Hellostone, I'm sorry to read that your biopsy results show a Gleason staging higher than you were hoping for.  But as you stated, you now have a better idea regarding what your current situation is, and as such, now you can become more focused on reviewing available treatment options.

The one recommendation that I would make to you, as a lay person, is to find and engage an Oncologist, and, going forward, have the Oncoligist participate in your treatment options review and planning.  In my case, the one constant is that I have an Oncologist with me throughout my PCa journey. I consulted with her prior to surgery, and then later before my hormone and radiation therapies, and now today in a every-four-months visit for a watch/wait consultation mode, tracking my PSA changes.

We here in the Forum are with you, and I wish you the best of outcomes on your PCa journey.

www.floridaproton.org. UF Health is connected to the UF school of medicine. I am staying in one of their reccomended fully furnished apartments for $1600/mo. Apartment is one mile from the center. Jacksonville in the winter is not a bad place to be. The Lupron ADT is really no big deal if you stay active in the gym. The side effects are hot flashes, and a little weight gain around the middle. Hot flashes are not what you may think. No towel needed (LOL). Where are you located in this great big world. 

Stone,

Sorry to hear about the positive diagnosis. I wonder if any thing else is described in the report. The number of positive cores (5) and the high percentage found in each needle represent a voluminous cancer case which added to the perineural invasion finding lead to the possibility of existing extra prostatic extension.

This prognosis doesn't imply the need for ADT, but your doctor may see it not contained, suggesting that surgery may not be enough to assure total clean up. Radiation added to prostatectomy could be an option, however radiation alone applied as prime therapy can do the job. The CT may be seen as a protocol requirement in the diagnosis process. I do not think it will add more information than what was found in the previous mpMRI.

In my lay opinion, RT should be considered due to the voluminous grade 4 (aggressive) found in all the positive cores and high PSA. I wonder if you have done a DRE.

Second opinions will help you in formulating a final decision. You should also consider the quality of life in the future because you are young and will be embarking in a journey where the side effects from the treatment will affect you much.

Get your family involved in the decision.

Best wishes and luck in this difficult moment of your life.

VGama.

Stone,

Can you copy the pathologist's report and paste it here. Typically the template bores at three regions in each lobe (2x3x2)=12, adding additional two needles to investigate MRI findings. What was yours?

Regarding sizes, I do not think that you got such a relatively small prostate as you comment. 23cc is absolutely a normal sized gland for a 53 years old. Older guys (above 60) have bigger glands (40cc) also considered normal sized. In any case, the size doesn't imply that surgery is better than radiation or vice versa. By hypothetic rule, surgery is recommended in contained cases as one assures a total clean up dissecting the whole gland. Cases where containment cannot be assured are usually moved to radiotherapy. Some doctors like the so called "... mother of all treatments... " and deliver combination therapies with protocols that include surgery plus radiation added to ADT. One should also to consider that surgeons (urologists) prefer to recommend surgery as much as radiotherapists recommend radiation. In the end, it is us who decide on the treatment and who assume full responsibility on the outcomes. We all sign an agreement before the treatment, relieving the hospital and physicians of any responsibility on the treatment.
Second opinions help in reaching that decision.

Please note that you are not alone. We all here have experienced the same difficulty in deciding on an option. We read a lot and listen to the doctors and once comfortable with something we decide. Surely that is the best we managed to get and surely it is the best choice. Be confident. You will get it too.

Best,

VG

Stone,

You're moving in the right direction. I hope the RO helps you in understanding the situation. Take along a list of questions and discuss about anything even if that seems awkward to be done to a RO. For instance, about the particulars of your gland size in regards to type of treatment, and about the atrophic glandular changes identified by the pathologist. Inquire if the finding  affects judgement were it related to diffused or focal atrophy.

My comment on the biopsy report; I have counted 11 needless, two of them directional to the base/mid areas (Gr 4+3) closer to the center of the gland. It may relate to the area identified in the MRI, which corresponds to the same direction of the nerves bundle running above closer to the shell, also diagnosed with cancer from the base (under the bladder) to the apex (attached to the rectum).

It shows a voluminous cancer with the aggressive Gr 4. The right globe was disregarded, with just three cores, probably because of the MRI negative results. Though I think that it should have been treated equally with the 6 traditional needles, the doctor’s assumption in avoiding the full protocol creates ambiguity. It will be difficult to decide in preserving the right lobe whole or even in preserving the nerve bundle if surgery becomes an option.

In any case, the biopsy results are valid and proper to proceed with a conclusion. Now you need to receive a clinical stage from where to decide on a treatment.

Please let us know about the discussion with the RO.

Best wishes.

VG

Stone,

Thanks for the update. Overall it seems that you got a good consultation at the RO department. Sorry to hear that the RO did not spend much time clarifying doubts. These guys cost money by the hour so they limit their timing with matters involving exclusively the treatment. They leave those diagnosing aspects to be discussed by the interim doctor (or should I say, the hygienist.) before the meeting. We need to be prepared in advance with some knowledge on the matter and start by inquiring before allowing them to give us the conclusion. I am surprised that you have started these meetings without a Clinical Stage that should have been established already by the urologist (?)

Regarding your meeting, I cannot fully understand the reason for the comment on the "similar cure rates" when, at the same time, they recommend an extensive combination treatment involving EBRT+Brachy+ADT, which usually is recommended to cases with extraprostatic extensions (not contained). We know that surgery would have lower rates of success if extraprostatic extensions were present. Probably they want to say that in contained cases, both therapies got similar rates, differing only in terms of the side effects.

Regarding the protocol and its sequential, it all depends on the type of brachy they are suggesting. Low Dose Brachy (LDB) done with seeds implants, is usually applied alone to treat contained cases, but it is also used as a RT booster applied adjuvant to the EBRT. High Dose Brachy (HDB) that involves insertion of temporary RT rods is usually recommended in risky cases. These usually are administered neoadjuvant followed by EBRT as a boost, but in some cases it becomes adjuvant to EBRT.

The intent of the combi is to focus and deliver the maximum radiation to the areas where cancer hides avoiding areas known to be usually free from cancer. The main protocol involves the whole gland (Brachy alone or EBRT+ Brachy) plus the area surrounding the gland (nerve bundle, seminal vessicles, etc) inclusive of the localized lymph nodes (EBRT alone). In a protocol involving seeds implants as prime therapy (+/- 15Gy), an adjuvant EBRT would be used to reinforce the dose of radiation delivered to the gland (20 to 35GY). In this respect CK (SBRT) substitutes well LDB or HDB in contained cases. Combination RT in EPE cases aim in distribuiting higher total doses (9oGy) to the various regions.

ADT in the context of the treatment serves to improve the effects of the radiation. In trials it has demonstrated a 35% increased benefit in the RT outcome. Therefore, the sequential is usually started with ADT followed two months later by the neoadjuvant EBRT and adjuvant LDB that is applied two/three weeks after that. The hormonal involves a Lupron (3-month) shot followed by one or more shots to a defined total period (6 months for your case). These shots will give a blow to the cancerous cells, maintaining them quietly along their life cycle (approximately 6 months). You will experience sort of menaupose symptoms due to the chemical castration (hypogonadism). These usually vanish two month after the end of the effectiveness of the drugs (2x3 plus 2). The RT side effects typically start being felt at one month into the treatment.

As you may understand, "Perineural Invasion" is never seen as a matter of concern in radiation planning because the isodose will cover those areas. The RO therefore is more concerned if there is a positive Bone scan.

In your next meeting with the MO, apart from discussions on treatment options (administered individually or in combinations), you can inquire about the effects of the hormonal treatment and how to counter each particular symptom, would these became nasty or unbearable. You can also inquire on his opinion regarding extra exams that may complement the treatment of choice such as; a bone densitometry scan to check bone health (ADT affects the bone), a colonoscopy to check for ulcerative colitis (may prohibit RT), a complete blood analysis inclusive of the testosterone (regulates the hormonal drugs), etc. Surely this time you should take along copies of the MRI and biopsy report.
Doctors working at the same hospital may have access to the data of a particular patient but they do not look for the details. They procure the conclusions reached by other physicians, trying always not to interfere with their opinions.

I think that you have been assisted at Boston's Dana-Farber. Is this the place where you have done the mpMRI and the biopsy?
You also mention the name of the surgeon, Dr Kibel (meeting of March) , and I wonder if he is Adam Kibel, a specialist in genitourinary oncology. Is he the urologist you met initially?
I have read several of Dr A. Kibel papers, most particularly involving combination treatments. He is an advocate of the so called "mother of all treatments" or more scientifically saying, "Multimodal therapy". This is an approach to treat cancer involving combined weapons to fight the cancer from several fronts at the same time. Surely the practice will assure higher possibility of cure but it will also involve more risks and side effects that may prejudice the quality of life of the patient. Multimodal therapies have shown benefits regarding long chemical free periods (remission) but I have not read yet about their benefits in terms of longer survival rates. Recently, multimodal treatments also include immunotherapy approaches that have shown success in treating cancer. I am from the old school following sequential therapies trying to keep Q&L as much as I can.

I recommend you to prepare a List of Questions for the meetings with the doctors. Try to include items in regards to required preparedness for each type of therapy, the time it takes to recuperate and the expected side effects, like; incontinence issues, libido and ED, late radical proctitis of RT, etc.

Here are some links with information on the above;

https://www.cancer.org/cancer/prostate-cancer/treating/radiation-therapy.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6043740/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5721712/

Best wishes,

VGama

I agree with Josephg above. The PET exam will be very valuable in the screening as it checks the whole body. You doing it well in taking time for added information. Do not worry if this delays the final decision, Your status doesn't change in a couple of months. More tests more precise information and better opinions drawn by the physicians. Surely that bone involvement will limit the options. Typically MO recommends systemic approaches where Urologists may prefer a radical. The final decision is yours and you should consider the risks in each treatment, apart from the benefits.

I want to know the results of the PET. I hope they identify and locate the neoplasia.

Best,

VG

NOTE: I wonder about your suggestion in changing threads. You can keep this thread by changing its title, if that is your reason.