PC profile - your thoughts

Hi all,

following the RP I now have much more information about my husband's pc and the picture is odd in some ways and I appreciate your thoughts.

Firstly his psa numbers are low but he has 3+4 cancer. I know this happens often enough.
But then his free psa %s were really very high so it is odd he has it at all.
Then the volume of his pc is low (0.2cc) but there is Gleason 4 in that small amount of cancer. And it is spread right through the prostate in 7 spots.

Knowing what I know post rp, it seems to me that this cancer is not doing the usual thing. From the papers that I read Gleason 7 cancer is usually associated with a higher volume than Gleason 6 and averages over 3ccs. Secondly the high free psa does not make sense to me as it too is associated with a low chance of cancer and especially high grade cancer.

I am trying to understand this and I am having difficulty. Your thoughts are very much appreciated.

An

Thanks Cooper for being so upbeat.
We are really pleased to have done the surgery now we know there is some Gleason 4 in there. Our tolarence for risk doesn't allow for living with high grade cancer no matter the quantity. The medical practitioners we have seen post-surgery have concurred and said we were very lucky to catch the Gleason 4 early.

My question is more about high free PSA and low volume cancer being incongruous with Gleason 4.

An

Post Edited (An38) : 8/25/2010 6:47:39 PM (GMT-6)

I think that these numbers seem reasonable -- and I think they tell you that you made a good choice to have it treated. Do you have an actual copy of the path report? If not, ask your doc for it. Remember that 3 + 4 means that the majority of the cells examined were 3. You want to look at the total amount of cancer found since a lot of 3 could explain the free PSA.

My situation was somewhat similar to your husband's. My PSA was only 3.6 when I sent in for biopsy but it still came back 3+4. Cancer was relatively small (3 cc / 7% ) when removed, though 10X as big as yours.

My urologist explained to me that cancer is often a multifocal disease, meaning that it often develops at several spots in the prostate independently and nearly simultaneously. It's not as if there is one starting cancer and everything that's cancerous came from this one starting point. So the idea that there's something strange about having multiple small points of grade 4 ca may not really be on target.

Given that it moved to a 4 quickly, consider yourselves lucky that you found it and got it out while it was still so small. The outlook is very favorable.

It was also a stroke of good fortune that it was found at all in the biopsy. Look at this way: For the entire cancer to be .2 cc that means the cancer (if a sphere) would have to be something like 7 mm in diameter, a little more than a quarter inch in diameter. Now, take that quarter inch mini-marble of cancer and imagine it broken into 7 little bits and then those bits stuck at random inside a prostate the size of a ping pong (table tennis) ball. It could easily have been missed by the 12 biopsy needles, and then you'd be in the situation of having a false negative biopsy (as many on this site have experienced) and then finding the cancer with a repeat biopsy 1-5 years later, but by then it's bigger and potentially higher grade. Lucky you!!!!

I read 7 focal points of cancer within the prostate, not extra-prostatic extension. Gleason 3+4 has a 4 involved, which is what my Dr. says changes all the rules. As well, we are told a small spot of 4 is worse than a big volume of 3.

An, remember that Walsh tells us you can have a PSA of 2 and have extensive cancer, or have a high PSA and be simply afflicted with BPH. PSA is an indicator, not a guarantee.

Lastly, your decision was made, and the deed was done. Do not second-guess yourselves. It has no positive value.

My personal, non-physician opinion is that you have treated it, and you have a very high chance of being cured. But only a lifetime of 0 will tell that.

Hello all,

Just a point of clarification, logoslidat - the margins were negative. The 7 focal points were in the prostate. I'm sorry if it was not clear.
Proscapt, you make a good point about PC being a multifocal disease so perhaps I shouldn't be so surprised about 7 different spots blooming with cancer at once. And procscapt you are right that we were extremely lucky to find cancer at all on the biopsy.

142, we are very happy with our decisions, I would just like this all the data I have on my husbands PC to make a little sense (blame it on me being an engineer). The RP last Friday has gone very well, my husbands catheter was taken out today, it looks like he is already continent and he had his first half erection this morning. We have a lot to be grateful for.

Greg, can you refer us to any articles or books that explain the connection between high free PSA and low volume cancer. I thought high free PSA related to having no cancer. Most websites relating to free psa look like this

http://www.psa-rising.com/prostatecancer/fpsa-flowchart.htm

Doctors tell people all the time not to have a biopsy because they have a high free PSA. This is based on the fact that a high PSA (over 25%) corresponds to a low risk of having cancer and furthermore people who have high free PSAs tend to have low grade cancers. Neither of these were true for us.

This coupled with the fact that we have such a low volume of cancer but with Gleason 4 in it makes me wonder if this is a particular subtype of PC with these particular characteristics.

An

Thanks Sephie. We are thankful that my husband's cancer has not invaded the capsule although I know your husbands PSA has stabalised back to zero (and I hope and pray it stays that way). I do know that if we weren't as pushy with the doctors as we were we still would be waiting for the next yearly PSA report as our primary care physician was reluctant to send someone with a PSA of less than 4 to a urologist. He chose to remain ignorant of the concept of PSA velocity and didn't find the rise from 1.8 to 3.6 in one year alarming. And the urologist was reluctant to do a biopsy with the free PSA value being so high but did it to humour us. Then he accepted the ASAP diagnosis without question and we didn't. I know that without asking questions we wouldn't be where we are today so I continue to do so.

Greg, I finally understand what you mean about the free PSA being high being completely consistant with low volume PC. It clicked just a little while ago. I saw the free PSA % as a switch, high for no cancer, low for cancer. But the PC being low volume would mean that the vast majority of the prostate emits free PSA as if it has no cancer. Low volume PC would not change the ratio much because the amount of free and bound PSA it emits would not be enough to change the ratio. Thank you so much for helping me through this part of the puzzle.

Thank you Retire. We just did what you are doing now, finding answers and helping others on the way.

An

Post Edited (An38) : 8/26/2010 7:22:21 AM (GMT-6)

I am not sure what you mean by free PSA.  However, I had what I thought was a low PSA (2.7) and I still biopsied positive.  According to my doctor the issue

is how fast does it go up.

 

As you can tell from my signature the biopsy came back with only 2 cores of 12 @25% with a 3+4 Gleason.

 

Post operative biopsy indicated only 2% in 5 of 35 slides.  I was talking to my surgeon less than two hours ago.  He told me do not let the low numbers fool you.  The cancer was spread throughout the prostate.  He also indicated that the 4 in the Gleason score meant that you do not fool around with it. 

 

From what I have seen on this discussion group there have been a lot of Gleason scores go up after the post operative biopsy.

 

As one of you said, the PSA is only and indicator that says take a closer look.

 

I did get criticism from several sources for choosing surgery. The suggestions were radiation, wait and see, diet, prayer by itself, organic herbs.  All of this came from people at the church we go to.  The only two people that did not offer an opinion were Prostate Cancer themselves.

 

An38 said...
I am trying to understand this and I am having difficulty. Your thoughts are very much appreciated.

An,

Here’s the important part to focus on…(looking forward at what will likely happen, not backward)...

Your husband’s case characteristics and relevant results are virtually the same as the most frequently occurring PC cases found today—low risk or lower-intermediate risk, found early, and surgically removed with no margins.

The best news is that it is highly unlikely that he (and the other guys in that most frequently occurring scenario) will ever have to deal with prostate cancer again in his lifetime.  Furthermore, if continence and sexual function were good before surgery, there is a strong statistical likelihood of full recovery in those areas by about the first of next year.

That’s news to celebrate!

Post Edited (Casey59) : 8/26/2010 10:43:06 AM (GMT-6)

An,
Second guessing is brutal. It's why I and it seems so many others on this site say don't look back after making the decision. I found myself is the completely bizarre situation in the first post-surg psa reading apptmt. last wk when we had the prostate path report too of wanting to hear there was more cancer than was first found on the biopsy. The surgery and recovery is so difficult that I wanted more confirmation that my husband's decison had been the right one (I'd leaned more towards the AS option).Surgeon said it's a gender thing - the wives question and second guess a lot more than the guys. I think as each zero psa reading comes in (the 3 month intervals will fly by) it will relieve your mind. Happens with women with mammograms after cancer too - nervous for the subsequent year or 2 then time passes and as each "no change" comes in you relax. Keep asking your questions, but as Casey 59 just said - Celebrate!

An,

I am very happy for you and your husband.  The initial recovery signs seem very positive.

Retire1965

Hi Casey,

Yes, the storm of 99. It was a big one and some of those roofs were in tarps for years as roofing contractors were booked out. I was working late in downtown Sydney that day and I remember it very clearly.

I too worked in the Optus Headquarters on Miller Street not in 1999 but a few years ago. It's a small world! Optus have now moved out to a large technology park in a place called North Ryde, their "campus" is modelled on Google's campus.

An