What to do about a Gleason 6?

Also encourage your friend to participate directly in the discussion to prevent misunderstandings.

I would add to the above replies the fact that, whatever Gleason one's cancer is rated, the treatment option is decided on the location of the cancer. For instance, contained cases (whole cancer within the gland) have high rates for cure by any type of radical treatment but localized cases (cancer existing around the gland) are susceptive to the extent of the spread and that in such cases surgery would not be practical.
Image exams are imperative when judging the clinical stage of a patient, which will influence in the final decision.

Best wishes and luck in his journey.

VGama 

Anyone whose PCa is rated Gleason 6 has all treatment options available to him and, since it is "low risk" has the time to decide which choice is best for him.  The thing for your "friend" to do now is to do the research necessary on the available options before he actually has to make the decision.  The following is my response to other men who asked for similiar advice.  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 valid.

. . . 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 what 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!

Steelchuggin26 said:

Several options for G6 PCa

Hello there, your friend, while it is unfortunate that he has been diagnosed with prostate cancer,  his gleason score is quite favorable. Gleason 6 cancers are slow growing cancers that don't have to be treated right away.

Options for gleason 6 cancers include: 

Active surveillance- The Dr will do psa tests every few months to assess the PSA and note any changes, rises in PSA may warrant repeat biopsies to investigate for potential higher grade cancers.

Surgery- Radical prostatectomy removes the gland, and this gives the pathologist and the doctor the best assessment of the cancer. Usually the biopsy gets it right, but in 20% of cases gleason scores are upgraded because the pathologist found higher grade cancers that the biopsy missed.  Having surgery gives the best clinical picture. It can tell whether or not there is spread outside the gland, such as to the seminal vesicles. But as with any surgery, there is a small, but real chance of complications.(my dad development dvt and pulmonary emboli from his surgery). 

Radiation therapy- this can be done via external beam, or by brachytherapy,  which places radioactive seeds into the gland to kill the cancer. Not to worry, thetc seeds are generally not toxic to you as they emit radilation in the gland only. Your body is not affected. External beam therapy uses a focused beamy of radiation directed to the prostate, this is an outpatient procedure, and does not require hospital stay in an otherwise healthy man. Radiation too has risks of unwanted side effects, so your friend should discuss this with his dr if this is the route he goes.

Him being 55 is rather young for prostate cancer, but it's not unheard of. And with you stating he is otherwise healthy, the Dr will likely recommend surgery, but the decision is entirely your friend'should decision.

 

Side note- Surgery and radiation have similar success rates, though if surgery is done, radiation can still be used if cancer recurs. In general, if radiation is done first, most surgeons will not operate because radiation leaves scar tissue, and scar tissue is difficult to cut through, unless the physician is well experienced.

Your last paragraph is correct per my understanding and reading also, Steel.

When I met with my Radiation Oncologist discussing RT (a guy I already knew and admired before our consultation) I asked him toward the end, "IF radiation fails, what subsequent treatments are possible second-line ?" He responded immediately, "Hormonal."   For me, that was too few words.  But he also said, "failure of IGRT on a low Gleason, low PSA disease is extremely unlikely."

I eventually chose DaVinci RP surgery, but remained ambivalent the whole time, and believe I would have been happy with radiation instead -- bless every man's choice.  But my surgeon, who has now done about 1,000 DaVincis, lists on his website that he has a subspecialty "doing post-Radiation prostate surgery."

I asked him if operating on the prostate post-surgery was rare, and he told me directly that following RT it is indeed extremely rare and tricky, but he has done it. He said following RT the gland become extremely fiberous and difficult to work around, as you noted.  Most surgeons do not attempt post-RT prostate surgery, but RT following surgical failure at cure is very common and mostly unproblematic. And also has a pretty good success rate.

Your comment about the clarity of a pathologist's report post-removal was a factor for me also....I prefer certitude when available. And my chart was changed from Stage I to Stage II, based on the patholigist's dissection and analysis.  While imaging is advancing yearly, it cannot match having the gland under a microscope in a lab.  These are just facts I have learned, not recommendations toward anyone for any thing.

max

SV,

 I agree completely with everything stated above.  Your friend should get involved here and then he can ask questiosn and get the answers he wants from those of us who have been and are fighting this hard battle..  All of our situations are different and thus we can only offer our stories to help your friend make decisions.

Best wishes

Will

I wanted to mention that since my intial PSA and visit to the urologist, my urinary frequency has picked up - especially 4 weeks out from the biopsy.

thanks to all!