is that there may be a role for some of these therapies even with a minimal chance of cure. That role is known as "debulking" the tumor(s), and the idea is to wipe out the core of the cancer in and near the prostate in order to lower the overall burden on the system. I believe that most of the doctors I respect would recommend debulking rather than the course I am taking, but not all of them would, and I'm confident they understand the course I am taking and consider it well within the range of reason. This is where I am taking charge and making the crucial call. However, I may elect to debulk the tumor in the prostate at a later time.

Surgery for debulking is controversial, with some doctors thinking that it can even lead to enhanced aggressiveness if the surgery does not get all the cancer, a failure which is likely in cases similar to mine. On the other hand, my impression is that this theory of increasing aggressiveness is a minority view, and I can find only one reference to an actual study - an old one, and I have not had a chance to look at it. Some doctors feel that if the theory is true, it is more applicable to high Gleason disease than low-risk Gleason Score disease. Also, Mayo Clinic surgeon Horst Zincke published encouraging results on the length of success of hormonal therapy for men who had previously known mets in their lymph node mets at the time their prostates were removed. However, I believe that radiation is more accepted for debulking, though cryo would also probably work well.

One study that is well-known to those of us who are very concerned about the issue of debulking is referred to as the Zagars study, published in 1994 based on research from MD Anderson Cancer Hospital, one of the most highly regarded institutions for prostate cancer. Here's what Dr. Charles Myers wrote about that study on page 50 of his book "Beating Prostate Cancer -- Hormonal Therapy & Diet" (2006): "... In this study, patients with lymph node spread were placed on hormonal therapy and followed until they recurred. (Note that these men did not have their prostate glands removed.) Once a patient recurred, researchers recorded where hormone-resistant disease emerged. In more than half the cases, hormone-resistant disease first emerged in the prostate gland.... Thus, all other things being equal, you would expect hormone resistance to emerge at locations where there are a large number of cancer cells...."

Debulking is an option on my mind, and I would probably choose radiation years from now if I took that course. However, the Zagars study, which indicated value for debulking, was done at a time when hormonal blockade technology was not nearly as advanced as the technology I'm using, and I expect to get at least one more good cycle of triple hormonal blockade and a followup off-therapy cycle. With a bit of luck, counting a half year or more of success now with thalidomide, that should give me another three to four years of good cancer control and good to excellent quality of life. If I again were to achieve a nadir of <0.01 while on triple blockade, I would have an excellent shot of success on a round of therapy and an off period after that. Dr. Mark Scholz, one of the foremost experts in hormonal blockade, told me that patients on intermittent blockade (like me) who lasted at least four to five years without developing androgen independence (like me, already at eight years) had an excellent shot at additional cycles of blockade without developing androgen independence (hopefully me). (This was in a face-to-face side conversation following his presentation and followup "Meet the Speaker" session at the 2006 national conference - one of the benefits of attending the conferences in person.)

Meanwhile, technology is advancing at a rapid pace. :) It is likely that my options several years from now would be substantially better than they are today. :) The time I have gained so far during the past eight years, for instance, has seen the maturing of DaVinci robotic surgery with its superior side effect profile, really effective cryo therapy, some solid longer-term encouraging data about proton therapy effectiveness, and the emergence of IMRT, advanced IMRT, and TOMOtherapy-like approaches. The past eight years have also seen great advances in supportive care, such as the drug Zometa (for bone density and help with bone mets), and nutrition (such as knowledge of the need for and safety of vitamin D at higher doses, and of the apparent benefits of pomegranate). There is also much greater knowledge of hot to combat the side effects and complications of various therapies, particularly hormonal blockade.

Going on thalidomide now with resumption of triple hormonal blockade following that is not an entirely risk-free course. I think it is unlikely that I would develop androgen independent prostate cancer (AIPC), otherwise often called hormone refractory prostate cancer (HRPC), but it could happen; if it does, my doctor and I know what to do next. It appears unlikely that I would develop detectable distant metastases while on what looked like successful hormonal blockade and a followup off-therapy period, but that too could happen. There is also some risk in using the hormonal blockade drugs, Boniva for bone density, and thalidomide, but in my case I have been on all of them before and done well, and my doctor monitors me closely. With monitoring and timely reaction to any problem, the risks look quite low. To me, the risks are acceptable.

As far as I know, debulking would still be an option after at least one more full cycle of triple therapy followed by an off-therapy period. :)

Well, that's the short and long of it from my viewpoint. Thanks for asking. :)


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