Selecting treatment based only on PSA

Nell9 · May 2013

A recent 12 core biopsy showed one core with cancer. Rated as T1c; Gleason 3+3 (6); PSA now at 24, doubled in three years; earlier biopsy, about six years ago showed no cancer. In all other aspects I am in good shape. I am able to select any modality of treatment within Kaiser's Senior Advantage HMO. Dr. recommends IMRT, friends who have been to Loma Linda recommend Proton. My Dr. puts no importance to either color Dopplar UT or Prostate-MRI (Tesla 1.5 or 3.0, with analysis software), which I have not had done. I have had Xray and bone scan MRI showing all within gland, at this time.
Any suggestions as to what to do?: I am hesitant to do anything at this time without some further knowledge about the aggressiveness of the cancer. I am exploring getting another color Dopplar UT done, I had one about seven years ago which did not show anything. Since it would be done outside of Kaiser I can afford it - $700. I do not yet have a cost for a prostate-MRI which Kaiser will not pay for.
At this time I am pretty much thinking of getting PSA numbers every three months to see how they go before jumping to make a final conclusion. My Dr. says that without more information, I'm at risk by using AS if the cancer is aggressive.
What I would most like to know; are there any nonintrusive ways to determine the aggressiveness of the cancer?

hopeful and optimistic · May 2013

Dear Nell

I am sorry for your diagnosis.

There are various questions that need to be answered, and concerns that need to be addressed so you can optimize your treatment decision.

What is your age?

What month was the recent biopsy done?

What was the involvement of the core that was positive, that is what was the percent of the core that was cancerous? (A criteria for low, low, Active Surveillance is less than two cores of 12 with less than 50 percent involvement in each, Gleason 3+3+6, PSA less than 10, Prostate Size/PSA equal to 0.15 or less., this varies some depending on age, etc.). Let us know the percent of the core that was cancerous.

You need to have a second opinion by a world class pathologist outside the Kaiser organization (an independent review of your slides) so that you will not be under or over treated. This is very important, especially for low aggressive Gleason of 3+3=6.

Your PSA is 24. As you know even though the PSA is an indicator only, this is a very high number for one who would be on Active Surveillance. It is possible that you may have a urinary infection that is causing this increase. Have you been treated for this possible urinary infection with say a month of Cipro?

Since Kaiser does not offer MRI with high power magnet as well as Color Doppler tests for diagnostic testing , your doctor is going along with Kaiser and poo pooing a test that you require to find out where you stand.

There is an MRI guided biopsy that uses an MRI with a preferably a 3.0 high power Tesla Magnet to find suspicious lesions, then biopsy the suspicious lesions in real time. The effectiveness of this is high. This is preferable to a color Doppler test.

You mentioned Loma Linda. Are you in Southern CA.; if so I can recommend a couple of support groups that will be helpful to you since I live and attend groups in So CA.

Nell9 · May 2013

hopeful and optimistic said:
Dear Nell
I am sorry for your diagnosis.

There are various questions that need to be answered, and concerns that need to be addressed so you can optimize your treatment decision.

What is your age?

What month was the recent biopsy done?

What was the involvement of the core that was positive, that is what was the percent of the core that was cancerous? (A criteria for low, low, Active Surveillance is less than two cores of 12 with less than 50 percent involvement in each, Gleason 3+3+6, PSA less than 10, Prostate Size/PSA equal to 0.15 or less., this varies some depending on age, etc.). Let us know the percent of the core that was cancerous.

You need to have a second opinion by a world class pathologist outside the Kaiser organization (an independent review of your slides) so that you will not be under or over treated. This is very important, especially for low aggressive Gleason of 3+3=6.

Your PSA is 24. As you know even though the PSA is an indicator only, this is a very high number for one who would be on Active Surveillance. It is possible that you may have a urinary infection that is causing this increase. Have you been treated for this possible urinary infection with say a month of Cipro?

Since Kaiser does not offer MRI with high power magnet as well as Color Doppler tests for diagnostic testing , your doctor is going along with Kaiser and poo pooing a test that you require to find out where you stand.

There is an MRI guided biopsy that uses an MRI with a preferably a 3.0 high power Tesla Magnet to find suspicious lesions, then biopsy the suspicious lesions in real time. The effectiveness of this is high. This is preferable to a color Doppler test.

You mentioned Loma Linda. Are you in Southern CA.; if so I can recommend a couple of support groups that will be helpful to you since I live and attend groups in So CA.

Selecting treatment based on PSA?

Dear Hopeful +;

Thanks for your comments and also reading your history. Here are answers to some of the questions you asked.

I am recently turned 79. The recent biopsy was done 3/11. The only core with cancer was reported as: C: right apex. Adenocarcinoma, Gleason Grade 3 + 3 = 6, involving 1 out of 2 cores and 10% of the needle core tissue. No perineural invasion is identified. No lymphovascular invasion is identified. Chronic inflammation.

All other cores were reported as benign but with either chronically inflamed tissue, A,D, and F; or acutely and chronically inflamed, B and E.

My bone scan showed "lots of arthritis but no cancer metastatic to bone." All of my lab work "look good". The CT and review of radiology comments "there is no definite region of cancer spread".

I am not sure as to what is meant by 'size' all I have received is a volume number of 45ml and a verbal comment that it is average. So if I use the volume and divide it by the PSA (45/24=1.8).

Do you have a recommendation as to a 'world class pathologist outside of Kaiser" here in Sacramento? I've recently contact UCSF to see about a consult and second opinion. I suppose they could evaluate the slides.

I had no urinary infection and only took Cipro once about five years ago with no reacourance of prostitis.

This is the first time that I have heard of an MRI Guide biopsy. Who does it and what does it cost? Why did you have so many cores if this is a good to get to "the suspicious lesions in real time"?

Loma Linda only came up since they were the first (?) to do the proton treatment. In Sacramento my Kaiser has already suggested IMRT and claims that the results are as good as, or better than proton treatment. It's hard to determine the differences since double blind studies can't be done on this issue.

I am scheduled for another PSA test late next week, about 11 weeks since the last one.

Aside from the PCa, I am in pretty good health and because of some planned travel this summer and China in the fall would like to put off any potentially harmful treatment until about Thanksgiving time -- or later if the numbers work out.

Thank you for sharing your experience.

Nell9

VascodaGama · May 2013

Asia, You will love to visit it

Nell9

Based on the results you posted, the clinical stage T1c seems proper. Your cancer seems to be not aggressive in spite of the high PSA (24 ng/ml).
PSA doubling (PSADT) of three years (36 months) is usually considered to be good, indicating indolence. Some doctors regard cancer aggressiveness if the PSADT is lower than 14 months. In fact, the reason behind the high number could be in part related to the chronic inflammation described by the pathologist.
In any case, an important parameter to judge aggressivity is the velocity in which the PSA progresses. Higher numbers may indicate more aggressiveness of the cancer. Look at this results;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582974/

I think you doing very well in trying to get a definite conclusion in your PCa case, consulting with proper specialist, but I would like to recommend you to follow the progress (if any) with periodical PSA tests and MRI 3T image studies, before committing to any treatment they (the doctors) may recommend. The bone scintigraphy study could be substituted with a F18-PET scan which may not be covered by your insurance but it is worthwhile to diagnose your status better. It is based on cells activity instead of their size.

I am not a doctor but my lay opinion is that at the age of 79 you may lose more if engage in a radical treatment, prejudicing your quality of life greatly. You want to live well in the many years you still got to enjoy. Not be crippled by the side effects a major therapy may cause.

One more comment regarding your high PSA in a slow growing doubling period, and low aggressive Gleason pattern of 3 in a score of 6 {adding still the low percentage found in adenocarcinoma}, is that you could be confronting a case of micro-metastases. This is diagnosed when a positive case got negative image studies, normal size prostate gland (up to 45cc) and elevated PSA. Micromets are cancer spread in many tiny colonies that cannot be detected in traditional CT or MRI.
The success of a treatment is also difficult to attain because these cases may not be localized. Without proper targets to shoot at, misses can be expected.

I would be looking forward to the travel to Asia you want to accomplish. That seems to be more important than the worries of having the bandit as an unwanted guest.

Please remember that there are other means of controlling PCa (other than radicals), would that turnout to be your case. Do things timely and coordinately.

Welcome to the board.

Wishing you luck.

VGama

hopeful and optimistic · May 2013

VascodaGama said:
Asia, You will love to visit it

Nell9

Based on the results you posted, the clinical stage T1c seems proper. Your cancer seems to be not aggressive in spite of the high PSA (24 ng/ml).
PSA doubling (PSADT) of three years (36 months) is usually considered to be good, indicating indolence. Some doctors regard cancer aggressiveness if the PSADT is lower than 14 months. In fact, the reason behind the high number could be in part related to the chronic inflammation described by the pathologist.
In any case, an important parameter to judge aggressivity is the velocity in which the PSA progresses. Higher numbers may indicate more aggressiveness of the cancer. Look at this results;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582974/

I think you doing very well in trying to get a definite conclusion in your PCa case, consulting with proper specialist, but I would like to recommend you to follow the progress (if any) with periodical PSA tests and MRI 3T image studies, before committing to any treatment they (the doctors) may recommend. The bone scintigraphy study could be substituted with a F18-PET scan which may not be covered by your insurance but it is worthwhile to diagnose your status better. It is based on cells activity instead of their size.

I am not a doctor but my lay opinion is that at the age of 79 you may lose more if engage in a radical treatment, prejudicing your quality of life greatly. You want to live well in the many years you still got to enjoy. Not be crippled by the side effects a major therapy may cause.

One more comment regarding your high PSA in a slow growing doubling period, and low aggressive Gleason pattern of 3 in a score of 6 {adding still the low percentage found in adenocarcinoma}, is that you could be confronting a case of micro-metastases. This is diagnosed when a positive case got negative image studies, normal size prostate gland (up to 45cc) and elevated PSA. Micromets are cancer spread in many tiny colonies that cannot be detected in traditional CT or MRI.
The success of a treatment is also difficult to attain because these cases may not be localized. Without proper targets to shoot at, misses can be expected.

I would be looking forward to the travel to Asia you want to accomplish. That seems to be more important than the worries of having the bandit as an unwanted guest.

Please remember that there are other means of controlling PCa (other than radicals), would that turnout to be your case. Do things timely and coordinately.

Welcome to the board.

Wishing you luck.

VGama

More information

Below is my layman opinion of your case and insights that for the most part compliments VG’s post.

VG is right about concentrating and looking forward to your trip to China. In fact VG is generally right about everything he posts. You will be wise to read his posts very carefully.

US TOO an international support group publishes a monthly Prostate Cancer Education and Support Hot Sheet. (You can pick one up by attending a support meeting in your area which you can finding by goggling US TOO)

The call number for the organization is 1-800-808-7866 or www.ustoo.org

IN the April 2013 Hot Sheet there is an article on page 5 that discusses some points that are germaine to you.

……………………

Nell, according to this article age is an important factor in determining the requirements for Active Surveillance since men with localized prostate cancer have a 10 year disease-specific survival exceeding 97%, making AS a reasonable option for many men. Your age of 79 is a large factor in favor of the choice for AS.

Apparently , a dr. Andrew Loblaw, MD who practices at Sunnybrook Health Sciences Center in Toronto lists the eligibility of patients that he sees for AS.

Eligibility for AS requires a biopsy Gleason score (GS) less than or equal to 6 and a PSA level less than or equal to 10ng/mg.

For men older than 70, the criteria consisted of a GS less than or equal to 3+4=7 and a PSA level of less than or equal to 15ng/ml.

For his follow up men have a repeat psa every 3 months for 2 years and then every 6 months thereafter. Scheduled follow up biopsies occurred after 1 year and then every 3 years until age 80.

…………………….

I agree with VG, that you need to emphasize continued enjoyment of a good quality of life, and not active treatment which can have radical side effects. However be viligent to ensure that AS is appropriate.

…………………….

The resolution of a MRI with a powerful Tesla 3.0 magnet is very fine, and can give an indication of extracapsular extension, suspicious lesions that may be in one lobe or two, and how large these lesions are; and the MRI will indicate the size of your prostate and stage your disease.

The MRI does not show distant metasisis, as VG mentioned a PET SCAN would show this. I believe that PET SCAN may not be needed if the MRI is negative for extracapsular extension.

Most likely the MRI is the only diagnostic test that you will require, however the urologist at, say UCSF, which you mentioned, and is an excellent hospital for the treatment of prostate cancer in virtually everything, a great choice of a first class hospital, where the doctors are excellent and a lot more knowledgeable and smarter than I am, may wish to do a MRI Guided biopsy based on your MRI to see what is going on. Only a few cores of very suspicious nature will be biopsied. Basically this is a new technology that is cutting edge that has significantly greater ability to detect cancer than the random biopsy that you and 99 and ½ of patients undergo.

You mentioned that you had a bone scan that was negative. Generally there is a very low incidence of metasisis found via a bone scan.

Gleason score 2-7, PSA equal to or less than 15, clinical stage equal to or less than T2b, the CT Scan findings 0/244 (0%)

Gleason score 2-7 greater than PSA 15 and / or clinical stage more than T2b, the CT Scan finding 8/174(5%).

Source: A Primer on Prostate Cancer, Stephen B. Strum md, FACP

……………………

You asked me about my treatment and the large number of cores that were done in my biopsies.

The first one that I had was random like yours and 2/12 cores were positive 3+3=6, less than 5 percent in involvement in each of these positive cores.

Three years ago I entered a research study, and so far I’ve had two biopsies in this study. Basically a multiparametric MRI is done using Telsa 3.0 Magnet, suspicious lesions are indicated and ranked, then the results of the MRI are fused with a three dimensional biopsy machine made by Artemis(this more advanced than the two dimensional biopsies that are currently the standard), the urologist then uses the Artemis machine to target the suspicious lesions. In addition to these suspicious lesions, random samples of cores are taken in the rest of the prostate.

Now is the procedure that I undergo as good as the MRI targeted biopsy? That is the million dollar questions, and the results are still out…

WORLD CLASS PATHOLOGISTS and Labs, once again according to “the Primer on Prostate Cancer” which I keep in my desk and often refer to.

David Bostwick (Virginia) 800 214-6628

Francisco Civantos (FL) 305 325-5587

Jon Epstein (Maryland) 410 955-5043

David Grignon (Michigan) 313 745-2520

John McNeal(California) 650 725-5534

Jon Oppenheimer (Tennessee) 888 868-7522

Dianon Laboratories 800 328-2666

UroCor 800 411 1839

(UroCor and Dianon have recently merged into one company)

High PSA can be caused various sources.

VG mentioned chronic inflammation described by the pathologist as one.

I believe that another source can be a urinary infection where treatment of high amount of Cipro over a month may reduce this PSA and you are home free. If that does not work there are other drugs that may be used to treat a potential infection where Cipro is not effective.

For your upcoming PSA, I guess that you know not to do any vigorous exercise such as bike riding, massaging the prostate or sex before the PSA test.

Proton therapy

I’ve read that Proton is no better than IMRT and costs a lot more.

If the cancer is localized, several at this thread have done SBRT; one form of deliverance is Cyberknife. There is a recent thread that I started on SBRT that you can read.

Not saying that you want to do any of these, just informing……I suggest that you keep on thinking about AS, and do your due diligence.

jwoodie · May 2013

Nell9 said:
Selecting treatment based on PSA?
Dear Hopeful +;

Thanks for your comments and also reading your history. Here are answers to some of the questions you asked.

I am recently turned 79. The recent biopsy was done 3/11. The only core with cancer was reported as: C: right apex. Adenocarcinoma, Gleason Grade 3 + 3 = 6, involving 1 out of 2 cores and 10% of the needle core tissue. No perineural invasion is identified. No lymphovascular invasion is identified. Chronic inflammation.

All other cores were reported as benign but with either chronically inflamed tissue, A,D, and F; or acutely and chronically inflamed, B and E.

My bone scan showed "lots of arthritis but no cancer metastatic to bone." All of my lab work "look good". The CT and review of radiology comments "there is no definite region of cancer spread".

I am not sure as to what is meant by 'size' all I have received is a volume number of 45ml and a verbal comment that it is average. So if I use the volume and divide it by the PSA (45/24=1.8).

Do you have a recommendation as to a 'world class pathologist outside of Kaiser" here in Sacramento? I've recently contact UCSF to see about a consult and second opinion. I suppose they could evaluate the slides.

I had no urinary infection and only took Cipro once about five years ago with no reacourance of prostitis.

This is the first time that I have heard of an MRI Guide biopsy. Who does it and what does it cost? Why did you have so many cores if this is a good to get to "the suspicious lesions in real time"?

Loma Linda only came up since they were the first (?) to do the proton treatment. In Sacramento my Kaiser has already suggested IMRT and claims that the results are as good as, or better than proton treatment. It's hard to determine the differences since double blind studies can't be done on this issue.

I am scheduled for another PSA test late next week, about 11 weeks since the last one.

Aside from the PCa, I am in pretty good health and because of some planned travel this summer and China in the fall would like to put off any potentially harmful treatment until about Thanksgiving time -- or later if the numbers work out.

Thank you for sharing your experience.

Nell9

Nell, I have had a similar

Nell, I have had a similar experience with Kaiser except that I am 65 and my PSA went from 8 to 60 over 10 years. After four negative core biopsies, I finally had a positve 3+4 TURP biopsy. Followup bone and CT scans were clear. Surgery or RT was "up to me." I then consulted Dr. Gottschalk at UCSF for a second opinion, who referred me to a research study using MRI/coil guided biopsy indicating 4+3 with possible extra capsular extension. This took RP off the table. so I have chosen HT followed by RT. If I was your age, I would be inclined towards AS with follow up treatment if/when needed.

Selecting treatment based only on PSA

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