McHugh Decision Worksheet

McHugh Decision Worksheet – Have you learned enough about yourself and your prostate cancer to answer these questions intelligently?

Your “Decision” is more complicated than just doing what someone you know did.

Evaluate the “Who are you” issues, your cancer specifics, and the risks and benefits of the treatments; then fill out this worksheet. If you score mostly 1’s and 2’s, you are a radiation type; mostly 4’s and 5’s, you may be a surgery type; mostly 3’s, then you are probably undecided. Use the insight gleaned here in addition to your other research to help you reach your decision. At the end of the worksheet are caveats related to each question, previously referenced in this book, which should be considered and well thought out in each of your answers. (A printable PDF download of this worksheet can be found under “Helpful Links” at theprostatedecision.com.) 

 

1. How important is it to have other options for treatment if your PSA begins to rise after surgery or radiation?
Not  important	Minimally important							Somewhat important				Important								Very important
1	2							3				4								5
2. Does the need for an incision, a catheter, and the risk of incontinence deter you from surgical removal?
Yes – very much			Yes						Probably					Probably not – other factors more important							Not a factor – other issues drive my decision
1			2						3					4							5
3. Which most closely describes your biopsy and PSA?
Micro-focuson one sideGleason’s 5-6PSA normal or mildly elevated				Small volume on one sideGleason’s 6PSA normal or mildly elevated						Small volume on both sidesGleason’s 6PSA between4-10					Moderate volume on both sidesGleason’s 6-7PSA between4-10							High volume on both sides Gleason’s 7 or higherPSA over 10
1				2						3					4							5
4. How would you describe your urinary stream?
Completely normal, on no prostate meds				Minimal obstructive voiding symptoms						Mild symptoms, on prostate medication					Off-and-on slow stream, small caliber of urinary stream							Slow, with small force and caliber of urinary stream
1				2						3					4							5
5. Which most closely matches your health and age?
Marginal health,over 70 years of age				Good health, over 70 years of age						Marginal health, aged 60-70					Good health, 40-65 years of age							Excellent health, 40-65 years of age
1				2						3					4							5
6. Above all other issues, the most aggressive method to treat your cancer is the one most important to you.
Definitely not most important factor.					Probably not most important issue						Undecided – other factors play a role						Yes			Very strongly yes
1					2						3						4			5
7. Do you think surgical removal or radiation gives you a better chance of preserving sexual function long term?
Definitely radiation						Radiation				About the same					Surgery			Definitely surgery
1						2				3					4			5
8. Which treatment do you feel is most likely to cure you of your prostate cancer?
Radioactive seeds and external beam radiation.							Probablyradiation				Don’t know – about the same.					Probablysurgical removal						Surgical removal of the prostate
1							2				3					4						5
9. How important is the ease of treatment, limited time out of work, and impact on lifestyle to you?
Most important factor in my decision		Important – has large role in my decision						Somewhat important – other issues also factor					Not a primary factor in my decision						Ease of treatment has no role at all in my decision
1		2						3					4						5
10. What method of treatment would you choose if it were  based solely on your personal research, the wishes of your family, and your interviews of friends who have been treated for prostate cancer?
Radiation		Probably radiation						Don’t know					Probably surgical removal						Surgical removal
1		2						3					4						5

 

Important points to consider and understand in answering each question.

 

1.   You can do full course external beam radiation after surgical removal if there is a later rise in your PSA. If you have radiation first and your PSA rises, indicating a return of your cancer, you have limited options for surgical intervention to treat the cancer or any of the side effects of radiation, i.e. obstructive voiding symptoms.

2.   This question hits at the ease of therapy issue. Radiation with seeds is an outpatient, 90-minute procedure with anesthesia and wearing a catheter usually for only one day. Surgery is associated with more risks, longer hospital stay, longer need for a catheter, and an incision or incisions depending on the method chosen to remove the prostate. If ease of therapy is your main focus, this is hands down in favor of radiation. External beam therapy is inconvenient in terms of the number of trips required for treatment but is simple to do with minimal treatment risks.

3.   The characteristics of your biopsy give you insight as to the aggressiveness of your cancer. I believe that surgical removal is the most aggressive form of treatment for prostate cancer. (Your radiation therapist may disagree, ask him or her for yourself and get their view.) If your biopsy indicates aggressive disease, you should be thinking more about aggressive therapy. If your biopsy suggests a less aggressive cancer, you may opt for the less aggressive therapy, radiation or cryotherapy, in hopes of having both a curative result and ease of treatment.

4.   If you are having problems with a slow stream, this should heavily influence your decision. You now know that surgical removal will help this symptom, which is most likely unrelated to your cancer and related just to the natural enlargement of the prostate commonly seen in males as they age. You also realize that radiation will make this symptom worse, and if you are adamant about pursuing radiation as your treatment of choice, a procedure to correct it must be done before radiation because surgical correction after radiation is fraught with difficulties. (It is better to cure at the beginning rather than the end.)

5.   It all starts with good health; if you don’t have it you will not be a candidate for surgical removal and possibly not a candidate for seeds, as seed implantation also requires anesthesia. If you are in good health but in your mid-70s, then your years at risk come into play and you may choose a less aggressive therapy, potentially leaning toward radiation, particularly external beam. If the cancer does reoccur, your age or other medical problems may make it irrelevant. Good health and young physiologic age indicate an extended years-at-risk profile and favor a more aggressive therapy. Marginal health and limited years at risk favor a less aggressive therapy.

6.   This stresses the point that a patient needs to declare to himself what he feels is most important to him regarding treatment. It will either be cure, and what he feels is the most aggressive form of therapy will be the driving factor, or a blend of ease of treatment with an acceptable cure rate. The cure-only patient, like I was, is a “Damn the torpedoes – I want it out!” type.  If other factors rule your thought process, you may opt for a less aggressive route in an attempt to “have your cake and eat it too.”          

7.   This is a trick question, but obviously if preserving sexual function is important to you, you really need to know the caveats here. In a nutshell, surgical removal has more risk of the complete dramatic loss of sexual function if the nerves are severed at the time of the prostatectomy. You now know, however, that with a properly performed Walsh Nerve Sparing Prostatectomy and some luck, your nerves will be spared and your erectile function will be salvaged. If the nerves are spared, sexual function can return to your baseline. Surgery is big risk, big reward. Radiation will not result in the dramatic loss of sexual function, but you may see a deterioration of your erections over time to an undetermined level, even impotence. The reason this is a trick question is that sexual function takes a hit with either treatment, and when you consider all the factors and potential end points of the various treatments, this question is probably a wash and number 3 is the right answer. In my case, sexual function slowly improved over the course of a year to the point that I no longer need to take drugs for erections. Remember that I was relatively young and had no other medical problems at the time of my surgery. The degree to which sexual function is preserved with either of the treatments depends heavily on the pretreatment erectile function and general health of the patient.

8.   Once you are told you have prostate cancer, you will begin weighing the risks against the benefits of the various treatment options. Some patients worry less about the risks than their general feeling of what is the most aggressive form of therapy and the one that they feel gives them the best shot at cure. In general, an aggressive mindset is a surgery type; someone who is weighing risks, benefits, and concerns about impact on lifestyle is generally a radiation type. (This is a rephrasing of question 6, but this is so important. It is not wrong to heavily value the ease of a particular treatment, but it is imperative to see it for what it is: a decision that is not based solely on cure.) As I have mentioned earlier in this book, as cancers go, prostate cancer is somewhat unusual in this regard, which is probably related to two issues. The first is the misconception that all prostate cancers act in a benign fashion (Why kill a fly with a shotgun?), and the second is the fear of potential complications, namely incontinence and impotence.

9.   This question clearly differentiates the surgical removal-type patient from the patient who wants what he feels is a good treatment, but equally values impact on lifestyle and ease of the treatment. The patient of the latter mindset will usually choose radiation, particularly seeds, as it is an outpatient procedure involving 20-30 puncture wounds to the perineum, one day with a catheter, and no incision.

10.   I added this question to make the point that patients will often value what they have learned through their personal research and what other people they know have done more that what their urologist may advise. This is not necessarily a flawed approach, but hopefully the apples to apples and prostates to prostates evaluation will prevent a patient with very unfavorable biopsy parameters from choosing to do what his friend with very favorable parameters did. Also, remember that procedures have both short and long-term effects. You must be aware of both and factor each into your decision as well.