New diagnosis and treatment options

TJ12 · January 1

Hi, I’m a caregiver to a loved one newly diagnosed with prostate cancer. We’re still learning and have really valued this discussion board- thank you all. My loved one is 73 years old, active and generally healthy (but does have heart disease well managed) and his PCP told him 6 years ago not to get PSA anymore. This year he saw a commercial on TV that prompted him to ask for the PSA which came back as a 14. Eligibility for MRI is complicated by pacemaker, so first step after repeat unchanged PSA was biopsy. The result was a mix of 6 (3+3) and 7 (3+4), with the majority of it being the 6. The providers are recommending either surgery or radiation due to the presence of 7. The doctor who did the biopsy said that while she was performing the biopsy she formed an opinion that the cancer has not spread (can this really be something she could tell while doing a biopsy) but out of abundance of caution, a PET scan is scheduled. (again, MRI tricky due to pacemaker.) they are saying if it has spread, recommendation will be radiation. If it has not spread, they say the outcome/success rate of the surgery and radiation is exactly equal so it comes down to his choice of which type of treatment he wants.

Does all of this sound right?

Does anyone have any positives or negatives experiences with treatment at UVA?

Any strong recommendations for one option over the other? Will either treatment option be complicated by his heart disease?

will/should hormone therapy be offered with either option? Thus far it has not been mentioned.

thanks for your time if anyone has any thoughts!

centralPA · January 1

Hi, sorry you find yourself here, but you are asking the right questions.

For the biopsy, how many samples did they take? What percentage of those samples were positive? Were they on both sides of the prostate?

TJ12 · January 1

Thank you. 8 samples. Base, mid, apex, and anterior on R and L. 6 of 8 positive. Only 2 not positive were left base and right base.

Right mid and left mid were both Gleason 6 with 5/10 percent of total tissue.

Right and left apex were Gleason 6 with 5 and 30 percent of total tissue.

Right and left anterior were the ones containing 7 (3 plus 4) (right is 5 percent total tissue with 30 percent Gleason 4) (left is 40 percent total tissue with 5 percent Gleason 4) cribrifirm pattern absent. Perineal invasion absent.

Clevelandguy · January 1

Hi,

Based on what you have stated it sounds like some form of radiation therapy might be a safer bet due to the heart problem. Radiation followed by hormone therapy could be used, I would talk to the doctors about the hormone (ADT). ADT can have some nasty side effects.

Dave 3+4

centralPA · January 1

Hi, if you use the guidelines at the NCCN,

https://www.nccn.org/patients/guidelines/content/PDF/prostate-early-patient.pdf

then it suggests that your loved one is in the Unfavorable Intermedate risk category due to the presence of PCa on both sides, along with the PSA value and grade group =2. Life expectancy then becomes a key decider between therapies, along with his pre-existing condition.

Highly recommend taking a look at the guidelines, recognizing they are guides. Radiation without hormone blockers, or a short course of them, would seem to be tolerated by the heart the best?

Old Salt · January 1

In response to your question, YES that sounds right.

You are taking one step at the time to come to the right conclusion with respect to therapy for your loved one. I agree with you that the urologist who did the biopsy was speculating whether cancer had left the prostate since she didn't sample the whole 'thing'.

More in general, it is usually a good idea to ask for a second opinion on treatment options. However, I would wait for the results of the PSMA scan. Since you seem to be in Virginia, there are several excellent prostate cancer facilities in Northern VA and Washington DC.

With respect to 'hormone therapy' (ADT) and cardiac issues, it would be best to consult with the cardiologist. I did that (many moons ago) and he told me that ADT would not affect the bypass cardiac surgery that I had had. Of course, your loved one's situation with the pacemaker is a different story. Again, it's something to keep in mind for the near future once you both know more about the recommended therapy.

TJ12 · January 12

https://csn.cancer.org/discussion/comment/1711910#Comment_1711910

Thank you! He got some good news this week, the PET revealed that the cancer has not spread outside of the prostate. The final treatment plans offered are surgery OR radiation 5 days/week for a month plus 6 months of hormone therapy. He’s leaning toward surgery. The cardiologist says he is considered moderate risk for surgery. But the hormone therapy also carries cardiac risks and according to the radiologist will have side effects for 12 months. My loved one’s personality type seems to align with the surgery approach. Even though surgery is invasive and has side effects, he seems to mentally be more drawn to removing the cancer all at once rather than radiating it and treating it over time with the hormones. Does anyone who’s had either have any thoughts on that mindset? I don’t think he’s a candidate for the newer treatment called cyber knife (I may be wrong about the name of it) but he hasn’t been offered that anyway. The radiologist said that a 3rd option could be implanted seeds which deliver radiation over time, but that they really did not recommend that as an equal option. At this point we welcome any insight on ideas/factors that are important to consider when making a treatment decision. We’ve read information and talked to the providers, so really open to input from folks who have actually survived this!

VascodaGama · January 12

Hi, caregiver

You received good and valuable comments from the survivors above.

I think that the initial biopsy urologist's opinion on "cancer has not spread" was based on the live image of the ultra sound probe while gunning the gland. They gather as much information as possible during the diagnosis but request additional exams to certify their findings later.

I doubt that the PET managed to identify extraprostatic extensions closer at the prostate bed, but I trust that the results are negative for metastases in lymph nodes and at far places. Thought the PSA is high (14 ng/ml), the case seems being localized.

In my opinion, your partner's choice of surgery (RP) is proper if he feels confortable with the approach. Radiation is also an option and it could be administered solo without the "help" of the hormonal treatment.

In fact, the hormonal treatment consists in blocking the access to androgens by the bandit so that instead of monthly LHRH agonists/antagonists which effects last longer, one can opt to daily antiandrogens whose half-life is much shorter. At any signal of worsen cardio vascular condition one can stop the hormonal timely.

The big difference in RP and RT are the risks and side effects that prejudice the quality of life. RP is more prune to incontinence cases in 73 yo young guys and RT is more attached to proctitis and cystitis. Surely, any suspicious of extraprostatic extensions would be better covered with RT than with RP.

Regarding CyberKnife (SBRT), this is a RT modality that would be privileged as it is done in 5 sections instead of the suggested IMRT that takes 5 to 6 weeks of administration. Brachytherapy (implanted seeds) is also another modality in localized cases. It is more invasive than SBRT.

If the choice involves the use of LHRH agonist/antagonist, I would recommend you to choose the antagonist Firmagon that is friendlier to cardiovascular issues.

Try investigating more on the risks and side effects attached to each modality. You are close to formulate a decision.

Best wishes and luck in this journey.

VGama

Clevelandguy · January 12

Hi,

To answer your question I had robotic surgery back in 2014 removing my Prostate. Went home the next day with a catheter/bag setup for about 10 days(the worse part of my whole experience). Graduated from an adult diaper to a light pad over a few weeks, ED took about 1.5 yrs to get a “useable” member. Today I wear a small light pad to catch a drip or two now and then. Like you said I wanted to get all the cancer out and if needed to, do radiation clean up. So far my PSA is still <.1, if I had it to do over again I would choose surgery. Best approach is to get a top notch doctor + excellent facilities to get the best results. Other treatment types like Cyberkife or Proton are also excellent choices if you prefer radiation. Good luck…..

Dave 3+4

TJ12 · January 21

Thank you all very much for taking the time to respond and advise.

Vgama, the radiologist he consulted with is adamantly recommending hormone therapy for 6 months along with the radiation. You mentioned doing the radiation solo. Do you know of a different “type” of radiation, perhaps a newer technology or something, that would eliminate the need to add hormone therapy with it? Do you know of any treatment centers that would have more advanced radiation options like that? We are having a hard time understanding if radiation is the same everywhere or if there are different technologies that make it “better” at certain facilities. Not sure if this question even makes sense!

one example is I’ve seen the “proton” type mentioned in this forum. Is that “better” or just a different type used in certain scenarios, etc?

Maybe there is a good resource for listing out the types of radiation someone could point us to?

thank you.

Old Salt · January 22

Six months of 'hormone therapy' won't be fun, but men generally recover after the drug has washed out of the body.

With respect to radiation, it can be done with photons and protons. Proton therapy isn't new and I have read several success stories. However, we don't know how it compares to photon therapies because proper comparitive studies haven't been done. Moreover, it's expensive and not always covered by insurance. An advantage of proton therapy that is often mentioned is that the protons won't 'strike' nearby organs. Whether this is clinically significant is not clear.

It's quite easy to find a list of possible radiation therapies. For instance,

Prostate Cancer | Memorial Sloan Kettering Cancer Center (mskcc.org)

VascodaGama · January 23

https://csn.cancer.org/discussion/comment/1712552#Comment_1712552

Hi again,

According to clinical trials, the combination of RT + ADT is about 35% more efficacious than RT alone. This is behind the reasons for NCCN's recommendation in having the combo in radiation treatments.

Your radiologist is just following the advice of his association. Surely that there are radiologists who would do RT alone or with other protocols.

I agree with Old Salt's opinion that 6 months wouldn't hurt that much. You can discuss with the radiologist about your concerns on ADT and get second opinions from another oncologist.

Please do your investigation regarding the several treatments for PCa, the risks involving in each one and go through a treatment that most satisfy your husband.

The experience of the radiologist and of the institution goes hand-in-hand with the outcomes. You have time to inquire. Do things timely and coordinately. Be positive.

Best

VG

Unknown · September 23

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