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Dad's Biopsy Report....Questions.

Posts: 4
Joined: Jan 2016

Hi. I'm a concerned and scared daughter who is trying to do as much research as possible. My dad is 65 and was diagnosed with prostate cancer this past week. Needless to say, this was devastating news and we are struggling to accept his diagnosis and are frightened about his prognosis. However, I'm attempting to be strong and supportive for my parent's sake. My dad has had prostate infections over the past 20 years. However, his PSA didn't begin to rise until this past year. At its highest, it was 6.5. At the time of the biopsy, it was 4.9. When my parents met with the urologist to get his biopsy results, he discussed surgery followed by radiation. He has scheduled my dad for a CT and Bone Scan. I'm confused as to how the doctor could make recommendations without having all the test results. Also, do you think, based on his biopsy results that he should get a second opinion? Here are the biopsy results and everything we know as of now:


DRE-positive for nodule

Gleason Score-7 (4+3)

6 of 12 cores positive for cancer

5 cores 4+3 and 1 core 3+4

4 cores 60-70% tumor volume, 2 cores 15-30% 


Any suggestions or advice would be greatly appreciated. The doctor stated that my dad's cancer is in the "intermediate' stage. What does that mean exactly? What are the chances of his cancer having spread? Is there something more we should be doing at this point? Thanks so much for taking the time to read. Also, thanks for this informative site and for sharing your stories. 

Posts: 1013
Joined: Mar 2010

Sorry to hear about your father's prostate cancer (PCa) diagnosis.

The severity of the cancer risk is rated by Gleason score: Gleason 6 (low), Gleason 7 (intermediate) and Gleason 8+ (high).  PSA level is also used to help determine risk but it is a possible indicator of aggressiveness -- low to high.  With a Gleason 7 and PSA 4.5,  the need for treatment is not urgent and you have the time (which you and your father should take) to research and learn about the variety of treatments available.

It is standard practice to get a 2nd Opinion on PCa biospy slides.  There is no hard fast rule for assessing PCa samples -- there's a lot of judgment involved -- and a 2nd opinion could come back lower or higher.  The best place to send your father's slides for a 2nd opinion is the Pathology Dept at Johns Hopkins Medical Center and the person to send it to there is Dr. Jonathan Epstein, who is regarded as one of the leading experts in PCa biopsy assessment.  He did then 2nd opinon on my biopsy over 5 years ago.  Here are links to the 2nd Opinion Service at Johns Hopkins and some info regarding Dr. Epstein:



There are a wide variety of possible treatments that your father is eligible for with a Gleason 7 diagnosis.

The urologist's recommendation of surgical removal w/radiation follow-up is the standard urologist response -- they are surgeons -- but is is not necessarily the BEST one for your father, especially since surgery presents the greatest risk of side effects -- infection, collateral organ damage, inpotence and incontinence -- when it's done.  You can just troll through the threads on this and other PCa forums to read a vast number of post-surgical horror stories to verify this. 

On the other hand, many men undergo surgery without too much difficulty BUT almost all of them still experience some post-surgical incontinence and impotence which can take a year or more to be resolved.  For those men who remain permanentnly impotent and incontinent following PCa surgery, of which there are many, their only recourse would be install a penile implant (which restores the erection but not the feeling or ability to ejaculate) and/or adult diapers and/or an Artificial Urinary Sphincter (AUS) to deal with the lack of urinary control.  There are other much better alternatives to this.

The other alternatives are a variety of radiation treatments with acronyms that you will soon become all too familiar with: SBRT, CK, IMRT, IGRT, BT, PBT and so on.  The 3 main radiation techniques currently in use are: SBRT (stereotactic body radiation therapy) the most well known of which is called CK (Cyberknife), IMRT (intensity modulated radation therapy) and BT (brachytherapy) of which there are 2 types: LDR (low dose radiation) and HDR (high dose radiation).

I was a Gleason 6 with a PSA of 9 at the time of treatment with CK and am currently in remission; cancer free after 5 years which is considered "cured."   CK is a highly precise method of radiation delivery which minimizes the possbility of side effects.  It delivers radiation w/a sub-mm level of accuracy in 3 dimensions, which can also control for body and organ movement during treatment.  NO other method can come near it in this regard.  I and many other men who have had CK have reported absolutely NO impotence or incontinence following treatment.  Treatment is completed in only 3-5 sessions w/in a week.  I strongly urge you to consider this as the 1st option for your father.

IMRT and BT are also acceptable methods of treatment that are better than surgery.  The method of radiation delivery is not as precise as with CK and the likelihood of side effects is a bit greater but not as great as with surgery.  IMRT is the most common form of radiation treatment and is the form often used when surgery fails, as it often does. IMRT usually requires around 40 sessions over a month to complete treatment.

LDR BT involves the placement of radioactive seeds (with a 1/2 life of 1 year) in the prostate.  The seeds remain in the prostate FOREVER and will come up in metal/body scans at the airport and elsewhere.  Improper seed placement/movement are the greatest problems w/LDR BT.  If the seeds do not have the proper level of radiation and/or placement, the cancer may not be killed and healthy adjoining tissue and organs (rectum/bladder/urethra) can be damaged.  HDR BT is better because the seeds are only placed in the prostate temporarily and then removed.  CK was modeled on HDR BT but vastly improved upon it  Both BT methods are completed wi/in a day but usually require hospitalization overnight and a later return for the removal of a catheter.

This is just a quick overview of the options available to you father.  You can easily explore them further by doing research on the Net. Please take the time to do so and DO NOT let your father's urologist rush him into surgery before learning what the other options are.

Good luck!



Posts: 4
Joined: Jan 2016

Thanks so much for your reply. You have given me a lot of information to digest and research. I'm going to urge my dad to send his slides to JH for a review. Hopefully, we might get some good news and his GS will be downgraded! Also, it's good to hear that we have time to carefully consider all options without rushing into anything. I have a couple more questions: does the GS 4+3 verses 3+4 hold any real differences or significance? Does the presence of PNI indicate the cancer has most likely spread? Do you consider his tumor volume to be high? The more I read, the more confusing some of the information seems...one article says PNI is irrelevant while another says it is significant. Very frustrating! Do you think my dad would be eligible for active surveillance?

I'm very thankful I found this site! Interacting with other people who are or who have been in our situation really helps put this journey into perspective. Your remission or "cure" is inspiring to hear about. 

Old Salt
Posts: 822
Joined: Aug 2014

Swingshiftworker has given you solid advice. I will try to answer some of your questions, but am not a medical professional, just a Gleason 9 guy.

Gleason 4+3 is considered to be more serious than 3+4. Treatment will be based on the first number (4), but I agree that you and your dad should study all the options available to intermediate-risk patients. A re-evaluation of the pathology is very important because, as just stated, it will help devising the optimum therapy.

The PNI diagnosis only means that there is a possibility (!) that the cancer has spread. Scans should indicate whether the cancer has metastasized, but they won't reveal micro metastases. And, yes, you will find conflicting papers on many of these issues.

I doubt that there are Active Surveillance protocols that would accept a case like your Dad's. If his pathology would be down-graded to 3+3, yes, but that's unlikely (sorry!).

My recommendation would be to start hormone therapy combined with radiation. SBRT (CyberKnife) seems like a good option. If SBRT is not available, IMRT is another (lengthier) radiation procedure to consider.


Posts: 4
Joined: Jan 2016

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.

hopeful and opt...
Posts: 2336
Joined: Apr 2009


Generally a bone scan is recommended for patients with Gleason 8 to determine if the cancer has gone to the bones. The american urological association does not recommend for those with less than a gleason 8. In your father's case where the cancer is extensive with a gleason of 4+3=7 this recomendation is appropriate.

A MRI provides better definition than a CT scan, so it is a better diagnostic tool

There are other diagnostic tests , one being an MRI T3 which can show if there is  extracapsular extension. This information is important for treatment decision. If there is extracapsular extension there will still be cancer if surgery is done, so hormone treatment along with radiation is more appropriate. Radiation treatment goes beyond the prostate and is more effective in erradication cancer that is outside the prostate than surgery.

Here is information that confirms Hormone therapy works best when combined with radiation for locally advanced prostate cancer


advanced prostate cancer

By Charlie Schmidt

When prostate cancer spreads from the prostate gland into nearby lymph nodes or bladder tissue, it is called locally advanced prostate cancer. The standard treatment for it is a combination of radiation therapy and hormone therapy. Radiation kills prostate cancer cells. Hormone therapy, formally known as androgen deprivation therapy (ADT), deprives prostate cancer cells of testosterone, which they need in order to grow and spread.

But both types of therapy have their own sets of side effects. So is such a one-two punch really needed? It is. That’s the conclusion drawn from the largest clinical trial of the combination to date.Medicine

Using radiation therapy plus ADT against locally advanced prostate cancer came into favor after studies began showing that men treated with both radiation and ADT lived longer than men treated with radiation alone. In one such study, French researchers divided 415 men with locally advanced prostate cancer into two groups: one group was treated with radiation only, while the other group was treated with radiation and three years of ADT. Ten years later, 60% of the men on the combination treatment were still alive, compared with 40% of those who had been treated with radiation only.

What that and other studies did not investigate was how combination therapy stacks up against ADT alone. An international research team has addressed this question, and the results strongly favor combination therapy.

“Adding radiation to ADT more than halved the risk of dying from locally advanced prostate cancer,” said Malcolm Mason, a professor at Cardiff University in Wales and lead author of the study.

Mason and his colleagues enrolled 1,205 men between the ages of 50 and 80 who were diagnosed with locally advanced prostate cancer between 1995 and 2005. Half of the men were treated with lifelong ADT; the other half were treated with ADT plus a seven-week course of radiation.

After 10 years, 43% of the men treated with ADT alone had died, compared to 34% of the men treated with ADT plus radiation. That translates into a 30% lower risk of death from any cause in the combined treatment group. Deaths specifically from prostate cancer were nearly 50% lower among men who got ADT plus radiation. Mason cites that as the study’s take-away conclusion. The results were published in the Journal of Clinical Oncology.

Side effects were roughly comparable in the two treatment groups, with about one in three men reporting a low sex drive and difficulty getting or keeping an erection. Other side effects included bowel problems, hot flashes, and a frequent urge to urinate, which were all slightly more common in the combined treatment arm.

“This paper is significant because it shows that ADT by itself is not enough for men with locally advanced prostate cancer,” said Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and Editor in Chief of HarvardProstateKnowledge.org. “They also need radiation therapy.”

But Garnick points out that a critical question remains: as part of combination therapy, how long should ADT last? In a separate study, the French researchers showed that three years of ADT was more effective than six months. But ADT can be difficult to tolerate, and some men in the trial’s three-year treatment arm weren’t able to complete it.

“We try to give at least two years of ADT to men with high-risk disease, but it depends on what they can tolerate,” Garnick said. “And as the optimal duration isn’t known, this will require further study.”


To be honest, there is a fairly good chance that in your fathers case with extensive intermediate cancer that there  may be extracapsular extension. ....so the need to MRI.....also, there is a pet scan that is a diagnostic tool.

The side effects of surgery is greater than other treatment types.....and is age related...that is, a man of 65 is more likely to suffer side effects such as incontinance and ED ,etc than a younger man with the exact same surgery.

Generally surgeons recommend surgery because that is what they do............the side effects of multiple treatment types is cummulative, so the  side effects of surgery, radiation and hormone treatment, if given would all fall on your father.


Posts: 1013
Joined: Mar 2010

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!

Max Former Hodg...
Posts: 3699
Joined: May 2012


Your father is fortunate to have you helping him figure out his options. Several guys have given wonderful, detailed responses., so I will try to be brief .  With a Gleason of 7, your dad's disease is what the English call "of the middling sort" -- neither currently the worst or the least.  PNI escape, if confirmed, would complicate things. PNI means "perineural involvement," which means cancer may have exited the gland via a nerve bundle, sort of the way a prisioner does a jailbreak through an air shaft in the movies.  His involvement is somewhat widespread across the tissue samples. 

Be aware that doctors "sell" to the patient what they themselves do. Urologists are surgeons, who give first thought to surgery. Radiation oncologists, no surprise, are mostly going to recommend radiation.  At a minimum, met with a radiation oncologist after all of his results are available.

First-line therapy in the US for minor to intermittent levels of PCa are right at 50% choosing surgery, 50% radiation.  IF it is determined that any disease has exited the gland, the preference of many doctors shifts toward radiation, and usually via IMRT/IGRT delivery.

There is no need to rush this decision. Speak to at least two or more specialists, do some reading, and go from there.




VascodaGama's picture
Posts: 3405
Joined: Nov 2010


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;




Best wishes and luck in his journey.



Posts: 4
Joined: Jan 2016

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.


hopeful and opt...
Posts: 2336
Joined: Apr 2009

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.

Posts: 1013
Joined: Mar 2010

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.

Old Salt
Posts: 822
Joined: Aug 2014

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.

Max Former Hodg...
Posts: 3699
Joined: May 2012


Vasco's last post was brilliant, and summarized everything that has been discussed here.  Keep his post for reference as you and your dad move forward.

As was mentioned, denial of the bone scan was probably simply because he did not meet the Gleason 8 criteria.  A CT is inferior to the MRI, but a lot better than nothing. With his relatively low PSA level, I doubt any involved nodes would be large enough to be spotted on CT, but again, it is better than no scan at all.

Subjectively/impressionistically, I am now of the opinion that probably IMRT/IGRT radiation would be my first choice. Cyberknife is wonderful for exactly defined tumors, but is not a good choice for radiating disease that has potentially "spread."  But IGRT is itself highly precise, and has good technology to avoid damaging clean tissues.  It is very possible that other therapies might be recommended into the mix, in addition to radiation.  Besides seeing a radiation oncologist, you need to consult with a medical oncologist also. A medical oncologist is one who treats via drugs. He would best understand how to rightly administer hormonal therapy, chemo, and so forth, although some urologists are competent at these things also.

I myself had surgical removal for  Stage IIA exactly one year ago. All doctors said mine looked like Stage I, but more disease was discoved inside the gland once it was analyzed by the pathologist after removal.  This is not an uncommon sequence of events.

I feel the guidance you receive from professionals will tend toward radiation now.   Surgery is a radical, painful thing. Cutting it out for "debulking" is not a route I would choose, given his particulars.


Old-timer's picture
Posts: 196
Joined: Apr 2011


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)

Max Former Hodg...
Posts: 3699
Joined: May 2012


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



VascodaGama's picture
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Joined: Nov 2010

I am sorry for the stress you are confronting. Insurances are never there when we need them. However, the clinic caring for your father surely can find a way to have these traditional exams done under insurance coverage. Sophisticated image studies are usually not covered by insurances if the practice is considered as investigative, but one may avail them through clinical trials or under the government National Health System (free of charge) if the doctor manages approval.

Typically these tests require a doctor’s referral if one wants to go private. I do not know where you live or the price charged at your place but in the EU a bone scintigraphy scan costs about the same or lower than a CT exam; Approximately 300 Euros including the contrast and radiologist’s report. The traditional MRI goes for 450 including the Gadolinium contrast. The PET is expensive but possible to do it for 800 Euros. To these prices you will add second opinions from specialist. You will also add expensive sophisticated contrast agents (C11, F18, etc) that require proper facilities for production and administration. An example is the C11 PET plus CT costing about 2,200 Euros. The FDG-PET/CT (fluorodeoxyglucose positron emission tomography which identifies lesions in bone, (therefore substituting the traditional Technetium-99m bone scintigraphy scan) costs about 2,000 Euros. This FDG-PET/CT would be the “golden exam” detecting prostate metastasis in bone, as you refer in your post.

Image exams equipment of low resolution typically provide false negatives if the cancer is tiny in size. One should look for the best faciities using higher resolution or providing techniques that fuse several information (As indicated by Swing above). The bone scan done with a Gamma ray machine only exams bone lesions/deformations which are common in advanced cases (Stage IV patients) that may not be your dad’s status. Does he have any symptoms?

As I commented before, you should consider in getting second opinions on the data in hand and on the recommendations of his urologist. Insurances usually cover the expenses of additional consultations. You can inquire about prices of tests and procedures in the hospital at your place.

Best wishes,



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