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Treatment options for Gleason score 4+3

Charlie5168
Posts: 17
Joined: Mar 2013

My friend had Gleason score 4+3 on 2 cores with 20% & 85% involvement and Perineural invasion. I would appreciate if you can advise whether it can be treated with robotics surgery or open surgery/radiation would be better as it showed Perineural invasion on his path report? His PSA was 6 - 8 within the last year.

 

Thanks a lot for your advice

richardlvance
Posts: 10
Joined: Aug 2010

Greetings.

 

I'm a 4+3.

I'm on androgen blockage monotherapy. That's a pill a day that blocks the cancer from taking up

testosterone and its more potent cousin DHT (the stuff that makes you bald). This can be followed

by radiation (I would only do Proton beam, NOT ANY OTHER RADIATION for localize cancer) or not.

The latest fad is 2-3 months of combo androgen blocade (Bicaltumide) with a 6 month Lupron shot

then radiation. That has been found to be so potent as to give survival results almost

identical with men who are never diagnosed with PC. Beware the Lupron side effects!!! Whicj is why

I took a pass on the Lupron. I want to see where my PSA goes just on the pill.

I also take a DHT blocker to aid in enlarged prostate (Old man gotta pee) problems

and it aids the bicaltumide by cutting off the DHT which is the real PC fuel, not testosterone.

 

With just 2 cores positive I pray your friend does not overreact. He should have the biopsy samples sent off

for a 2nd opinion, to a major cancer center. It may turn out to be just 3+3 in which case active surveillance is the best

game. My 1st biposy gave me two cores at 3+3. I sent them to MD Anderson who tossed one leaving

a single 3+3 core. I did nothing for 4 years, just watching PSA. Then I did a stupid and started on

some DHEA supplements for energy. DO NOT! The PC cells use both testosterone (after conversion to DHT)

as fuel but also uses DHEA. DHT is the favorite but if you boost DHEA the cancer gets a boost and mine did boost.

 

 

I am not an MD, these are my opinions only based upn 4 years of research and experience.

Charlie5168
Posts: 17
Joined: Mar 2013

Thanks Richard for all the details. It really helps. My friends actually had 5 cores positive:

- 2 cores 4+3 with Perineural invasion. 20% & 85% involvement.

- 2 cores 3+4 also with Perineural invasion.

- 1 core 3+3 

 

He seems like to have Robotics surgery. However, I am not clear wnether Preineural invasion is considered as localized PC. If that is the case, surgery would still be an option.

Charlie

hopeful and opt...
Posts: 1332
Joined: Apr 2009

 

Speak with the urologist about prescribing a Tesla 3.0 MRI . This test is very effective in indicating if there is any nodule involvement, if there is involvement in one or two lobes, will show size of prostate, any evidence of extracapular extension, will stage the disease. An MRI with the 3.0 Tesla magnet, is the gold standard. There are certain major hospitals that have MRI machines with a 3.0 Tesla magnet. In my layman’s opinion it is advisable to have such a test before any surgery or another active treatment which is a localized one. If the cancer is outside the prostate these type treatments may not be a best decision for treatment since additionally treatment will still be required, and side effects of various treatments are cummulative.

 

The side effects of surgeries are basically greater than other active treatment types. Surgery is less successful  among older men than younger; so for example a doctor may perform an excellent surgery for a 50 year old, who will have no side effects and the exact same surgery for a 70 year old who will have side effects.

How old is your friend?

Charlie5168
Posts: 17
Joined: Mar 2013

Thanks for your suggestions. It makes sense. I'll advise my friend to follow accordingly. I guess perineural invasion doesn't mean cancer is out of the prostate. If that is case, my friend may have a choice with surgery. He is 65 years old though with good health but I'll also mention to him regarding surgery risks for older people.

hopeful and opt...
Posts: 1332
Joined: Apr 2009

""Perineural invasion" on biopsy means that there is an increased chance that cancer could spread out of the prostate, but Gleason grade and amount of cancer in the cores are more important. Even with perineural invasion your cancer could still be very curable depending on other factors. In some cases, it may affect treatment and in other cases it has no significance. How this finding will affect your specific treatment is best discussed with your treating doctor."

Sugery.....there are other localized treatments other than surgery that have comparable cure rate without the major side effects that surgery has....one localized treatment that is very effective is SBRT, a form of radiation. This localized treatment does not have the potential major side effects that surgery has.

It is my lay opinion that if cancer is found outside the capsule, a medical oncologist needs to be the lead doctor in your medical team. Hormone therapy may be the only treatment that is necessary.

Here is a thread that was done with a man of more aggressive cancer than your friend that you and your friend may find useful.

http://csn.cancer.org/node/258414

 

Charlie5168
Posts: 17
Joined: Mar 2013

Thanks a lot for all the valuable information. My friend will ask doctor whether Tesla 3.0 MRI can be ordered. It is good to know the reason and hope doctor would agree. We'll review the provided link and really appreciated all your advices.

 

Swingshiftworker
Posts: 635
Joined: Mar 2010

If you can get a endorectal MRI using a Tesla magnet, you should also ask for an MRSI scan as well. 

While the endorectal MRI can better determine the location, volume and stage of the cancer, the MRSI (magnetic resonance spectroscopy imaging) measures the location and concentration of choline and creatine, which are markers for cancer, which will give you more precise info about the location and extent of the cancer (if any).

See: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1578527/

In my case a endorectal MRI/MRSI scan was done to determine if there was any recurrance of cancer following 3 increases in my PSA levels 2 years after treatment.  The MRSI results determined that there was absolutely NO indication of recurrance of the cancer in my prostate despite the rising PSA levels, which later dropped w/o further treatment.

FYI, these are very expensive tests and are not routinely authorized for early diagnosis, but if you can get them all the better.

Good luck!

 

 

 

hopeful and opt...
Posts: 1332
Joined: Apr 2009

 

 

Five years ago, I had a spectroscopy with a Tesla 1.5. I had to pay $900 dollars for the Spectroscopy. At the time the spectroscopy was considered investigational, and not covered by medicare. It may or may not be covered by medicare at this date.

 

Since then I have had 3 different multiparametric Tesla 3.0 MRI's as part of my Active Surveillance program. The Tesla 3.0 differs from the 1.5 in that it has a finer resolution.

 

Generally centers of excellence have at least one Tesla 3.0 MRI machines. There is a high volume of usage, and the personal are skilled in administrating and analzing the results of the MRI. Additionally these centers shine, as far as active treatment in various specialties.

Charlie5168
Posts: 17
Joined: Mar 2013

Thanks all for sharing the information. My friend is insured through Kaiser and he is hoping doctor will approve his request for Tesla 3.0 MRI. I'll also mention to him regarding Spectroscopy.

He told me that Kaiser is under tight budget therefore his request may not always be agreed by his doctor and approved by his insurance but it won't hurt to give it a try. He also mentioned that doctor is aware of Perineural invasion therefore decided not to have nerve sparing which could mean more side effects.

 

Swingshiftworker
Posts: 635
Joined: Mar 2010

If you're with Kaiser, good luck getting an endorectal Tesla MRI or an MRSI.  I don't know if they'd ever approve either of these for early PCa diagnosis, but count yourself lucky if they do.

FWIW, I was with Kaiser all my life (59 years) until I was diagnosed w/PCa.  The only treatment options given me were active surveillance, brachytherapy and surgery.  After doing some reading, I decided that wasn't good enough for me.  In the course of my research, I learned about CyberKnife and found out that it was offered at UCSF under Blue Shield which was available under my group health care plan but I had to wait until "Open Enrollment" to make the change. Fortunately, I was diagnosed in Jan 2010 before the open enrollment period in April, became a Blue Shield member in July and finally received CK treatment at UCSF in September.  I would have received treatment earlier if I didn't have to make this change, but fortunately the 9 month delay did not negatively affect the result.

BTW, if you're in CA, Kaiser does have CK facilities in SSF.  However, the last I heard, Kaiser does not use CK for the treatment of PCa.  It only uses it for brain, spinal, lung and other cancers that they consider "inoperable."  CA Kaiser has a BIG investment in its BT and surgical programs for the treatment of PCa and, if you want any other form of treatment, you will have to go outside of Kaiser to get it.

Charlie5168
Posts: 17
Joined: Mar 2013

Thanks for info on Kaiser and glad to know 9 months delay didn't cause any negative effect on your PCa. My friend seems like to be treated through RP therefore he is probably OK with Kaiser. Not sure his plan is if tesla 3.0 MRI couldn't be approved by the doctor. Hope he'll have enough confidence without doing this test before surgery.

hopeful and opt...
Posts: 1332
Joined: Apr 2009

As I understand, Kaiser is a meat and potatoes type institutution. I do not believe that they offer MRI's for prostate cancer.

If surgery or anotherlocaized  treatment is done, and the cancer has escaped the capsule, that is possible in this case, other treatment(s) may still be necessary and side effects are cummulative.

Various treatments that Kaiser does not offer can be negotiated. What part of the country does your friend live in?

I hope that your friend has had or will have an independent second opinion on the pathology...it may be possible that Kaiser will pay, or it may cost a couple of hundred dollars.

I wonder if Kaiser offers some form of IMRT. The prostate , and some area outside the prostate can be treated...greater treatment area...To me SBRT may be preferable, but IMRT is a  choice.

 

Charlie5168
Posts: 17
Joined: Mar 2013

My friend live in San Jose CA area. He told me that Kaiser should have good capability for RP. Hope they can also do IMRT/SBRT is the needs arise. I'll check with my friend whether he is willing to get 2nd opinion on his path report if Tesla 3.0 MRI is not authorized.

Thanks for your advices.

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