Should I have a prostate biopsy?
Posted , 74 users are following.
Introduction
I’m 70 and have a PSA which was at 4.6 when I was 66, and while it has been regularly monitored over the past 18 months or so has been moving up and down between 6 and 7. My doctor thought that I should be referred and I have had two hpital appointments, but I have so far decided against having a prostate biopsy, though it is obvious that my local hospital’s oncology department would like me to have one. The health worker I saw at my first hospital appointment was happy to discuss the issue with me, but I suspect the consultant I just saw probably thought I should stop wasting his time and get booked in for a biopsy without further delay.
I have received information from those two appointments, but I have obtained much more information from online research. Based on studying a number of online medical reports over the period 2008 – 2014, it is evident that there is increasing prejudice, at least in the US and Australia, against the use of prostate biopsies. The primary reasons for this seem to be an increasing risk of serious infections from the most common type of biopsy, a growing recognition (though this may be controversial) that psa screening and biopsies are ineffective in reducing the incidence of terminal prostate cancer, and that screening and biopsies contribute to massive ‘over treatment’ of prostate cancers
Summary of Statistics (some of which may be controversial but all of which are based on (my interpretation of) studies published in urological journals, research reviews and conference speeches by leading urologists).
Of every 100 men who have a prostate biopsy:
· 97 didn’t need it (that is, they don’t have a prostate cancer requiring treatment)
· 6 will get a serious infection as a result (a figure which has doubled in recent years), which will cause them to be hospitalised, and from which a very occasional man will die, while others (we don’t know how many) will have persistent painful side effects
· between 17 and 22 will be offered treatment that they don’t need, as a result of which about 25% of men in their 70s will become incontinent or impotent.
The Perceived Indicators for Biopsy
Primarily a raised psa; a psa which has increased rapidly over a fairly short period, typically a year; smoking; family history of prostate cancer; age (considered with the other factors). I have a raised psa, but it’s not dramatically high – it’s been between 6 and 7 over the past 1 ½ years, and it has not increased dramatically – it was 4.6 five years ago. I do smoke, and I am 70, but I am generally in good health, and there is no history of prostate cancer in my family that I know of.
Statistics Based on Recent Urological Papers
Of every 100 men who have a biopsy, between 75 and 80 have no cancerous cells and didn’t need the procedure; 20 to 25 will have cancerous cells found on biopsy BUT a large percentage of these men will have a tumour which develops very slowly, will not be terminal and doesn’t really need any treatment. Only a small percentage will have an aggressive tumour requiring immediate intervention; the Harvard School of Public Health, in a 2014 paper, put this percentage at 10 – 15%, or 3 men out of the 100.
This means only 3 out of every 100 men who have a biopsy really needed it. And there are two other real concerns.
1. The one certainty with prostate biopsies is that 100% of the men who have them will have ‘side effects’. Some will be shortlived and not really a problem, but some will be painful and longer lasting, and some men, currently about 6 out of the 100, will be hospitalised with serious infections, and the very occasional one will die. There are no statistics for the number of men receiving treatment for post-biopsy infections at doctors’ surgeries. I don’t necessarily see this as a reason not to have a biopsy, because obviously if you really need a biopsy to diagnose a terminal cancer then it’s worth putting up with the side effects. But do you really need it?
2. Most worryingly, doctors apparently can’t tell from the biopsy result whether cancerous cells denote an aggressive tumour which requires immediate treatment, or a slow developing tumour which probably does not need any treatment. As a result, as I understand it, all patients with cancerous cells may generally be assumed to need immediate treatment, such as hormone replacement, radiotherapy, chemotherapy, even though 85-90% of them don’t need any treatment. Research papers suggest that in men in their 70s, 25% who have this treatment will become incontinent or impotent as a result. Many of these men will suffer these consequences despite the fact that they didn’t ever need the treatment they were subjected to.
It’s also worrying that at two hospital appointments the issue of what happens after the biopsy has not been raised, even though it was clear that both the people I saw thought I should have a biopsy. Maybe they would say that it would have been raised if and when I agreed to a biopsy, but given concerns about receiving unnecessary treatment, I feel it should have been raised at the time the issue of having a biopsy was raised. Would they have explained to me that if cancerous cells were found, they might not be able to tell whether I needed treatment or not? Would they have told me that there was a risk (if not a certainty?) that I would be ‘offered’ treatment that I might not need? Since they did not have that conversation with me I cannot answer those questions.
Conclusions
My psa is raised but not highly raised and it didn’t move up fast, so I feel it is not at present a firm indicator of the need for a prostate biopsy – it’s inconclusive. The only additional risk factor I have is that I smoke, and I suspect that is often overplayed by the NHS. According to NHS statistics, I should be suffering the ill effects of smoking by the age of 70, in the form of early signs of lung cancer, but when I had a chest scan a year ago it was clear. In addition I have an enlarged prostate – which was determined at my first hospital visit not to feel cancerous – which means I would have a heightened psa anyway.
I have been offered another appointment by the hospital in six months, and I am going to take that up, but unless things change I think that has to be the last for the moment. It’s pointless me trooping up to the hospital every six months when I don’t want a biopsy – which is all they can do by way of diagnosis – and there could be people with aggressive tumours urgently needing those appointments. So I need to decide over the next six months finally, whether I am going to have a biopsy or not.
The hospital has asked me to have another psa blood test before I go for the 6 month appointment, but I have asked my GP for three-monthly psa tests, so that I can get more of a feel for movement on the results before I go for the hospital appointment. If my psa is suddenly moving up rapidly over the next six months, then, depending how fast and how far it is moving, I may agree to a biopsy. Otherwise it is unlikely that I will, in which case there is not much point in the hospital continuing to see me – though I will ask my local surgery to continue monitoring me with 4 or 6-monthly psa tests.
At the age of 70 I still work full-time (for myself), and having unnecessary treatment for prostate cancer would certainly have far more of an impact on my life than having a slow developing prostate cancer which would not affect my health or life expectancy, and might even have more of an impact in the short term than having an aggressive prostate tumour. So it’s a numbers game. None of us is going to live forever, and at my age quality of life is more important than lifespan. Younger doctors especially often don’t take account of this, and assume that keeping you breathing, no matter what state you are in, is some sort of medical triumph. Not surprisingly, there are lots of older people who don’t see it that way!
15 likes, 312 replies
gale10132 terryw
Posted
terryw
Posted
Hi Vermon007
It sounds as if we have a lot in common. Other people across the pond have posted on all sorts of diagnostics not available on the NHS - or from Veterans Administration by the sound of it - and the stuff that is is not great! As far as the NHS is concerned, as I've said before, if its a choice between improved prostate diagnostics for old guys and better services for sick babies there's no contest. Since VA don't deal with sick babies I'm not sure what their excuse is.
I know this probably doesn't help you very much, and there are many people posting here who can give you all sort of info on procedures which I haven't had. Personally, given all my circumstances - no family history of pca, no symptoms, slightly raised but fairly stable psa - I decided to duck out of this whole merry-go-round. It seems likely that I have a slow growing tumour - or even just BPH and not a tumour - and I'm never going to have any problems. Time will tell - but we all have to make our own decisions and live with the consequences.
I hope it works out the best for you.
Good luck Terry
Vermont007 terryw
Posted
Hello there; and thanks for the quick response. I apologize to everyone else who read my Post because I can't respond to each.
I feel as though I'm having to prove a negative due to this original PSA that Inever asked for. Maybe I'll someday be able to say that "it saved my life" but for the moment it's causing more aggravation.
I have never paid much attention to the Prostate Problem Community . . . everyone I've known has been a mite squeamish about it; or extremely bitter. In the past 6 weeks I've begun to realize that so many of the advertisements on commercial TV in the US must be aimed at this portion of society: catheters and erectile dysfunction Hopefully you've been spared some of this material in the UK.
I've been met with some resistance in the medical community just because I tend to ask questions . . . . and within the VA, it seems that they are not accustomed to anyone not immediately accepting their recommendations, or giving the least amount of push-back. Establishing a dialogue or engaging in some level of discourse regarding a course of action isn't something that they are accustomed to.
I have herroneous thoughts about the motivation of the folks at the VA . . . . but clearly they are not greed or intent on maximizing profiit when they are a much criticized government sponsored not-for-profit.
When I ask "why" they immediately jump to an expensive TRUS Biopsy instead of considering the far less expensive alternatives available to verify the diagnosis in a non-invasive manner, I'm told that they employ the "standard of care" established by the professionals in the for profit mediacl community and that this has proved to be medically efficaious.
I'm not one to make trouble; but in this area, we only get one chance to make the proper decisions, and I refuse to be stampeded into behaving in a manner that's contrary to my better judgement.
I'm also influenced by some more notorious people who have come out and publicly acknowledged that they were rushed into taking irreversable actions which have altered their lives forever.
Curtis Slewa, who you may know as the founder of the "Guardian Angels" in New York (providing physical protection for the public riding the Subways of NYC) recently revealed that he had a Robotic Prostatectomy Surgery which rendered him impotent and weariis surgeryng diapers continuously. He's now a Radio commentator and says his robotic surgery was conduted without any warning as to what the permanent side effects might be/would be of having his Prostate Gland removed . . . . maybe his Urologist was too squeamish tp discuss the matter.
Curtis doesn't sound as bitter as many; and he's performing a public service by talking about his misfortune. I greatly thank him for that.
And thank you for opening this discussion of this quandry. . . . . I didn't know how recently you had done that, as your Post just says "over 1 year ago".
I hope not to hijack your thread; but just add another voice to the discussion, and writing about this matter helps me to keeps my thoughts in order.
Yes, we do have a lot in common.
Vermont007
Posted
I apologize for not thoroughly editing this last post. I see that I omitted some clauses and you're being subjected to more spelling errors than you deserve . . . . I'm accustomed to Forums that allow for post-submission editing and maintain an active spell-check presence.
I won't make that msitake again.
terryw
Posted
Hi Vermon007
I started this thread about two and a half years ago - I'll be 73 in mid April next year and from memory I started it in the summer after I was 70. The number of guys who have posted on it since then from around the world shows that there is real concern about the issues surrounding prostate screening and diagnostics. Which ever way you go, there is a great deal of uncertainty and no easy answers. I keep reading about better diagnostics being developed, but I'm not expecting any of them to be available to me, because the UK NHS will no doubt continue to use the inaccurate but cheap options.
Some guys who have posted clearly are unwilling to get involved in these uncertainties and would rather just accept -and do - whatever the doctors tell them, and I have no problems at all with them making that decision for themselves, but personally I'll listen to the doctors and then make my own decisions. Right now I don't have any problems and everything down there is working as well as can be expected when you're in your 70s. If that changes in the future then I'll look at diagnostics and treatment options, if any, and if not, then we all have to die of something. Meanwhile I'm just pressing on regardless.
I wish you the very besr of luck and hope everything goes well.
All the best Terry
Vermont007 terryw
Posted
I'll try not to be so verbose as I was in prior Posts.
I went in for a confirmatory PSA, and I had dropped down to 4.33. This after spiking up to 8.91, and being told I should consider a TRUS Biopsy.
Having been told that a PCA3 test was only available at VA if you had already subjected yourself to the Biopsy, I asked about the possibility of an fPSA (Free PSA % versus Complexed PSA %), and the Urologist says, sure, you can have that test !
I say, why didn't you mention that less invasive test back in October and she says "you seemed so focused or intent on the PCA3 that I didn't mention any other tests" . . . . and I about flipped out The only recommendation she had in October was stampeding me straight to the TRUS.
Boy am I glad I hesitated and waited for replacement PSA (which replaced the PSA that was ordered immediately following a DRE !)
;Now I'm waiting until mid-summer of 2017 to see what an fPSA will reveal. That is the problem with this whole scenario . . . . once you have a spiked or elevated PSA (for whatever reason) you are destined to have to PROVE A NEGATITIVE for the rest of your life.
I have more to say but I was embarrassed at the length of prior submissions so that's alll I have to say today.
I'm going to write Senator Bernie Sanders (one of my State's Officials) who takes an interest in VA matters, and explain how willing the VA is to subject vets to an expensive TRUS Biopsy before utilizing the cheap diagnostic tools available in this area, which would save the TaxPayers a considerable amount of money that could be used elsewhere.
hank1953 Vermont007
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Hank
craig84609 Vermont007
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That is horrible. I can't believe that they will put one through a biopsy and if it fails then they will do a PCA3 test. Give me a break!! Why don't the idiots that thought that one up go through a biopsy and then they may change their minds about it. This is why I don't want to have a PSA test, but I am being forced into having one because I am on Testosterone. If it is high for any reason, then I will be subjected to repeat tests and my doctor may withhold any medication, until he is sure that I don't have PC. This whole thing makes me upset and I want to refuse the PSA. I will however take a PCA3 to prove that I am not at risk. I would think that a PCA3 test should be the next step after a high PSA. My doctor already warned me if my PSA is high that she will likely want to do a biopsy. I told her you can want anything, but that doesn't mean I will say ok. I would refuse the biopsy until a PCA3 test is done or a 3T MRI to see if I have a problem that needs a biopsy.
carol76739 terryw
Posted
my father who is 82 had an MRI scan in November which showed the the areas of prostate cancer, he then had a biopsy beginning of December. He had no side effects from the biopsy and it was done under local anaesthetic.
the prostate biopsies will show the type of cancer, his being adenocarcinoma a slow grousing cancer. It will show different types of cancer. Admittedly his psa was higher than yours (13.7) and was advised to have both MRI and prostate biopsies.
he now knows what type of cancer, where the cancer is and currently there is no spread of cancer!! He now will wait to see if psa rises higher to make an informed decision for treatment.
it is also well documented that men with a lower psa have prostate cancer.
terryw
Posted
Hi Carol
Glad to hear that your Dad is going on well.
It's certainly true that some men with a low PSA have PCA - but some don't.
It's true that some men who have biopsies have no problems - but some do.
This whole area of PCA screening and diagnosis is pretty problematic at present, certainly in the NHS in the UK which often has tight budgetary restraints. So for example, I'm pretty sure I would not get an MRI on the NHS prior to a biopsy - only afterwards to see if there had been any spread of any cancer a random biopsy detected. Nor are more reliable tests such as the PCA3 available on the NHS as far as I know.
Consequently we all have to make our own judgements. I'm happy that your Dad is happy with the decisions he's made, and I'm happy with mine although they are probably not for everyone and I would never suggest they are.
All the best Terry
steve90726 terryw
Posted
Terry,
?What a great post! I am in exactly the same situation as you when you first posted this. I will be 70 next April. I have been watching my PSA for 11 years and it has been steady between 4 and 5, except that the last one increased to 6.3. A recent PCA3 test turned out positive with a score of 75. DRE has always been negative. My prostate is enlarged (it has been for years) but I can urinate fairly well although slower than normal. A cystoscopy showed pinching of the urethra, but otherwise normal. My new urologist, like my prior one, is strongly urging me to get a biopsy. I am resisting for the same reasons you had. It's not an easy decision to make and it keeps me up at night. Anyway, thanks for the well written post about the dilemma many of us face.
terryw
Posted
Hi Steve
Good to hear from you! I'm now 73 next April. Since you can get a PCA3 I'm betting you're in the US? I would certainly have a PCA3 if it was available on the NHS in the UK. But I decided not to have a biopsy.
When I was 66, with a PSA of 4.6, I was told that I could expect my PSA to rise from 4 to 5 between 60 and 70, but by 70 it had risen to 6.5, probably because of an enlarged prostate, perhaps due to BPH. It then stayed pretty static at that level. Certainly my PSA has not doubled in a year or even five years, which are the usual criteria for having a biopsy - though as you know, if you see a specialist they just want a biopsy anyway.
I probably do have prostate cancer, but it seems certain to be slow growing so it doesn't bother me If anything changes - if my PSA shoots up, or if I develop some symptoms - then maybe I'll think again, but right now I'm not having a biopsy, though that is very much a personal decision based on my circumstances.
I wish you all the best and hope it works out for you.
hank1953 terryw
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Guest terryw
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Hi everybody, like Terry I'm also based in the UK and aged 64, I have been reffered with a PSA of 4.6 which is up from 3.6 at Sept 2015 just over twelve months ago.
Was retested in September 2016 and it came back at 4.1 with a recomended retest 3 months later in December, which now came back at the 4.6 level mentioned earlier.
Having had a GP refferal, met the Uroligist on Wednesday 1st Feb 2017, DRE was normal but enlarged, but as my father who is 90 with T3 prostate cancer, they feel I should have a biopsy done as early as next Wednesday 7th Feb 2017, and they have also requested an MRI scan beforehand which is this Sunday 5th Feb, this is the consultants policy before they proceed to the biopsy.
Having read many prostate related forums, it seems this disease has no specific lower scale PSA reading that means anybody can relax with any rising PSA level, and views differ vastly as to whether they should proceed to a biopsy.
But for me the consultant was quite concerned, so I'm going to see if the MRI throws me any curved balls, but will most likely have the biopsy done, if for nothing else just for peace of mind and see where I go from there, I get the biopsy results10 days later.
I also spoke to Prostate Cancer UK who were very thorough, and basically thought that a biopsy is not out of bounds due to the year upon year increase in my PSA readings and my family history, although they did stress they cannot offer advice, only discuss the information given to them, and I was gratefull for their opinions.
I'll repost when I have something of value to add after the procedure and when I get my results, but would like to thank everyone who contributes on these forums, as it gives newly reffered people like myself more insight at to what may be to come?
I wish everyone well with their treatments and whichever road you take it's great when people update their posts to let us know how they are doing.
Malcolm
Vermont007 Guest
Posted
I'm pleased for you that you're being offered the MRI imaging BEFORE sending you directly to biopsy.
Recognize too, that a negative biopsy isn't conclusive because those 12 needle core tissue samples don't reach into all areas of the Prostate.
Post inbetween the two procedures . . . . I for one will be very interested in reading your observations.
steve90726 Guest
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dbcriss steve90726
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Vermont007 dbcriss
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Guest steve90726
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Hi steve, nobody knows how they will react until they need too and I'll cross that bridge as I get to it. Saw this from 2013 about 3 emminent UK urologists who were all diagnosed with PCa, and I know Consultant John Anderson died around 18 months after his diagnosis, don't know how the other two faired.
In a cruel twist of fate, these three top prostate cancer experts have ALL been hit by the disease. Their stories are vital reading for men - and their loved ones
[b]http://www.dailymail.co.uk/health/article-2291798/Prostate-cancer-In-cruel-twist-fate-prostate-cancer-experts-ALL-hit-disease-Their-stories-vital-reading-men--loved-ones[b].html#
dbcriss Vermont007
Posted
I can see taking age into consideration. If a person is 90 then why bother. But for younger men why wait until it becomes symtomatic? Then it may be too late depending upon what a person thinks is a symptom. And aggressiveness, how do you determine that? More than one doctor has told me that there are not nearly enough data points to say what's aggressive with what person. That's just a guessing game for today. And why does where in the gland make a difference even if you could know where in the gland? I think you have the options of wait and see b/c that's what a person desires to do, or do something about getting rid of the cancer. Once you have prostate cancer you can choose to do nothing, but as far as I know there is no accurate way for doctors to predict if your cancer will cross that threshold of being just a worrisome PSA number and becoming a life threatening issue in your normal lifetime, or not.
steve90726 dbcriss
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gale10132 steve90726
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Vermont007 gale10132
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gale10132 Vermont007
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ES28567 Vermont007
Posted
I had HIFU about 6 months ago and so far happy with the results. The procedure was easy but the recovery is an experience in itself.
I still have all my man parts. No retro, no incontinence, can pee with no retention. Sleep through the night. Only issue is even though the PSA is slightly down from prior to procedure, it is still high. So urologist is recommended another MRI guided biopsy. I'm thinking of just watching the PSA number to see if it rises, stays the same, or goes down and then decide. Right now I can live a normal life, symptom free. I went from almost no stream (close to needing to self catch) to totally emptying my bladder and going hours (depending on how much I drink) without the need to pee.
ES28567 Vermont007
Posted
I did a reasonable amount of research (including reading books and even interviewing people who've had some of the new innovative procedures) looking at all my options. There is a good book out about Proton radiation called..."you can beat prostate cancer and you don't need surgery to do it" by Robert J. Marckini. If a person is interested in radiation therapy, then this is the best option (in my opinion) because of the lowest side effects from radiation. Downside is it is VERY expensive and most insurance won't cover the cost. But if I were considering radiation therapy, it is the procedure I would try to do.
steve90726 ES28567
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craig84609 ES28567
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So what was the recovery like? This is the kind of treatment I would consider, but as it is fairly new there isn't much on it.
Vermont007 gale10132
Posted
Fractionated focused-beam radiation is ththe kind of therapy that Former President Jimmy Carter elected to receive for treatment of his brain cancer lesions in 2014 or 2015; and it received much coverage when he was deemed cancer free after several non-invasive sessions.
It is now covered by most insurance in the US, including Medicare and Mediaid). What's necessary is to identify the exact nature of the cancer cells involved and the frequencies of the radiation that they will respond to.
This therapy is referred to it as "fractionated" because it can be delivered in much higher dosages that with whole body radiation, and it can be segmented into separate sessions as the effect on the lesion can be observed in-between treatments.
As I understand it, this focused beam treatment is most effective where a framework can be built to stabilize the target tumor; as with the skull and hips/groin areas, and less suitable in areas where soft tissue is involved and constantly moving (Heart/Lungs, and GI Tract).
ES28567 steve90726
Posted
Wow Steve! You came across really negatively. I was trying to keep my comments brief. I'm at the hospital with my father so I can't reference the book at the moment to answer your questions but the book I referred to talks about All the available procedures at the time of the writing. It talks about the advantages and side effects of each Procedure. It has a wealth of information in it. It was very uplifting and gives hope to those like me who were/are looking for alternatives to avoid surgery. It is very pro Proton radiation and sites about 20 years of historical results. As we all know, insurance is VERY, VERY slow to approve new procedures regardless of their success rates (even when the side effects are proven to be minimal and will GREATLY improve a mans quality of life (compared to conventional procedures). The proton radiation isn't really much different than the radiation they do now except conventional radiation goes in one side, through the body (hiting the cancer area) and then continues through the rest of the body, exiting the opposite side. Think of a bullet entering one side and exiting the other and damaging everything in its path. In contrast, Proton radiation goes in oneside and stops at the area of cancer, releasing the most energy at the target area. It's still radiation it's still doing the same thing. But the differences it does not damage anything on the opposite side of the cancer. It's also like the bullet analogy but it stops and releases the most energy on the cancer and does not do any damage elsewhere. If someone was to choose radiation I was just express my opinion that radiation which does less total damage to the body but still destroys the cancer is a step in the right direction and seems like a logical progression in the right direction of men's health. And 20 years of statistical results would tend to support my opinion. You are certainly entitled to yours. Having said all this...I still chose HIFU as my personal choice because I wanted to avoid surgery AND radiation of any kind and the cost was also 50% less expensive. HIFU also has a 15+ year successful track record (around the world) but only a little over a year in the USA. Insurance will not use any data outside of the USA. So regardless of how successful and beneficial the procedure is, insurance is sloooooow to approve anything that will cost them money. I believe that If this was a women's issue, it would all be fast tracked. But at least their is hope for us men.
steve90726 ES28567
Posted
I am sorry if I came across negatively, I didn't mean to. I am skeptical of claims of "succesful track record around the world." Unfortunately, in the field of oncology, success has been rather lacking. That is why during his 2016 State of the Union Address, President Obama called on Vice President Biden to lead a new, national "Cancer Moonshot" focused on making a decade of progress in preventing, diagnosing, and treating cancer in 5 years, ultimately striving to end cancer as we know it. You say that "20 years of statistical results would tend to support your opinion." That sentence is absolutely critical. In my opinion, any therapy that is considered a real breakthrough would be quickly adopted wordlwide. To give an example, it took little time for the polio vaccine to be adopted around the world. If proton radiation has been that effective for the last 20 years, I can't imagine why it isn't widely used here. Perhaps it could be that those statistical results you quote are controversial and efficacy has not been well established for prostate cancer. I say perhaps because I am not up on the subject so I could be wrong. I apologize in advance if all this sounds negative to you. But I am not writing this to cheer you up. I am just giving my opinion on a difficult subject where choices are few and there are no guarantees, at least not yet. I wish you well.
steve90726 ES28567
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For whatever is worth:
http://www.healthnewsreview.org/2012/12/oregon-just-saying-no-to-expensive-proton-beam-therapy-for-now-at-least/
?"Critics call proton therapy an example of profit-driven medicine gone awry.?"
gale10132 steve90726
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ES28567 craig84609
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Hi Craig,
So the link I have provided covers everything related to my HIFU experience. I tried to document in detail and personal feeling my whole experience with details of my symptoms to preparations required prior to procedure to minutes after I wake up through the journey of recovery. My goal was to be as open and honest as possible (adding some humor along the way) so anyone going down this path might find some helpful hints to make their journey easier). We all heal differently but at least my experience would give other men some frame of reference.
The link is within the patient forum so I don't think this post will get deleted. When you click on it, and go down to the replies, you will need to click on page one to see the posts in the correct order. Also, the posts are not all just mine so make sure when you read through the posts you know when it is me. Sometimes I am just answering someone questions and sometimes it is someone talking to someone else.
https://patient.info/forums/discuss/hifu-experience-530647?page=1
If you read the whole thing, I would like to know your thoughts.