Healthy 63 yr old with prostate cancer and favorable parameters on prostate biopsy report. Which treatment for prostate cancer best?

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Question:

I am 63 years old and in good health. I was recently diagnosed with prostate cancer (Gleason 6; low volume; TIC Stage 2). My urologist–a surgeon–went through the options with me and my wife. He also stated that he felt I was a prime candidate for using the new trueBeam radiation method (45 treatments). He set me up to meet with radiology oncologist. I also have an appointment with a surgeon he recommended that performs the daVinici Robotic surgery. After reading your book and the Johns Hopkins book, I was leaning towards the surgery — the “gold standard.” Now after meeting with the radiologist, many of my fears and concerns relative to radiation were “debunked.” Do you have any insight or could you direct me to any studies relative to the trueBeam radiation therapy? Treatments would be done less than six miles from my home — a real plus.

From the Varian Website about TrueBeam radiation:

With TrueBeam, we have seamlessly integrated imaging, beam delivery and motion management to produce a system that delivers unmatched synchronization. The result is a revolutionary and elegant solution with improved operation, precision and speed.

de·bunk
tr.v. de·bunked, de·bunk·ing,
de·bunks

To expose or ridicule the falseness, sham, or exaggerated
claims of: debunk a supposed miracle
drug.

de·bunker n.

Word History: One can readily see that
debunk is constructed from the prefix de-, meaning “to remove,”
and the word bunk. But what is the origin of the word bunk,
denoting the nonsense that is to be removed? Bunk came from a place where
much bunk has originated, the United States Congress. During the 16th Congress
(1819-1821) Felix Walker, a representative from western North Carolina whose
district included Buncombe County, carried on with a dull speech in the face of
protests by his colleagues. Walker later explained he had felt obligated “to
make a speech for Buncombe.” Such a masterful symbol for empty talk could not be
ignored by the speakers of the language, and Buncombe, spelled
Bunkum in its first recorded appearance in 1828 and later shortened to
bunk, became synonymous with claptrap. The response to all this
bunk seems to have been delayed, for debunk is not recorded until
1923.

The best treatment? Answer…there is no best treatment.

But here’s the great thing about the above case…he is a reasonable candidate for all treatments including surveillance therapy. This patient as all the good stuff…age is good, health is good, path report is good. Now the issue is which treatment best meshes with him and limits the downside of any of the potential side effects. Well, you won’t know until you have the particular treatment.

I chose to have mine removed and basically was lucky that I dodged all the bad side effects. If I had had my procedure on a different day or by a different doctor, I might not have been so lucky.

Now to “debunking” any fears about radiation. What would be my fears about having radiation?

The really bad stuff happens infrequently-colitis, persistent diarrhea, urgency incontinence, impotence and the unknown side effects down the road like hemorrhagic cystitis. I have seen patients with prostato-rectal fistulas. I was consulted on one last week with radiation colitis and had a colostomy. I’ve had post radiation patients with urethral strictures.
I did not like that any procedure that might be needed down the road would be more difficult because of the effects of radiation on surrounding tissues.
I had some obstructive voiding symptoms and I was concerned that would worsen with radiation and then I’d be limited as to what I could then do about it surgically.
Regarding seeds: I was concerned about all the voiding symptoms and the “non exact science” of placing the seeds.

Here’s the thing…you can’t really debunk these issues. The minor side effects occur commonly-how severe or the duration is an unknown…that’s a fact. And there are patients out there who have had a bad time with the aftermath of radiation. That’s a fact. You can debunk that the chances of the bad things about radiation probably won’t occur, but it would be disingenuous for any radiation therapist to state that they are unfounded fears and that they won’t happen. That’s a fact. Not a bad idea to ask a radiation therapist, “Tell me about some unfortunate things that have happened with your prostate cancer patients after radiation.” They will have a few examples-uncommon yes but “you know what” happens.

The TrueBeam as best as I can tell is a system that allows for the treatment of prostate cancer with radiation and has corrected a problem with older systems and that is making sure the beam is on the target, i.e. that all the radiation goes where it is supposed to go and adjusts if the patient moves. Obviously if a patient moves even a bit the radiation would then be off target. Does this mean that it limits collateral damage? Yes. Does it mean there will be no collateral damage or that the prostatic urethra won’t get inflamed? No. Radiation is radiation and its effect on the body is a given-again to what degree is an unknown. A good question for the radiation therapist might be to clarify that TrueBeam is synchronized, but the radiation, the dosage and the time frame are the same as non TrueBeam. It seems that all the non surgical forms of radiation all have a catchy name…nanoknife, prostarecision, etc.

External beam radiation (a broad term of which TrueBeam is and radioactive seeds aren’t) is much better tolerated with fewer prostate side effects than seeds. Seeds probably do a better job of putting large amounts of radiation right where it needs to be. In this particular prostate cancer-favorable pathology-I think that external beam radiation is a good choice.

It fits the patient, the disease, and the “who are you” factors as the treatment is convenient. Also I hear in the tone of the patient that he likes the idea of radiation over surgery. I like it!

I also think (if the patient can live with it and wrap his mind around it) that surveillance is a good option.

Before you think I was hard on radiation…surgery has its own issues and it is a less than perfect treatment with unknowns after the treatment.You could die on the table or leak urine, I mean flat-out leak forever or for 3 months like I did. “There is no free ride my friend.”

Summary:The TrueBeam makes sure that patient movement is accounted for in the treatment to assure that the maximum dose of radiation gets where it should. I don’t think its “better radiation.” The favorable path makes external beam a good option. And I think this patient has “done it the right way.” He understands his disease and has matched the disease with the treatment in the context of his personal situation. He should think a bit about surveillance…once a year biopsy and twice a year PSA and proceed to treatment if any untoward change. Of note, at five years, about 20-30% of the people in surveillance “fall out” and pursue treatment and with a very low % consequence to waiting until signs of progression.

And of course…a bit of luck that the bad things that happen to the unfortunate few don’t happen to him.

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