Dad's Biopsy Report....Questions.

Ugagal said:

Thanks for answering my

Thanks for answering my additional questions, 0ld Salt! (Love the username)

If my dad chooses radiation as his first treatment choice, does that automatically preclude him from future surgery? What are your reasons for not recommend ing surgery? From what I've read so far, the recovery from the surgery can be quite difficult. 

The urologist discussed the possibility of doing all three..surgery and radiation followed by hormone treatment.

One of the old arguments against radiation is that, while you can do radiation after surgery, you can't do surgery after radiation.  This  is NOT necessarily true but, after you've done radiation, why would you want to bother doing surgery? 

This never made sense to me.

If the cancer is confined to the prostate, the theory is that once the prostate is removed, ALL of the cancer is gone BUT many men have learned that this is not so.  Often after surgery, there is still some remnant of the cancer left in the body which results in a recurrence that requires further treatment with radiation.  In the meantime, the patient has suffered a traumatic surgical procedure (doesn't matter if it's robotic or open; in fact, some sources say that open is better than robotic) AND has subjected the patient (among other things) to the risk of infection, malpractice --  in the form of damage to associated organs, mainly the rectum and bladder which are closely aligned w/the prostate, the potential for permanent impotency (if the erectile nerves are damaged or have to be cut out because of the spead of the cancer) and the possibility of permanent incontinence due to damage lower urinary sphincter (between the bottom of the prostate and top of the penile structure) and/or damage to the upper sphincter (between the top of the prostate and the bottom of the bladder.  

BTW, one of the things seldom mentioned by urologists is that once the prostate is removed and the "gap" closed by attaching the top of the penile structure to the bottom of the bladder, the visible length of a man's flaccid (and probably erect) penis is reduced by an inch or more.  This may not sound like a big deal to women but I can tell you that unless your father is extremely well endowed (which, if he is like the rest of us, mostly likely he isn't), it probably will be important to him.  Most urologists skim over this little side effect.  One of the urologists I spoke to even denied that it happens!  It does happen.  Look it up.

Fact is, the surgical prostate removal is a very difficult thing to do correctly, which is why (if you choose surgery) it is recommended that you choose the most experienced surgeon you can find -- especially if you've chosen robotic surgery.  The surgeon should AT A MININUM have a couple hundred robotic PCa surgeries under his/her belt , but even that may not be enough experience to know how to perform procedure properly.  The prostate is a very tiny organ hidden behind and adjacent to some very important organs -- most importantly the rectum and bladder which are often damaged during the procedure.  It's actually more difficult to do robotic surgery (where you have to use artifical hands and cameras) than open surgery (where everything is out in the "open" and exposed for visual inspection by the surgeon).  On the other hand, open surgery is more traumatic on the patient and presents greater risk of infection than robotic, which has been the main selling point of robotic surgical procedures.

It's not that radiation is not without it's risks, it's that if surgery is so risky, why would anyone consider it, if he had any other choice available to him?

As a prospective patient, it NEVER made any sense to me to undergo surgery if radiation would do the job as well and, fact is, modern radiation techniques are equal to surgery in terms of their effectiveness in removing the cancer AND much better in terms of minimizing the risks -- mainly impotence and incontinence -- and maintaining the patient's quality of life (QOL).  QOL following treament is VERY VERY important and is one of the main reasons to choose radiation over surgery.

Fact is, you CAN do surgery after radiation but why would you want to do so?  If radiation fails, you can do radiation again, especially if you do a multiparametric MRI scan of the prostate to locate the remaining cancer and pinpoint the reapplication of radiation w/a precise delivery method such as CK.  Follow up treatment w/IMRT or BT is also possible. However, this is seldom necessary because what radiation does is KILL all of the cells in the prostate (both good and bad) in order to eradicate the cancer.  If the cancer is still confined to the prostate and if the radiation is delivered effectively, the prostate is dead and there is absolutely no need remove it surgically.

This is not to say that there are no risks associated w/radiation.  There is no risk of "infection," but if done improperly, there is still a risk of collateral tissue/organ damage, impotence and incontinence but such risks are much lower than associated with surgery.  The most common problem associated w/improper radiation treatment is damage to the urethra causing scar tissue that has to be removed via a TURP (a transurethral resection -- a kind of a "roto-rooter" procedure to clear the urethra tube).  There can also be some rectal damage (indicated by blood in stool) or bladder damage (indicated by incontinence).  There are also those to believe that there are certain long term risks associated with radiation treatment, mainly cell damage possibly leading to collateral cancers.  In my view, if you are suspectable to one form of cancer, you are probably also susceptible to others and the the treatment of one by means of radiation has very little to do with the other.  I do not believe that there has been any definitive proof to the contrary.

Hormone treatment is not usually recommended unless there is some concern about the degree and aggressiveness of the cancer.  Typically, this would involve a high risk PCa (Gleason 8+) with a high PSA level indicating aggressiveness.  I do not think this is the case yet for your father. 

FYI, there are all kinds of awful side effects which accompany hormone treatment by means of ADT (androgen deprivation therapy) and I would NOT recommend taking any such medications unless there's a clear need to do so (ie., a failed surgery and/or radiation treatment accompanied by an increasing higher PSA level) and until you've done the necessary research to determine the risks of the various ADT medications.  There are numerous threads in this and other forums about ADT treatment and its risks/ill effects as well.

Better to focus on what initial treatment that your father should choose.  That will be a big enough hill for you and he to climb.  Don't make it more complicated by adding ADT treatment in the mix until absolutely necessary.

The results of the CT and bone scans should indicate if there has been any spread of the cancer.  A better test is a mutliparametric MRI using a dye and endorectal coil which spectrographically locates the presence of choline which is a marker for cancer.   "Hopeful and opt. . ." (above) called this test the "MRI T3"  but it's actually the 3.0 Tesla (or 3T) MRI (the 3T refers to the currently most advanced version of the Tesla endorectal coil used in spectrographic MRI screening).  This test is also also referred to as an MRI/MRSI.  They are all essentially the same thing -- spectrographic MRI screening using a dye injected into the body w/an endorectal coil inserted in the rectum.  I had this scan done on me when there was a concern of recurrence of my cancer a couple of years ago.   So, I am quite familiar with it.

If there is any doubt about the spead of the cancer, this is the BEST test you can get to determine where the csncer is located and how far, if at all, from the prostate the cancer has spread.  However, if the cancer has spread, surgery is usually no longer an option.  Radiation w/chemo therapy and ADT treatment (if necessary) would be called for but this generally is only the case for more serious cancers usually at the Gleason 9 level.  So, it's premature to worry about this in your father's case until you actually know that your father's cancer has spread beyond the prostate. 

I know that you have a lot of questions and are bring overwhelmed with information.  Fighting this cancer can be a long, drawn out journey.  You  and your father are just starting that journey.  So, don't get ahead of yourself.  Just put one foot in front of the other and proceed from there.

Your objective now should be learning as much as you can about the various types of treatments available (along with their risks) and deciding which is best for your father based on his specific needs, desires and concerns.

Good luck in that endeavor!

Ugagal

Welcome to the board. Please note that we are survivors exchanging views and opinions based on our own experience with the disease or on researches we done or heard along our journeys.
I think you/your dad should get second opinions from specialists and proceed when comfortable with a decision. Take doctors recommendations as advices only. There are risks in PCa (prostate cancer) treatments which will be assumed by your father at his only responsibility. He will have to sign an agreement before intervention relieving his doctor and the facilities from all wrong doings.

Physicians prefer to opinion on modalities of their trade and experience but will not take responsibilities. It is their roll in the decision process, the patient will “decide” so that he should try to educate as much as possible and gather truthful data/information on the problem and his status, leading to his best choice.

I recommend him (you) to prepare a list of questions and take notes from every consultation, and later digest it (with you and family) and compare with other physicians opinions/recommendations. You do not have to rush but he should advance with a treatment, coordinately and timely, when all is ready.

From the data you shared I think that the findings of: PIN, positive DRE, the Gleason grade 4 and the volume (number of positive needles) aggravates his intermediate risk in disease aggressivity and provides a higher possible for existing extra capsular extensions (EPE). The image exams scheduled by his doctor are to evaluate the possibilities of being a contained case (whole within the gland) or localized (metastases in the surrounding area of the gland, the bed and local lymph nodes). These will influence the judgement of his status (advanced?). The initial recommendation/suggestion of surgery plus radiation is typical of a surgeon when DRE and PIN is present. However, if the case is not contained then surgery may not be the best choice. It would only treat the wound. It would not cure the problem. Radiation seem to be more appropriate.

Surely, in a non-contained case, surgery (RP) can also be a choice for debulking the bigger “portion” of the tumour (the whole gland). Radiation (RT) would be used to “zip out” localized metastases. The roll for adding hormonal treatment would be to improve the outcome of the RT.

In other words, treatment differs in regards to the status of the case. The image exam is therefore crucial for having the “best” clinical stage to make a decision. But such should be obtained with the latest techniques in image studies. Traditional CT and MRI do not detect small size tumours (5mm), so that you better request his doctor for scheduling him to higher standards of image exams, instead of the CT.
I think that you can understand now better the reason for his doctor’s suggestions/guessing. A CT will not reveal metastases making it to be considered a contained voluminous case, proper for surgery. The PIN would raise the possibility on future recurrences so that salvage radiation is recommended as adjuvant.

Debulking styles include all types of treatment that covers intentionally the whole gland (such as, surgery, SK, proton, laser, cryo, etc). IMRT is appropriate for “zipping” processes (localized metastases). Chemo and hormonal therapies are paliative ways to control the advance of cancer, used in systemic cases.
All treatments cause side effects that may become permanent night mares. One needs to know in advance their details so that one can avoid engaging in something he wouldn’t risk. ED (erection dysfunction) and incontinence are prevalent in PCa treatments. Your dad at 65 is risking quality of living.

A good book to understand PCa, probably biased through ward surgery, “Guide to Surviving Prostate Cancer” by Dr. Patrick Walsh (third edition.

Ideas to prepare your own List of Questions to the Doctors;
http://www.cancer.net/patient/All+About+Cancer/Newly+Diagnosed/Questions+to+Ask+the+Doctor

http://www.mayoclinic.org/diseases-conditions/prostate-cancer/basics/preparing-for-your-appointment/con-20029597

http://csn.cancer.org/node/224280

Best wishes and luck in his journey.

VGama

Ugagal said:

Thank you all so much for the

Thank you all so much for the excellent advice and consult. Unfortunately, my dad's urologist recommended a CT and Bone Scan rather than the MRI. His insurance reluctantly approved the CT but denied the Bone Scan. Isn't a Bone Scan considered to be the gold standard in detecting prostate metastasis to the Bone? Do you think insurance denied it due to the fact that my dad is GS 7 (4+3) and not GS 8? The doctor's office said we will resubmit the Bone Scan for insurance approval after we get the CT results. We are prepared to pay for the Bone Scan if necessary. Insurance is not something we are looking forward to dealing with during this journey.

His CT is scheduled for this morning and we then meet with the urologist on Tuesday to get the results. Needless to say, we are very anxious about the results. The PNI on his biopsy report adds to our anxiety about it possibly having spread outside the capsule. Based upon your experience and research, what do you think the chances are that it has spread? Should we realistically begin preparing ourselves for bad news? I've always believed in hoping for the best and remaining positive through difficult situations...this diagnosis is definitely challenging that belief.

 

Thanks again everyone and I will keep you posted on his CT results. This site is a wonderful resource for informative advice and reassurance.

 

As I had mentrioned the American Urological Association does not recommend a bone scan for men with a Gleason under 8 since there is a very limited detection of cancer among those with a less than a Gleason 8 that has traveled to the bone.

If I was paying for a procedure, I would choose a 3T MRI to determine local extracapsular extension. This test provides more definintion than the CT, and is more effective. (that is if nothing found in the CT). On the other hand if extracapsular extension is found, I would ask for a bone scan.

The reason for these diagnostic tests that your father will be taking will be to evaluate where he stands...I suggest that you cross this bridge when you come to it. That said, my lay opinion is that there is a chance that there is local extracapsular extension...........that the cancer has not spread to the bone.  This is highly treatable.....your Father will be OK.

Swingshiftworker said:

Hope for the best, plan for the worst . . .

My advice would be to  hope for the best BUT plan for the worst.   This is the most realistic approach.

The problem w/PCa diagnosis is that it is bascially a shot in the dark.  PSA tests are not definitive; they are just indicative of the possibility of PCa and it's aggressiveness but a PSA test tells you nothing about the possible spread of the cancer.   CT and bone scans may not reveal the extent or spread of PCa either.   

In fact, this often is not determined until a surgeon actually goes in to cut the prostate out. Ironically, this may be the only reason to do surgery -- to actually "see" how far the cancer has spread -- but there is a test you can do w/o cutting into the body to find out where the cancer is located and where (if anywhere) it has spread.  This test is MRI/MRSI  (as I prefer to call it) or multiparametric MRI (as previously mentioned serveral times). 

Problem is, the MRI/MRSI is a VERY expensive test that most insurers will not approve for payment unless it is proven to be "medically necessary" by your urologist or radiation oncologist.  "Medically necessary" is one of those vague terms that insurers use, more often than not to deny coverage.  It's up to your doctor to make the case that it's medically necessary and this normally only occurs when other forms of diagnosis have been exhausted and there is still some doubt as to the existence, location and/or extent of the cancer (or if there is some fear of recurrence of an already known/treated cancer).  Possible recurrence was what justified it in my case.

PET scans are an alternative.  They are not as precise as the MRI/MRSI but better than a CT scan for determining the existence and spread of a cancer.   I don't think the bone scan will be dispositive; they usually aren't because PCa needs to be extremelly advanced/agressive to spread to the bone.  More commonly, especially in intermediate risk cases, the spread will not be that extensive and will be limited to closely associated organs, most commonly the seminal vesicles and/or the bladder which the MRI/MRSI (but not the bone scan) would reveal.  

However, in order to get your insurer to approve a PET or MRI/MRSI, you'll have to go through the normal diagnostic protocals starting w/the CT and the bone scan before they'll even consider approving a PET or MRI/MRSI scan.  So, you'll just have to await the results of the CT scan on Tuesday. and go from there.

I was going to respond as well, but there is so much good information in the above posts that I won't be able to add anything substantial for now.

Yes, there is a lot of info for you and your Dad to digest. And of course, the doctor(s) will add to that avalanche. But, as has been said, there is time for further study and to think things over. Don't decide on a protocol right now.

It is often said on these forums that each prostate cancer case is a bit different and we do not have ALL the information pertaining to your Dad. After all it's his life and body. Psychological well-being, and Quality of Life issues should play a major role as well in the decision process. Easy for me to say, of course, but we all wish you and your Dad strength making these decisions.

Ugugal,

It is a shock to get a cancer diagnoses. I hope a few words from me will be helpful to you and your Dad. I do not chose to make a recommendtion; even the experts don't seem to know what treatment is best.

My initial numbers were much like your Dad's. Age 65, PSA 4.0, Gleason 3+4=7. The year was 1991. There were not as many choices for treatent then as there are now. I chose surgery over radiation. Thirteen years later, the cancer returned. Time for radiation (2004). That did not work. After four more years, I went on hormone therapy (2008). My PSA has been undetectable ever since.

Knowing what I do now, would I choose surgery? Yes, I would. However, I will hasten to add that I am not telling you and your Dad what you should do.

Your Gleason score is low enough that it should be OK for you to take a few weeks for study and contemplation.

Twenty-five years (and counting) with Prostate Cancer! Scary thought. Even though I don't get around as much as I did a few years ago, at 89 years of age I am in reasonably good physical and mental health and enjoying life.

I wish you and your Dad many more happy years.

Old-timer (Jerry)

Old-timer said:

A few thoughts

Ugugal,

It is a shock to get a cancer diagnoses. I hope a few words from me will be helpful to you and your Dad. I do not chose to make a recommendtion; even the experts don't seem to know what treatment is best.

My initial numbers were much like your Dad's. Age 65, PSA 4.0, Gleason 3+4=7. The year was 1991. There were not as many choices for treatent then as there are now. I chose surgery over radiation. Thirteen years later, the cancer returned. Time for radiation (2004). That did not work. After four more years, I went on hormone therapy (2008). My PSA has been undetectable ever since.

Knowing what I do now, would I choose surgery? Yes, I would. However, I will hasten to add that I am not telling you and your Dad what you should do.

Your Gleason score is low enough that it should be OK for you to take a few weeks for study and contemplation.

Twenty-five years (and counting) with Prostate Cancer! Scary thought. Even though I don't get around as much as I did a few years ago, at 89 years of age I am in reasonably good physical and mental health and enjoying life.

I wish you and your Dad many more happy years.

Old-timer (Jerry)

Jerry,

Your clinical history with PSa proves that there is always hope, that a good life is always a strong prospect, regardless of the diagnosis.

.