Starting the voyage...

Stand

I'm glad to have found this forum. I am just starting the prostate cancer voyage. I am a relatively physically fit 76 year old. I work out almost every day by either running, biking, swimming or weight lifting. Six months ago my PSA was flaged at 4.5 and went up to 5.91 mg/ml, prompting a biopsy that revealed a Gleason score: 8 (3+5). The cancer is present on the left side, not the right.
SPECIMEN PIECES CORE LENGTH CONTAINERS
A. Left base 3 0.2 to 1.5 cm All in (A1)
B. Left mid 5 0.1 to 1.7 cm All in (B1)
C. Left apex 5 0.3 to 1.6 cm All in (C1)
D. Right base 4 0.2 to 1.2 cm All in (D1)
E. Right mid 4 0.5 to 1.5 cm All in (E1)
F. Right apex 4 0.2 to 2.6 cm All in (F1)

So now I have secheduled the CT scan, Xray and bone scans to figure out how badly I have been compromized. I also have a cosultation scheduled with a radiation oncologis to explore all those options.
I am told that my cancer is relatively aggressive so doing nothing is not an option as far aas I am concerned. I have visited various sites trying to find information on my urologist, Dr. Patrick Gavin, but I can't find any information positive or negative.
He does da Vinci robotic Prostatectomy's and says that he has performed 35 of these procedures and participated in many while in medical school. As I was pretty much in shock with the news I didn't have the presense of mind to ask what his success rates and complication rates were.
I haven't met with the radiation oncologist yet, but I am leaning toward thinking, "get this thing out of me!"
Is 35 procedures suffecient? What other questions should I ask? Do I ask for patient references?
I am located in Richland Washington and the practice of Dr Gavin is assocciated with Kadlec hospital.

Thanks, I'll soldier on,
Stan

Max Former Hodgkins Stage 3

RP

Stan,

At some point in their careers, all DaVinci surgeons had done "35 RPs."  IN fact of course, at some point the most experienced DaVinci surgeon in the world had zero (0) syurguries under his belt.

Most commentators say that around 150 usually is assumed to confer high proficiency. But this is a truism, not an assurance of anything.  I had DaVinci at 58 years of age. Most say that over 70, surgery is a substantial challange. Not impossible or absolutely a bad idea, but review other options.  Radiation very likely would be much easier for you. Speak with an expperienced radiation oncologist, one at a good facility. I am unfamiliar wtih Kadlec Hospital, but other writers here no doubt are familiar.

max

ASAdvocate

I second Max' suggestion that

I second Max' suggestion that you consider radiation. Age seventy is generally the cutoff for surgery in many practices.

In recent years, the SBRT/Cyberknife variety of radiation has had some very impressive results in terms of non-recurrence and minimal side effects. Do not be mislead by radiation studies from twenty or more years ago showing delayed side effects.

VascodaGama

Appropriate diagnosis lead to the best outcomes

Stan,

Before deciding on a therapy you need to know your clinical stage. In your post you say it to be an aggressive type which probably made you scared and the wish for getting it out, but if the cancer has metastasized (spread out of the gland) then surgery alone would not be sufficient. Radiation in its many ways of application can accomplish the same results as surgery and still treat in one goal any localized metastases. It all depends if your case is contained or localized.

The scheduled image exams will provide data on the location of the cancer with which the doctor guesses a stage, but these traditional scans hardly detect the bandit when the bandit is small in size. Aggressivity doesn't help in localizing too. The best is an exam with a PET scan using a PSMA contrast agent that would provide a more reliable picture of cancer's hideaways. I would try discussing the matter with the radiologist on your next visit. Inquire about the 68Ga PSMA PET/CT exam or even the Axumin PET/CT that would substitute (or add detail) to the data from the exams you mention above. Please read this;

https://www.sciencedaily.com/releases/2016/09/160906145843.htm

http://www.nature.com/nrurol/journal/v13/n4/full/nrurol.2016.26.html

At your age you want the lesser risky and most efficient therapy. You cannot throw the problem to the hands of the surgeon even if this guy is well experienced in his profession. Treatments are associated with risks and unavoidable side effects that prejudice the quality of life. You should know in advance the details, discuss with your family and make an educated decision, most comfortable to you.

I wonder about your other examinations. Do you have a DRE? How many needles (biopsy) were done and how many were positive?

The above biopsy description doesn't comment on the findings. Can you provide the contents of the pathologist report?

You comment being fit but you had asymptomatic cancer without knowing. What about any other hidden illness?

Many guys are surprised when thinking to be fit and then found to have typical disorders of age. I recommend you a bone densitometry scan to verify bone health. PCa likes to spread to weaker bone. kidneys bad function (creatinine and glomerular filtration rate) prohibits the use of certain medications or contrast agents. You should get your lipids and other blood markers tested. A colonoscopy done now would identify any existing ulcerative colitis that could influence in the option of a radiation approach.

I hope you manage to digest the info and chose the best for you.

Best wishes and luck in your journey,

VGama

Stand

VascodaGama said:

Appropriate diagnosis lead to the best outcomes

Stan,

Before deciding on a therapy you need to know your clinical stage. In your post you say it to be an aggressive type which probably made you scared and the wish for getting it out, but if the cancer has metastasized (spread out of the gland) then surgery alone would not be sufficient. Radiation in its many ways of application can accomplish the same results as surgery and still treat in one goal any localized metastases. It all depends if your case is contained or localized.

The scheduled image exams will provide data on the location of the cancer with which the doctor guesses a stage, but these traditional scans hardly detect the bandit when the bandit is small in size. Aggressivity doesn't help in localizing too. The best is an exam with a PET scan using a PSMA contrast agent that would provide a more reliable picture of cancer's hideaways. I would try discussing the matter with the radiologist on your next visit. Inquire about the 68Ga PSMA PET/CT exam or even the Axumin PET/CT that would substitute (or add detail) to the data from the exams you mention above. Please read this;

https://www.sciencedaily.com/releases/2016/09/160906145843.htm

http://www.nature.com/nrurol/journal/v13/n4/full/nrurol.2016.26.html

At your age you want the lesser risky and most efficient therapy. You cannot throw the problem to the hands of the surgeon even if this guy is well experienced in his profession. Treatments are associated with risks and unavoidable side effects that prejudice the quality of life. You should know in advance the details, discuss with your family and make an educated decision, most comfortable to you.

I wonder about your other examinations. Do you have a DRE? How many needles (biopsy) were done and how many were positive?

The above biopsy description doesn't comment on the findings. Can you provide the contents of the pathologist report?

You comment being fit but you had asymptomatic cancer without knowing. What about any other hidden illness?

Many guys are surprised when thinking to be fit and then found to have typical disorders of age. I recommend you a bone densitometry scan to verify bone health. PCa likes to spread to weaker bone. kidneys bad function (creatinine and glomerular filtration rate) prohibits the use of certain medications or contrast agents. You should get your lipids and other blood markers tested. A colonoscopy done now would identify any existing ulcerative colitis that could influence in the option of a radiation approach.

I hope you manage to digest the info and chose the best for you.

Best wishes and luck in your journey,

VGama

First of all thanks every one

First of all thanks every one for the responses. I very much appreciate them.

I did have a DRE and nothing was detected. My warning was the increase in PSA to 5.91 mg/ml. There were 12 samples taken during the biopsy. My results were a Gleason score of 8 from the right side of the prostate. D, E, and F.
A. Left base:
- Benign prostatic glands and stroma with atrophy.
B. Left mid:
- Benign prostatic glands and stroma.
C. Left apex:
- Benign prostatic glands and stroma.
D. Right base:
- Prostatic adenocarcinoma with the following features:
- Predicted Gleason score: 8 (3+5).
- Tumor quantitation: Tumor is present on 2 of 4 core biopsy fragments, longest contiguous focus measures 6 mm (70% of tissue submitted).
- Perineural invasion: Absent.
E. Right mid:
- Prostatic adenocarcinoma with the following features:
- Predicted Gleason score: 8 (3+5).
- Tumor quantitation: Tumor is present on 2 of 4 core biopsy fragments, longest contiguous focus measures 5 mm (60% of tissue submitted).
- Perineural invasion: Present.
F. Right apex:
- Prostatic adenocarcinoma with the following features:
- Predicted Gleason score: 8 (3+5).
- Tumor quantitation: Tumor is present on 2 of 4 core biopsy fragments, longest contiguous focus measures 5 mm (70% of tissue submitted).
- Perineural invasion: Present.

I of course am not aware of any hidden age related illnesses. I do have occassional attacks of gout. But I do not take any medication, no blood pressure problems varies; typical would be ~110/68. I have a low resting heart rate of around 52, but that being said I also am unable to get my HR over 114 even when running  3 miles.

CT scan and X-ray are scheduled for next Tuesday and a bone scan for Monday the 24th. I am waiting for my consultation with the radiologist. Looks like the consensus here is I consider radiation form of treatment given my age. However the surgeon did tell me that normally he does not consider anyone over 70 for surgery, but that I am surprisingly fit for 76 so it is still an option for me.
I will take the advise and inquire about the "68Ga PSMA PET/CT exam" if that is available me at this point, or the Axumin PET/CT, I'm not sure what type of CT scan I am getting it just says CT with contrast.

I have a lot to learn that's for sure.

Cheers,

Stan

 

Swingshiftworker

Just in case . . .

OP: Just in case you haven't seen it yet, here's the "sticky" that I've been repostin repeatedly as an overview for newly diagnosed PCa patients who have joined this forum.  The post provides an overview of most of the commonly accepted methods of treatment for PCa but it the message was directed mainly at men who have been diagnosed w/PCa rated at Gleason 6-7, which is considered low risk. 

Gleason 8 would be another matter but I think the info could still be useful to men with more highly rated and aggressive cancers.

I understand that you are of a mind to "just get this thing" out of you but surgery generally would not be the treatment of choice for a man of your age nor for a man w/PCa rated at Gleason 8 or above becuase of the trauma involved in the surgery, the risks of serious side effects from the surgery and the possibility that the cancer has already escaped beyond the prostate.  Radiation also would may not be suitable if the cancer has metastisized.  So, the scans you are getting to determine the scope of the cancer are crticial to your treatment choice.

In any event, here's the sticky:

The following is a duplicate of one that I have posted in various threads on this forum to give men newly diagnosed w/lower risk prostate cancer (Gleason 6 or 7) an overview of the treatment options available to them.

Anyone newly diagnosed with prostate cancer rated Gleason 6 (and usually Gleason 7) has all treatment options available to him and, since this cncer is considered "low risk", he has time to decide which choice is best for him.  So, the first thing a new prostate cancer patient should do is to do research on the available options before he actually has to make the decision regarding which treatment to choose.

The following is my response to other men who asked for similiar advice about the treatment choices avilable to them.  It's a summary of the available treatment options and my personal opinion on the matter.   You can, of course, ignore my opinion about which treatment choice I think is best.  The overview of the choices is still otherwise valid.

Choices You Need To Consider:

 . . .  People here know me as an outspoken advocate for CK and against surgery of any kind.  I was treated w/CK 6 years ago (Gleason 6 and PSA less than 10).  You can troll the forum for my many comments on this point.  Here are the highlights of the treatment options that you need to consider:

1)  CK (SBRT) currently is the most precise method of delivering radiation externally to treat prostate cancer.  Accuracy at the sub-mm level  in 360 degrees and can also account for organ/body movement on the fly during treatment.  Nothing is better.  Accuracy minimizes the risk of collateral tissue damage to almost nil, which means almost no risk of ED, incontinence and bleeding.  Treatment is given in 3-4 doses w/in a week time w/no need to take off time from work or other activities.

 2) IMRT is the most common form of external radiation now used.  Available everythere.  Much better accuracy than before but no where near as good as CK.  So, it comes with a slightly higher risk of collateral tissue damage resulting in ED, incontienence and bleeding.  Unless things have changed, IMRT treatment generally requires 40 treatments -- 5 days a week for 8 weeks -- to be completed.  I think some treatment protocols have been reduce to only 20 but I'm not sure.  Still much longer and more disruptive to your life than CK but, if CK is not available, you may have no other choice.

 3) BT (brachytherapy).  There are 2 types: high dose rate (HDR) and low dose rate (LDR).  HDR involves the temporary placement of rradioactive seeds in the prostate.  CK was modeled on HDR BT.  LDR involves the permanent placement of radioactive seens in the prostate.  1/2 life of the seeds in 1 year during which time you should not be in close contact w/pregnant women, infants and young children.  The seeds can set off metal/radiation detectors and you need to carry an ID card which explains why you've got all of the metal in your body and why you're radioactive.  Between HDR and LDR, HDR is the better choice because with LDR, the seeds can move or be expelled from the body.  Movement of the seeds can cause side effects due to excess radiation moving to where it shouldn't be causing collateral tissue damage -- ED, incontinence, bleeding, etc.   Both HDR and LDR require a precise plan for the placement of the seeds which is done manually.  If the seeds are placed improperly or move, it will reduce the effectiveness of the treatment and can cause collateral tissue damage and side effects.  An overnight stay in the hospital is required for both.  A catheter is inserted in your urethra so that you can pee.  You have to go back to have it removed and they won't let you go until you can pee on your own after it's removed.

 4) Surgery -- robotic or open.   Surgery provides the same potential for cure as radiation (CK, IMRT or BT) but which MUCH GREATER risks of side effects than any method of radiation.  Temporary ED and incontinence are common for anywhere from 3-12 months BUT also sometimes permanently, which would require the implantation of an AUS (artificial urinary sphincter) to control urination and a penile implant to simulate an erection to permit penetration (but would not restore ejaculative function).  Removal of the prostate by surgery will also cause a retraction of the penile shaft about 1-2" into the body  due to the remove of the prostate which sits between the interior end of the penis and the bladder.  Doctors almost NEVER tell prospective PCa surgical patients about this.  A urologist actually had the to nerve to tell me it didn't even happen when I asked about it.   Don't trust any urologist/surgeon who tells you otherwise.  Between open and robotic, open is much better in terms of avoiding unintended tissue cutting/damage and detection of the spread of the cancer.  Robotic requires much more skill and training to perform well; the more procedures a doctor has done the better but unintended injuries can still occur and cancer can be missed because the doctor has to look thru a camera to perform the surgery which obstructs his/her field of vision.

 4) You may also want to consder active surveillance (AS), which is considered a form of treatment without actually treating the cancer.  You just have to get regular PSA testing (usually quarterly) and biopsies (every 1-2 years, I believe) and keep an eye out for any acceleration in the growth of the cancer.  Hopeful and Optimistic (who has already posted above) has already mentioned this and is your best source of info on this forum about it. 

 I personally could not live w/the need to constantly monitor the cancer in my body.  Like most other men, I just wanted it delt with.  Some men gravitate to surgery for this reason, thinking that the only way to be rid of it is to cut it out, but I did not like the risks presents by surgery and opted for CK, which is a choice I have NEVER regretted.  I am cancer free, there is no indication of remission, there were no side effects and my quality of life was never adversely affected.  Other men on this forum have reported similiar results.

 So, for obvious reasons, I highly recommend that you consder CK as your choice of treatment.  The choice seems obvious when you consider the alternatives but you'll have to decide that for yourself.

 Good luck!

hopeful and optimistic

Stan

As has been mentioned proper diagnostic tests are critical for a "best" treatment decision. If available to you, I recoment your requesting a 3T MRI instead of a CT scan. This test is superior to a CT scan, and provides much greater definition. It may show if the cancer has escaped the prostate, and where suspiicious lesions are within the prostate.

As far as surgery, a man of 70 or above having having the exact same excellent operation as say a man of 50, is morely likely to have side effects of ED and Incontinence, as well as be subject to adverse effects from the surgery itself.

There is a step learning curve for robotic surgery; a doctor is practicing until he reaches several hundred. Many doctors have preformed 1000's of these surgeries. Generally, 35 surgeries is not an adequate amount to be proficient. 

As a 76 year old man it will be best for you to explore various forms of radiation, or a combination of radiation and hormone treatment.

ASAdvocate

Those Gleason scores of 3+5

Those Gleason scores of 3+5 are not very common. There is a second opinion service offered by Johns Hopkins for about $250 to review your biopsy slides. Their chief pathologist, Jonathan Epstein, is the top prostate pathologist in the world. I think that you would be well served to contact Johns Hopkins and arrange to have those biopsy slides sent to Epstein for his opinion. On other PCa forums, this is default advice.

JJMWFF1955

Hello Stan,  I'm 77 now and had the IMRT 44 treatments about 4 months ago.  My Gleason was 8 and most cores positive.

I'm done seeing the radiaologist and will see the urologist next month for 6 month Eligard shot.  My only problem now is feet are slightly swollen and feeling numbness. I would think i need another imaging test to see if cancer is contained but it is hard to get the Doctors to listen, especially my GP.  I was supposed to have an appointment with Urologist on the 6th and after I went they canceled it while I was in the office, the nurse saying that the appointment was changed to next month because the Dr has to see me the same time i get the Shot. I don't understand why but what can I do?

VascodaGama

Voluminous high risk case

Stan,

My lay opinion on the info you share makes me think that your case is not contained. Six positive cores out of twelve represents a voluminous cancer and the evidence on "Perineural invasion: Present" indicates higher probabilities for spread (cancer escapes via the nerves surrounding the gland). In view of the above together with the Gleason rate 5 (highest aggressive type) plus the high PSA, are all much susceptivel for cancer not being totally contained (T3). In your shoes I would look for radiation treatment (RT), if applicable.

The field of attack is now the center of attention. The wider the isodose planning covers the more damage radiation can cause. Typically it should include the whole gland, the bed region and localized lymph nodes. The image exam will tell if the lymph nodes at the iliac are infested too. This is to be discussed with the radiologist after the scans. If your treatment includes a protocol of hormonal therapy (typical in similar cases), I would recommend you to get a blood testosterone test in advance for checking HT effectiveness along the treatment.

You got good opinions from survivours above. I advice you for getting second opinions on what is discussed. You may prepare a list of questions refering to the points you have doubts and clear them with the doctors you are meeting. Surely, you have time to find details, decide and prepare yourself for D-day. Cancer does not spread overnight. Do things coordinately and timely.

Best wishes,

VGama