- Prostate Cancer Question 1: RADIATION OR SURGERY
Q. Well, I am now officially a member of the “prostate cancer club.” My doctor called me yesterday with my biopsy results: Gleason 7 and PSA of 6.8 ng/ml. I am 63 years old and will do something soon to get rid of the prostate cancer. I have been divorced for two years now and still have an active dating life, which is one of the reasons I have been considering radiation therapy as my treatment. Losing my erection to prostate surgery would be too great a sacrifice for me right now. My best friend, who had a radical prostatectomy three years ago (and now successfully uses Viagra), tells me that with radiation you can never be sure all the cancer has been killed off, so I should go with the surgery? Annapolis, MD
A. With respect to surgery, it is fair to say that if you can be cured, you will be cured. By that I mean, if the cancer has not yet spread out of the prostate, and the gland is removed before that possibility ever develops, you will never have the disease again. It is not at all clear that radiation therapy can offer that outcome. With respect to potency, the nerve bundles are located within millimeters of the prostatic capsule. During surgery, one can separate them and still remove all cancer. It is more difficult for radiation to preserve these nerves while still applying the high energy to the prostatic tissues only millimeters away.
- Prostate Cancer Question 2: POSITIVE MARGIN REMAINING
Q. I love the Prostate Bulletin! Thank you! On July 2, 2007, I had my prostate removed by a surgeon using a Da Vinci robot. Unfortunately, the doctor left behind some of my prostate -- a positive margin on the left side. The pathology report showed: Adenocarcinoma (conventional, not otherwise specified), a Gleason of 3+4, with a stage of nT2c, and 20% of prostatic tissue involved. My biopsies had shown no prostate cancer on that left side. In 2004, I had a PSA of 1.72 ng/ml; in 2006, it was 1.92. Just prior to the surgery, my PSA was up to 2.0. I am thinking of coming to Johns Hopkins to have that remaining positive margin tissue removed by means of regular open surgery. Do you know of any similar cases (i.e., having an open surgery done to correct mistakes made by a robotic surgery)? Via E-mail
A. Whether the prostate surgery is performed by an open, robotic, or laparoscopic technique, the interior scarring will be the same. In general, it’s very rare to operate on the prostate a second time to remove additional prostatic tissue. We have done it once after an obviously incomplete prostatectomy was performed on a very young patient, but the operation was profoundly difficult, as scarring from the first operation made the field almost impossible to work in. If only a minute margin is suspected, it would be inadvisable to re-operate. It’s unlikely that the tissue would ever be found, and a lot of damage could be done.
Your situation is really too complicated to address here, but one can make a few general comments. If the positive margin is due to a small amount of tissue and the PSA falls to an undetectable level after prostate surgery, there may be no need to treat right now, although a practitioner might advise supplemental radiation therapy even before waiting to see if the PSA goes up. If, on the other hand, a large piece of the prostate was left behind, there were grossly positive margins, and the PSA was still elevated after surgery, then one could make a case for additional radiation therapy right away.
