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New Prostate Cancer Dx

RonJT
Posts: 32
Joined: Feb 2011

Hi to everyone on the board.  Here's my story so far.

PSA has been up and down since 2008 mostly in the 4-5 range.  Had a negative biopsy in 2009. Last 5 PSA's are as follows:

9/2/2014    6.5  %free PSA 7.7 

12/1/2014   7.4  %free PSA 7.7 

9/2/14      6.5  %free PSA 7.7

4/6/15      6.1  %free PSA 7.2

10/6/15     6.9  %free PSA 7.4  

2/8/16    7.5  %free PSA 7.6

 DRE was negative with no symptoms. My prostate is small with no BPH.  Last DRE felt suspicious so had an ultrasound and a small nodule was seen in the left lobe.  Had another biopsy on 3/2.  Results as follows:

Left Apex    3+3

Left Lateral 4+3

Left mid     3+4

left lat mid 3+3

left base benign

left lat base benign

right apex   3+3

right lat apex beniign

right mid benign

right base benign

right lat base 3+3

I am 67 and in very good health.  I am considering the pros and cons of Prostatectomy vs Intensity Modulated Radiation Therapy. Both providers are in San Francisco.  I will meet with the radiation oncologist and the surgeon in the next week. I am  interested in hearing from this very knowledgable group which I have been reading for some time.  Needless to say I am petrified but hopeful.  I am interested in hearing your thoughts.  Thank you in advance for any insights.  

Old Salt
Posts: 720
Joined: Aug 2014

when hearing the word (prostate) cancer for the first time. However, the results from your biopsy suggest that a favorable outcome is likely.

You have many options. With only two clinically significant spots on the left side, Active Surveillance is an option. Alternatively, several radiation therapies are available to attack these lesions. Personally I would consider CyberKnife (SBRT) first, and IMRT second.

Surgical removal of the prostate would be way down on my list of options.

My best wishes with the decision process; you have time to study all the options!

 

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Ron,

I am sorry to read of your diagnosis.

I notice that you have been a member of this site for quite a while, so I would think that you have knowledge about this.

First with 6 of eleven cores that are cancerous, with one  of the cores being fairly aggressive a 4+3=7, at age 67 in excellent shape you are not a candidate for Active Surveillance. Additionally your free PSA is low.    http://www.harvardprostateknowledge.org/what-is-the-difference-between-psa-and-free-psa

At various institutions there are slightly different criteria for acceptance to an Active Surveillance program. At Johns Hopkins the criteria is two cores or less with less than 50 percent of the core with a 3+3=6, PSA 10 or less, PSA/prostate size ratio 0.15 or less. After age 70 there is a relaxation of requirements to Gleason 3+4=7 and to PSA 15.

I wonder if you have had any other diagnostic tests, ie T3 multiparametric MRI, etc, etc.?

Did the results of your pathology discuss any other findings?

................................

It is important for you to research, read books, Internet, ask questions here. Attend local support groups..USTOO.org is an international organization that sponsors local support groups. You may wish to go to their site.

There are various active treatments that are available, Raiation to include SBRT ( aka Cyberknife, Novalis) is the most accurate of the radiation treatments only requiring 4 or 5 sessions. Others radiation treatments are also accurate, but not as much as SBRT. Additionally IMRT can require 40 sessions.

Surgery, can remove the prostate, however this treatment type can have more side effects than the others to include but not limited to ED and Incontinence.  Also prostate surgery is age dependent; that is a man who is 47 can have a perfect operation with no side effects while a man who is 67 can have the exact same operation with major side effects. At any rate if you have surgery, especially Robotic, the learning curve is very large. Unless a surgeon has done many hundreds, he/she is practicing, and the outcomes are negatively affected.

You also may wish to consider HDR brachytherapy for prostate cancer. (Although my layman's opinion is that SBRT will do the job with more accuracy, at any rate, I recommend that you read about HDR)

http://www.cancercenter.com/prostate-cancer/hdr-brachytherapy/

 

...........................

I am not exactly sure of the locations of the facilities in your area, , but UCSF is a world class institution....for prostate cancer they do everything well.

Also Stanford is an excellent place for treatment.

Generally centers of excellence have better facilities and medical staff. There is a difference in patient outcome versus a non center of excellence.

.............................

U.S. News and Report publishes an annual hospital ranking be specialty

UCSF is ranked #5 for urology; Stanford #18

http://health.usnews.com/best-hospitals/rankings/urology?page=3

Please reply with more information about your diagnosis, and any questions or concerns.

Best

H

 

RonJT
Posts: 32
Joined: Feb 2011

Thanks H. for your response.  I did not see anything else in the pathology that looked significant.  I do see that the 4-3 core was 7 of 12 mm or about 58%.  It did not indicate what percent was 4 vs 3.  Is that what you were referring to?   I agree that I am not likely a candidate for active surveilance at this point.  I guess technically I have already been there. For the last 10 years my PSA has been drawn every 6 months and has slowly risen from 4 to 7.5 over 10 years.  Had one other negative biopsy in 2004.  

I have certainly been doing a lot of reading on the topic recently.  I like my urologist and he too thinks the 4-3 finding requires some intervention.  I will definitely seek a second opinion on the pathology report before I act on this.  I know that I will also need further imaging studies (MRI, CT others?) before making my choice.  My understanding (so far) is that RT and Surgery have very similar outcomes in terms of mortality.  My first appointment is with the Radiologic Oncologist next week. The amount of information out there is pretty overwhelming.  I wish I had done better in my speed reading course in High School.  

hopeful and opt...
Posts: 2218
Joined: Apr 2009

Except for rare exceptions, the Gleason score is comprised of   the most prevalent pattern graded as primary, and the worst pattern (even if it is third-most prevalent) is graded as secondary, so a Gleason 4+3=7 is more aggressive than a 3+4=7. In your case the pathologist found 58 percent of the core to be cancerous. Basically, the percent of cancer in each of your cores is an indication of the extent of the cancer found, and might give an indication if there is extracapsular extension.

When one has a prostate biopsy, the pathologist may also determine  information other than the Gleason score that will give an indication of where you stand, and provide more input.

http://www.pathologyoutlines.com/topic/prostategrading.html

http://www.cancer.org/treatment/understandingyourdiagnosis/understandingyourpathologyreport/prostatepathology/prostate-cancer-pathology

A T3 multiparametric MRI uses the most powerful magnet (T3) in clinical use. The CT scan does not provide the definition that the MRI does. The MRI may show if there is extracapsular extension, that is if the cancer has a escaped the prostate, and will affect your treatment choice....if you wish , you may click my name to the left side...I believe that I wrote about the MRI.

There are also other image tests such as PET Scans. There are different PET scans that are available that you may wish to discuss with you doctor, and if it is appropriate to have one. Some are better than others. I would first pursuethe T3 multiparametric MRI.

  

 

 

RonJT
Posts: 32
Joined: Feb 2011

Thanks H,

                Yes have been a member 2009 when my PSA was rising enough to warrent a biopsy.  It was negative at that time. This week I have seen one surgeon at UCSF and have an upcoming appt with radiation oncologist hopefully next week.  Bone scan and CT are scheduled.  Has anyone seen a radiation oncologist there or have a recommendation for one?  I have posted my decision making process so far on my blog here:

http://csn.cancer.org/user/138408/blog

Hopefully it will be useful to others.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

See my post to you below dated 3/8/16.  It goes into great detail about my experience as a patient at UCSF.

 

RonJT
Posts: 32
Joined: Feb 2011

Saw a second radiation oncologist this week. This one from UCSF. He is scheduling a 3TMRI for later this month. Apparently it has to be at least 6 to 8 weeks after biopsy for best interpretation of results. Depending on the 3TMRI results he thinks a combination therapy would be best. Gold seed implant then eight weeks of external beam RT with 4 month of ADT. Depending on the results there would then be a boost RT using either brachytherapy, cyberknife or IGRT. I did not realize how many different radiology treatments were possible.  I assume  I would need to do the 3tMRI prior to starting the ADT.

 

Swingshiftworker
Posts: 1013
Joined: Mar 2010

Ron: What is the name of the radiation oncologist you saw at UCSF?

RonJT
Posts: 32
Joined: Feb 2011

I saw Mack Roach.  The 3t MRI will be done by Dr Shinohara.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

Don't know Mack Roach but he works at the Helen Diller Center where I was treated and was appointed the Chair of the Radiation Oncology Dept so it sounds like you are in good hands.  Shinohara, who also works at the Hellen Diller Center,  placed the gold markers in my prostate prior to my treatment w/CyberKnife by Alexander Gottschalk. 

Only met Shinohara once when he placed the markers; it was done very quickly and efficiently.  Don't think he'll actually perform the 3T MRI -- a MRI technician would do that.  He's probably the supervising physician responsible for final review of the scan.  In any case, he's been there a long time and has been involved in a lot of medical research involving PCa at UCSF.  Again, you should be in good hands.

Please keep us informed of your progress.  Good luck!!

hopeful and opt...
Posts: 2218
Joined: Apr 2009

I have viewed lectures by Dr. Roach, mainly from Prostate Cancer Research Institute (PCRI). He is very experienced, and considered aoung the very best in the world.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Ron,

With the others I welcome you seeking information here.

I had my prostate removed just over a year ago, when 58 years of age.  All things otherwise equal, and knowing what I know today,  I would NOT have surgical removal at the age of 67.  I was considering IMRT/ IGRT at the time.  Recovery following surgery varies for every man, from minimally troublesome to horrible. The older the patient, the more surgical recovery tends toward the latter end of the spectrum.

If you have no cardiac or respiratory issues, you are certainy young enough for the surgical route if you decide on it.  Be certain to demand removal of the seminal vesticles, and for the surgeon to do erectile nerve sparing when possible, but these practices have been pretty much universal for many years now. Undoubtedly they are standard proceedure at a place as highly regarded as San Francisco.

As noted by others, your numbers are not that bad, and you should anticipate full remission of the disease following whichever route you decide upon.

max

VascodaGama's picture
VascodaGama
Posts: 2958
Joined: Nov 2010

Ron,

You got good responses above. In my opinion, the positive  node dre is of concern and further examinations should be carried out before any decision on surgery. Usualy doctors direct a needle to those bumps for checking possible extra capsular extentions. A t3-mri would be helpful. If in doubt, go for rt to avoid doubling the risks of two therapies.

Sending this short reply from my phone.

Best

Vg

Swingshiftworker
Posts: 1013
Joined: Mar 2010

I am an outspoken opponent of surgery (either open or robotic) for the treatment of PCa.

Although it is still commonly recommended by urologists (because it's what they know how to do), there are a lot of very good reasons not to choose surgery -- mainly the risk to your quality of life. 

I won't bore you with a litany of reasons NOT to choose surgery here.  You can find any number of posts that I have made in this regard and it is easily researched on Google but, if you request, it I'd be happy to provide my standard warnings against surgery to those new to PCa.

When I was faced w/the choice of treatments just over 6 years ago, I quickly ruled out surgery because of the risks.  I was with SF Kaiser at the time and the only choices offered to me were daVinci surgery or Low Dose Rate Brachytherapy (LDR BT). 

After doing my own reearch, I also decided against LDR BT and discovered Cyberknife (CK) stereotactic body radiation therapy (SBRT) which was and still is a major advancement over IMRT or IGRT which are the common radiation techniques (other than (LDR BT) offered for PCa treatment.

I chose to receive CK at UCSF over 5 years ago and have effectively been cured of the disease.  I was a Gleason 6 w/a PSA of around 9 at the time of treatment.  CK has also been used successfuly to treat patients rated at Gleason 7. 

I strongly recommend (as has already been suggested) that you consider CK instead of IMRT and surgery for your treatment. CK is covered by Blue Shield of California.  Not sure about other carriers. 

Even though CK was available for the treament of other cancers at SSF Kaiser, it was not offered for treatment of PCa at the time of my diagnosis (which compelled me to switch to Blue Shield) but I am told that is is now being used at Kaiser to treat PCa as well.

The major benefits of radiation over surgery is the minimization of negative side effects -- most commonly incontinence and impotence.  The major benefits of CK over IMRT are the degrese of accuracy of CK in the delivery of the radiation to the sub-mm level which further minimizes the possibility of negative side effects AND the fact that treatment w/CK takes only a week (usually 3-4 treatments every other day) while IMRT typically will take 8 weeks of treatment -- 5x's a week -- for a total of 40 treatments.  Both methods have had good reported success over time w/IMRT reportly slightly more side effects.  So, all things being equal, CK has proven to be superior to IMRT in terms of effectiveness and convenience. 

The name of the head of the CK Department at UCSF is Dr. Alexander Gottshalk; Gottschalk was my RO.   UCSF of course also offers ALL other available treatments for PCa -- be it surgery, IMRT, CK, low and high dose BT, active surveillance, etc.   Dr. Pete Carroll and Dr. Eric Small are 2 other well-known physicians at UCSF who specialize in the treatment of PCa and have been often mentioned in PCa research literature.  Dr. Carroll led the development of the active surveillance program at UCSF.

UCSF has apparently opened a new Prostate Cancer Center in MIssion Bay.  Drs. Gottschalk, Carroll and Small are all named as staff members.  You can find info about the new center and them here:  https://www.ucsfhealth.org/clinics/prostate_cancer_center/.

Feel free to contact me by private mail here, if you'd like to know more about my experience at UCSF.

Good luck!

 

 

 

RonJT
Posts: 32
Joined: Feb 2011

Went today for my first dose of lupron at UCSF.  Also got the results back from my 3TMRI which showed the following:

FINDINGS: 

Prostate volume: 18.29 cc

 PSA density: 0.41 ng/ml2

 Post-biopsy hemorrhage: None

 Multiparametric MR evaluation:

 Heterogeneous appearance of the central gland is consistent with benign prostatic hyperplasia.

 Lesion 1: 

Left apex; 1.1 x 0.4 x 0.4; PACS image 41 and series #400 

On T2-weighted MR imaging, the lesion is seen as an ill-defined focus of low signal intensity (score = 3/5). 

The lesion demonstrates marked restricted diffusion (score = 4/5). ADC value: 938

Overall PI-RADS (version 2) score = 4 

No suspicious metabolism is seen in the lesion.  

Capsular margin and neurovascular bundle: Unremarkable 

Seminal vesicles: Unremarkable 

Lymph nodes: No evidence of lymphadenopathy in the field of view 

Bones: No suspicious lesions

IMPRESSION: 

- PI-RADS 4: clinically significant cancer is likely to be present as above.

- No evidence of extracapsular extension.  No evidence of seminal vesicle invasion.

- MR T-stage = T2A

- No lymphadenopathy.  No suspicious bone lesions.

 

While the MRI is encouraging (stage T2A), the biopsy shows a moderately aggressive pCA stage T2B. I believe the biopsy results would be more accurate than the MRI.  Is that not correct?  

 

My radiation oncologist is advising 5 weeks of IMRT followed by a boost.    The boost could be standard brachytherapy, HD brachytherapy, or cyberknife (EBRT).  During this time I will be on 4 months of ADT (Casodex and Lupron).  Does anyone have more info for me about the 3 possible boost therapies?  I am familiar with the 3 procedures but would like to hear from anyone who has undergone  one of them re: side effects, outcome, quality of life issues etc. Apparently I will be able to choose the boost therapy that I prefer.  I have not been able to find any studies that compare them to one another as a boost treatment.  Thanks for any and all info.

Swingshiftworker
Posts: 1013
Joined: Mar 2010

I left a detailed reply giving my opinion about the choice of using CK vs HDR BT vs LDR BT for the additional "boost" treatment in the other thread you started.

Old Salt
Posts: 720
Joined: Aug 2014

25 sessions of IMRT? At what dose? Followed by how many sessions of SBRT (at what dose)?

As an aside, I got an SBRT/Cyberknife boost (3 x 6.5 Gy) prior to 25 sessions of IMRT (1.4 Gy each). My prostate was significantly worse (Gleason 9), compared to yours.

Based on papers that I read, I believe that HD Brachy and SBRT (as boosts) are comparable in outcomes. You might consider the experience of the radiation oncologist when deciding which way to go.

RonJT
Posts: 32
Joined: Feb 2011

Thanks Old Salt.  I will get back to you with the RT dose.  Radiation is still 2 months away so there is time to gather more data.  I am pretty confident in my Rad Onc as he has a lot of experience at UCSF.

RonJT
Posts: 32
Joined: Feb 2011

Thanks for your input Old Salt

The dose for 25 sessions of IMRT will be 45Gy.  The cyberknife dose would be 2 sessions at 9.5Gy each.  So total dose would be 64Gy.  I am at risk for pelvic node involvement so they will be included in the RT.  Total ADT is scheduled to be 4 months Lupron + Casodex.  I am leaning toward cyberknife over HDR brachytherapy option for the boost.  Dr Gottschalk at UCSF is very experienced.  I am including this research article for anyone facing the same decision.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4721063/

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3228
Joined: May 2012

Ron,

I would assume your IMRT will be at around 3 Gray per application. By itself, IMRT usually has to be for a total of over 70 Gray to be regarded as reasonably curative. When combined with other modalities, this number might be lowerable; I don't know.

I too was T2a at beginning of treatment (which for me was RP).  A biopsy is more authorative in determing the aggressivity of a cancer, but for that particular piece of tissue only, which is usually generalizable.  The MRI is better at judging extent of the disease outside the capsule, for which a biopsy can yield only little information (volume of diesease; sometimes will indicated perineural involvement, etc.)

Your MRI results luckily do not sound too bad, and so I hope you quicly get to fully curatve results with as few side-effects as possible,

max

RonJT
Posts: 32
Joined: Feb 2011

Thanks Max.  Great info.

Old Salt
Posts: 720
Joined: Aug 2014

To add to the dilemma of which treatment to choose, one can just do five Cyberknife treatments.

Katz et al. published 7-year results (five sessions of 35 Gy each), and for intermediate-risk patients the 'success' rate was 90% (success = freedom from biochemical relapse) after 7 years.

http://www.ncbi.nlm.nih.gov/pubmed/25229051

As an aside, HD brachy is more invasive than SBRT.

RonJT
Posts: 32
Joined: Feb 2011

Thanks old salt.  Interesting articale.  I seem to be in the high intermediate risk group so for me bDFS is closer to 79% if I read things right.  Still not bad.  I would like to find a similar study for the 25 IMRT sessions plus Cyberknife boost. 

Old Salt
Posts: 720
Joined: Aug 2014

Unfortunately, there are very few refereed publications in the medical literature. I found just a (small) phase II study

http://www.ncbi.nlm.nih.gov/pubmed/20815416

24 patients that were followed for 6 months; the paper focusses on side effects. No long-term data; hence the paper doesn't address the topic of this thread. There likely will be a follow-up.

 

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