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adjuvant radiation and nerve damage
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adjuvant radiation and nerve damage

I am 56 years old and was diagnosed Nov. 2008 with prostate cancer.  Due to age and biopsy results(2 of 8 positive with Gleason 3+4), opted for nerve sparing surgery which I had Jan. 2009.  Post op analysis showed previously undetected anterior lobe prostate cancer with Gleason 4+5 and extra prostatic extension- post op stage is t3aN0MX.  Surgeon was able to save nerve bundle on right side.  Also, lymph nodes and seminal vesicals were cancer-free.  Surgeon has recommended adjuvant radiation to prostate bed.  I am wondering if I should go ahead with radiation after healing (14-18 weeks post-op) or simply monitor PSA at 3 month intervals and radiate if PSA starts to rise?  I am concerned that the nerve bundle that was spared will be lost with radiation and erectile function will be lost completely.  I am also concerned about radiation damage to other structures, i.e. bladder, rectum, etc.
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I was on my way to sleep when I thought about your message on MEDHELP, and I got up to write you.  I am going to be blunt, here.  I am a "Dr.," but a "doctor" of philosophy, not a medical doctor, so please seek confirmation of what I'm telling you here, from someone who knows prostate cancer better than I.....   I do read a LOT of medical literature, because I have a Gleason y (4+3) and a miserable biopsy report.

You have a Gleason 9 cancer.  That is a serious, aggressive cancer.  Despite the numbers you read in articles, it is a cancer that can be corralled for a good number of years.  But I am convinced by my reading of medical articles that someone with your numbers needs to seek help from medical specialists--A June 18, 2008, article in JAMA (Journal of the American Medical Association) was titled "Prostate Cancer-Specific Survival Following Salvage Radiotherapy vs Observation in Men with Biochemical Recurrence After Radical Prostatectomy."  JAMA 2008: 299 (23): pages 2360-2769.  Article by Bruce J. Trock et al.  (Han, Partin, Walsh, and other Johns Hopkins prostate specialists--these guys are THE BEST, probably, in the USA).  I will quote one line from this article, and then leave it to you to find the rest of the piece, if you are interested:  Says Trock and company: "Salvage radiotherapy alone was associated with a significant 3-fold increase in prostate cancer-specific survival relative to those who received no salvage treatment."  Their research also shows that adding hormone therapy to salvage radiation therapy (after recurrence, following radical retropubic prostatectomy) does not improve one's chances.  In short, they come down VERY HARD in favor of immediate salvage therapy once you have a PSA after surgery that indicates that the cancer is still active (they use a PSA of .2 as a cut-off).  They also write: "Salvage radiotherapy initiated more than 2 years after recurrence provided no significant increase in prostate cancer-specific survival."
     The numbers they present for men who have prostatectomy and then have a biochemical failure (PSA .2 or greater) are fairly bracing, I think--men DO often live a good number of years following the surgery and the biochemical failure, if they have salvage radiotherapy as soon as they know the cancer is still hanging around.
     This recent article in JAMA is, like most medical journal articles on prostate cancer, a pain in the *** (ouch!) when it comes to following their MATH.  Hell, the math alone is killing me.  I'm a retired university English professor, and I often fall into delirium and deep sleep just trying to follow the damned NUMBERS in these studies.
And the statistics are all over the place (one article tells me I have a 50% chance of biochemical failure, another tells me I have 97% chance of never having biochemical failure, etc.).  But I do tend to believe what the Johns Hopkins researchers write (they often disagree with themselves, going from one article to another, but they have performed RPP -- surgery -- on thousands of men, and I trust their figures, generally.
I do suspect that they "cherry-pick" patients for their articles.  I had a 4+5 Gleason 9 prostate cancer according to the biopsy (and I had Hopkins pathologists confirm that), but after surgery, my pathology report showed a Gleason 7 (4+3) that was organ-confined.  I know I was lucky, in that.  But all the Johns Hopkins surgeons turned me down because I had a Gleason 9, and I finally bitched my way to surgery by the Director of the Urology Clinic at Hopkins, Dr. David Y.S. Chan.  He is not one of their "star" surgeons, but he did a terrific job operating on me.  He called me at 8 o'clock on a Saturday Night to tell me the results of the pathology report--which were far better than I had expected.
     Anyway, this JAMA article I suggest for you is written by Hopkins surgons and researchers, and I trust it.  The MATH is hard to decipher, but the MESSAGE is pretty good, for prostate cancer patients who have "detectable" PSA after prostatectomy.
     So my advice for you is--PURSUE "SALVAGE" RADIOTHERAPY as soon as you can.  And read the JAMA article first, before you approach your physician with the request that he get his tail moving, to get you salvage radiotherapy.  The happy word here is "curative"---the salvage radiotherapy may not cure you, but it might.  And it will be given with "curative" intent, not palliative.  From what I've gathered from my reading of medical journals, salvage therapy can be VERY life-prolonging, and may even be totally "curative."
     My e-mail is ***@****, if you need to contact me.
     I tell myself every day (I don't always listen to myself, but I try): "This prostate cancer may eventually kill me, but it AIN'T GONNA KILL TOMORROW, and I try to move into the next day with as much optimism and high spirits as I can, and try to keep 'prostate cancer' in the very back of my mind, way back. if I can.
     My best wishes to you.  Be aggressive in pursuing treatment.  And be hopeful.

Dennis Jackson
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