consultation and still questions

Good morning all,

We did have our followup with the urologist who did the biopsy. Can't say that we learned much new. Apparently our request to have the slides read by a different pathologist was never processed, so we didn't have new information to go on.

I did ask about the prostate size in cc's, and was told 21. Guess that's good. I forgot to mention earlier that the DREs have all been normal. The doctor said Carter's 6.7 PSA was still considered to be low, but didn't discuss the rate of rise (velocity?) over the past couple of years.

He had no answer as to why only six cores were biopsied other than to say there is controversy regarding the appropriate number, and the size of prostate comes into play in the decision. He said the high grade PIN was just there because of the tumor, but when I pointed out that the PIN was found on the OTHER side, he just nodded. He did say that the presence of the PIN should not be a factor in the treatment choice.

He said there is no evidence of perineural invasion (how can he tell?), and that the 20% figure of malignancy found in the biopsied material means that the tumor is small. He said we don't need to worry about taking as long as three months to begin treatment.

It looks like our choice will be between robotic surgery and radiation. Carter is leaning toward radiation at this point. The doctor said it would be equally good, but when I did the Partin tables, I came up with a 78% progression-free probability for brachytherapy in five years, versus a 93% probability with surgery. I can't remember now whether that computation was based on BT alone, or a combination of BT and external beam. This urologist didn't seem convinced that a combo was better, but considering the fact of the Gleason of 7, that is probably the only way to go.

So...much to consider. We will go with the suggestion to see a radiologist and let HIM decide if Carter is a good candidate for radiation, and if there is a doubt we'll start looking into the surgery. We are less enthusiastic about surgery than most because we know surgery can come with unexpected consequences and complications. It has happened to me, and has had far reaching effects on my health and quality of life.

I have to say, though, that the numerous accounts on here of post-path reports containing more diseased tissue than predicted really worry me. I have so many concerns about either approach.

Didn't mean to write a book! I'll keep you posted, and will continue to follow your stories and wish you each much luck!

Juliet

A 21cc prostate is small and may have something to do with how many biopsy needles can be aimed into it. The shape of the gland is also relevant as the biopsy can only aim from one direction.
There are also all sorts of places round the prostate that the uro does not want "stab" with the biopsy needle.

Good to hear that you have a uro who has told you that you have time to think about what to do next/first

Perineural Invasion (PNI) refers to the growth of a tumor along the nerve (perineural) branches of the prostate gland. This path may act as a highway, allowing the tumor to escape outside the confines of the prostatic capsule. If it has not been detected then it suggest that there were some bits of nerve tissue in the biopsy sample that were clean, but it may also be one of those things that goes down on a report as a "zero" simply because it was not tested for. The rule here as with all this aspects of PCa is that if you are in any doubt about what he meant ask him to clarify things.

(As a comparison I believe lots of us get an MX on our staging rather than an MO. MO means mets were tested for and not detected, MX means they were not tested for.)

Alf

Juliet, you can still get the slides read by expert pathologists who deal with PCA everyday,but may have to go around your Uro to do so. What was the gleason score on original biopsy this has a lot to do with treatment. You seem very knowledgeable and proactive on this, continue this thruout. I hope, believe and trust the out come. This is NOT a death sentence!!

Juliet, Good Morning!

22cc prostate? There was only room for 6 needles! Mine was 72cc..

While the information derived from the Pardin tables has been proven to be very accurate, the published tables are derived from studies that are 10 years or more old..While surgeries percentages results have improved slowly over the years because of earlier detection and improved surgical techniques, the improvement in the results achieved by radiation MAY be even more spectacular as this field has seen tremendous advancements in recent years..Right now, today, radiation equipment is being upgraded as fast as treatment centers can afford to do so. If you should choose radiation as your primary treatment, the skill level of the Radiation Oncologist and the equipment he will use is more important than ever if you are to take advantage of these advancements..

Also, don't forget to investigate COST..Radiation treatment is much more expensive than surgery and some insurance companies impose heavy co-pays, so check THAT out too..The surgeons and R-docs will fight for your business (this is a multi-billion dollar industry) tooth and nail, so get ready for some heavy salesmanship..

Hi Juliet,

I agree that your situation can be frustrating and confusing.

The one thought I would leave you with is that you are not in a fire drill situation.  You have the opportunity to truly understand the various options and talk to experts.  You can also speak personally and via forum with patients who have undergone all forms of treatment.  Dont limit you options up front either (I had an open RP)

The one step I would encourage is to set a date at which you would like to make a decision as to your short term and long term treatment options.  Depending on your comfort level that could be 1 month from now or 12 months from now (or perhaps longer?)

The paradox with pca is that it is usually slow growing but sometimes fast growing.  There is not definitive way to tell the difference (although there are many tools to build probability estimates).  Therefore, you really have to first assess how much you like/dislike risk.

That will just tell you how quickly you have to go through the process.

All my best

Retire

Juliet, remember this little request:

"Could you please get pre-approval from my insurance company so we know beforehand how much our out of pocket expense will be?" Thank You..

Juliet........Listen well to JohnT's posts! They were the most helpful to me when my husband had a elevated psa. He's not emotional like the women posting here lol!!!It was very calming to read his ideas.He seems to be very knowledgeable about tests,scans & treatments. My husbands situation turned out fine [no PCa],John's voice was very reassuring. Just my thoughts!!! Cooper