Not yet what to do...

Hi again, Alain

Are you French?

I am Portuguese. Back in 1998 I stayed in Manila on assignment from Japan for a project in Mindanao that took 5 years. In 2000 was diagnosed with PCa in Tokyo where I obtained treatment. The follow up of my case was done at John's Hopkins, USA, with visits at their hospital in Singapore. You can also consider that hospital for treatment if not satisfied with the service in Manila.

Regarding your case, I think that you should visit St Luke's to have a proper consultation before making a decision on the treatment.

Treatments for prostate cancer are not easy walks in the park. It is serious and involves risks and side effects that will prejudice your quality of life.

You should get the opinions from both specialists for surgery and radiation and have those biopsy slices checked by a pathologist at St. Luke.

A PSA lower than 20.0 ng/ml does not confirm negative metastases in bone. Agressive Gleason rates of 4 may produce little volumes of PSA serum.

You should also inquire on the insurance scope of coverage before any decision. Typically insurances cover both types of treatments, including exams and tests done before and after the intervention. Some have limits for the length of hospital stays.

You should investigate on the several types of radiation treatment. IMRT is the longest but SBRT is done in just 5 days. Brachytherapy takes only one day plus two on hospital stay.

Hopefully you find a solution to your case.

Best wishes,

VG

Yes, I think you are experiencing a mixture of stress because of dealing with the unknown, together with the side effects of bicalutamide.

The best is to educate on the matter by reading about the various modalities, their benefits and side effects and prepare a list of questions for the doctor you may be meeting in your next consultation.

In any case, you need a clinical stage (obtained via exams and tests) to decide on a treatment. That depends mostly if you have a contained case, or a localized not contained or far metastatic case.

The MRI and Bone scan are important items in the diagnosis process. The number of positive cores in the biopsy and their location as well as the pathologist opinion on his findings (such as extraprostatic involvement, etc), will help the urologist in drawing a clinical stage.

I do not know if in Cebu there are proper specialists for prostate cancer but I imagine that the uro recommending you to start with hormonal therapy is limited in knowledge. ADT is recommended for very advanced cases or to older patients (>80 y/o) or to those that cannot sustain a radical treatment.

Surely, bicalutamide can give you time to educate on the matter postponing a radical treatment.

Make arrangements for meeting specialists at St Luke's, take copies of all tests done in Cebu, including the original biopsy cores (you can get them from the hospital attending you), and the results of a MRI and Bs. Then discuss with the doctors using a List of Questions. I recommend you to be accompanied with your wife and probably tape the conversation with the doctor.

To avoid traveling too many times, make prior arrangements for a scheduled MRI and Bs that could be done at the same facility in two days, obtaining the results (typically one week later) by e-mail.

Please note that doctors do not substitute us, the patient, in making a decision. They check, analyze and recommend based on their expertise and experience. We must be prepared to decide and absorb the consequences from such decision.

I am not a doctor. Survivors in this forum help newbies with comments based on their experiences.

Best wishes and luck in this journey.

VGama

Hi Alain,

I am retired and live now in Portugal. I am acquainted with Asia because I lived 30 years in Japan working for a big steel manufacturing company (engineering) that had offices in several countries including Manila.

In my times, St Luke's was the best hospital with the best specialists to treat PCa. Most of the professionals have studied and trained at big hospital universities in the United States.

The options to eliminate PCa are basically surgery or radiation. Chemotherapy and hormonal treatment are palliative, do not eliminate the issue but manage some control extending the period of life, so that the patient may die (many years later) of other causes.

Low risk (Gleason 6 and less than two positive cores and low initial PSA) contained cases have the highest rates of success and are usually treated with surgery. This may be the reason why some think that "...with surgery you can live longer".

However, recomending surgery for intermediate cases (Gleason 7), depend much on the results of the biopsy, unmasked PSA histology, image studies and symptoms.

One may think it to be contained but it may be not. For such cases radiation therapy may be a better choice as it covers a wider area of attack (the whole gland and surrounding tissues). Surely enough, surgery is also recommended but the success is not as assured as in low risk cases.

I wonder what it is written in the MRI and biopsy reports. How many positive cores and its location?

In your shoes I would get the opinion from an independent radiotherapist and rechedule surgery after being confident that such is your preference.

Regarding the side effects, incontinence and erectile disfunction is common in surgery. Colon issues and cystitis is common in radiotherapy.

Remember that cancer doesn't spread overnight. You have time to get second opinions, check the efficiency of the doctors treating you, the facilities and get in-line with the insurance matters.

Do not get lose. Try doing things coordinatly and timely.

In the end you will do well.

Best

VG

Hi Alain,

Thanks for sharing the info.

It looks like that Dr Sefino Cortez works in the so called "Medical Tourism", typical in the Philippines and procured by many as one of the top destinations for getting treatment because of its inexpensive yet world-class facilities and skilled doctors. Some insurances present packages covering travel and accommodation expenses.

However, the experience of these doctors is not assured. In PCa robotic surgeries (DaVinci) it is common to read that the surgeon should have 500+ interventions in his belt to be considered a well experienced doctor.

Regarding the biopsy report, they describe it to be of 12 needles (6 of the right lobe plus 6 of the left lobe), and diagnose it as: RIGHT AND LEFT PROSTATE TISSUES: ADENOCARCINOMA, GLEASON 7 (3+4), but there is no mention on the number of the positive ones.

Were all cores found positive?

You must check this calling the laboratory because above 4 positive would diminish the success of a lone surgery option.

Another important matter described in the biopsy report is the type of cells described as "...cribriform and infiltrating fused glandular tumor (Gleason grade 4)", which is linked to poorer treatment outcomes.

Regarding the MRI report, it describes your gland as very small of 15.5 cubic cm. Is it correct?

The typical normal size of a prostate gland is 20 cubic cm. What makes me curious is the size of the lesion they describe that is almost the same size of the total gland. It would mean that the all 12 needles were positive.(?)

The good thing is the description on negative involvement of the Neurovascular bundle, Seminal vesicles, and Lymph nodes. They describe "No osseous abnormalities" but the MRI hardly detects lesions in bone. This is the work of a Bone scintigraphy scan.

Overall they classify your case as PI-RADS grade 2, in which I have doubts because they consider your PSA of 4.6 ng/ml that is masked by the bicalutamide at the time you did the MRI. They should do the calculation using your original PSA of 11.32 ng/ml (August 2022).

I think that you should continue your investigations consulting other specialists as commented above.

Please note that I am not a doctor.

Best wishes and luck in this journey.

VGama

Best wishes for 2023.

l am glad for knowing that you requested a second read (opinion) on the biopsy slides. Next it will be a consultation with a radiotherapist to become acquainted with the goods and pitfalls of that treatment.

I believe that the level of diagnosis presented by you above will assure your living presence at the time your son completes the university studies and gets married. You will survive to greet your grandchildren. 😉

Best

VG