May 24, 2017
Decision regarding the surgery
Having ruled out active surveillance and radiation therapy, the final decision I needed to take was about the type of surgery and the timeline. I initially thought that I could wait a few weeks, but new information received on 23 May has prompted me to be a bit more aggressive about the surgery date.
However, various circumstances mean that the date is broadly as predicted, in mid-July.
I initially thought I’d undertake surgery in the public system, but finally decided on robotic surgery for a single reason.
I undertake open (not robotic) surgery in the public system at the earliest date (allowing around 4-6 weeks for recovery from the biopsy) and to undertake any feasible portion of the trip to Europe/India before the surgery.
QUALIFICATION: Given that I knew nothing about prostate cancer till 18 May, and have learnt everything I know about it in the past week, I will change my decision if new and more persuasive information comes in.
1. Type of surgery
I will undertake open surgery (not robotic) given there is no difference in outcomes between the two, particularly after the first three months.
2. Timeline for the surgery
a) Waiting for biopsy surgery to heal
It is a good thing to wait 6-8 weeks for the biopsy surgery to heal (details here).
b) Going only my biopsy results and PSA, it is OK to get surgery within 75 days from biopsy
The table, below, from a major study on this issue is very useful (Study: Delay From Biopsy to Radical Prostatectomy Influences the Rate of Adverse Pathologic Outcomes William T. Berg,1 Matthew R. Danzig,1 Jamie S. Pak, et al. -PDF is available online)
The table above shows that PSA is more influential in determining the severity of the cancer than the Gleason pattern score, alone. Further PSA is more reliable (being objective, compared with Glaeson scores which are subjective). My cancer is ranked Gleason 7 (but 3+4, not 4+3). Since this is a milder form of Gleason 7, a delay of between 105 and 150 days should be OK.
But even if biopsy has been poorly done and a portion of the tumour with Gleason 8 was accidentally excluded, I have up to 75 days.
Data from the biopsy suggest that a delay of 75 days is ACCEPTABLE (i.e. till 25 July 2017, given the biopsy took place on 11 May 2017. Surgery between 5 July and 25 July should not meaningfully impact the spread of cancer.
c) Relevant data: My tumour is located in the transitional zone and is pushing the edge
My MRI report is shows that the cancer is located in the transition zone (abutting it for 1 cm) and is causing a slight bulge in the body of the prostate.
There is evidence in the literature [see this] the the location of a cancer is related to the prospects of metastasis. Although there may be some time, I should not wait unnecessarily.
d) Relevant theory: At my age the cancer may become aggressive
It is a fact that even after radical surgery, prostate cancer returns (having probably spread prior to the surgery). All it takes is one aggressive cell to get out.
An oncologist from Mumbai told me that at relatively younger ages, cancer can mutate into the aggressive varieties more quickly, compared with what happens in one’s 70s and 80s. This, too, suggests, not waiting unnecessarily.
There is contrary evidence that “in the vast majority the cancer is born with a particular Gleason score.” “You might see progression in an individual, but we think that it’s uncommon,” she says. “We just can’t rule out this possibility in our study.” [Source]
“advanced cancers [that have spread] are not being found as much because PSA testing has identified them earlier, but aggressive cancers (high Gleason score) are being found at the same rate. The aggressive cancers are being found early (i.e., when they are “born”), rather than transforming into aggressive cancers over time.” [Source]
However, on balance, the logic does suggest that there remains a risk of metastasis given my age profile. Medical science doesn’t have all the answers.
I am now processing the surgery in the public system (which is free compared with $10,000 or so for robotic surgery through private health insurance). There is a wait time of around 30 days for prostate surgery in Victoria (such as here).
This is likely to take some time and might allow me to undertake a part of the planned trip.