Confused about biopsy - Input needed

Hi all,

My initial posts here were made last September after my diagnosis and I've been trying to decide what to do.

I'm 53, diagnosed with with PSA 2.0, up from 1.2 a year earlier. Gleason 6, initially told 2 of 12 cores positive, one 15%, one 5%. I got a second opinion from a top urologist / surgeon at one of the better centers in the country. He requested a second read of my original biopsy as part of the consultation. The second read of the biopsy slides also came back at Gleason 6, but with only 1 positive core at less than 5% cancer. 3 cores were "atypical glands".

I'm scheduled for surgery next week, but am now wondering if I should cancel and consider another biopsy before I jump to treatment. I read somewhere that up to 30% of post-surgery pathology specimens actually show no cancer ! Is this true ? My head is spinning right now. Don't know what to do.

Any help / thoughts would be appreciated.

To Almostretired,

I believe that your doctor knows what is best for you. The only thing you should worry about is to do everything to cast the monster off your body. You must also take serious medical info on how to face the after surgery effects.

Keep on fighting !!!!!!!!!!!!!!!!!

 

Dear Almost:

Of course you need to do what you are comfortable with...it's your body.  But, since you asked, I agree with GOP.  Surgery at this point with your stats also seems to me to be a "severe rush to judgement".  It's certainly not something I would do given what you have told us.

At the very least you should talk with a urologist who is experienced with the AS protocols to see if that might be a good option for you.  And, certainly, you should speak with a brachytherapist about that less invasive option. 

Finally, please take your time and do your homework.  PCa is generally slow growing and if you are having second thoughts then don't rush into anything that you may regret.

Good luck,

Jim

Hello again Almost; if I recall your posts from late last year, DRE showed a small nodule and also you have a family history of PCa with your father?  Those factors should also weigh in on your decision at this point in your journey.

I still believe you are a candidate for AS, heavy on the "Active" part.  Along with that you would of course be doing biopsies on a regular basis - and I would suggest that the next one is a saturation or "Stereotactic Transperineal Prostate Biopsy (STPB) - here's a link that explains it pretty well:  http://www.prostateimplant.com/STPB-stereotactic-biopsy.html

 

At this point I believe you have time to make a decision that you will be comfortable with - and with surgery scheduled in a week that you clearly don't seem good with, I would slow down and collect yourself.  There's no turning back once you've had your treatment, so again unless you are fully confident about this choice I would re-trench. . .

 

My best to you in your journey.

 

Doubts before a procedure chosen is normal, but perhaps not to your degree of doubt.  Pause may/may not be in order.  If you feel a strong need to pause (not permanently postpone) a treatment, now is the time.  There are no do-over’s.  However, some will question all their decisions no matter what, only you can decide that.  Are you running too fast with this? possibly/possibly not.  Is there a family history of prostate cancer?  Do you have good/poor health?  Are you capable of making drastic and sustainable diet/lifestyle changes?  Are you emotionally/mentally prepared to consider Active Surveillance, was it even offered?  Are you questioning surgery, or are you questioning treatment method chosen/prescribed?  Either way, you can come to terms with your choices, or change them.

A second opinion on how you should pursue may be in order.

We are about the same age and your biopsy results are somewhat less significant than I had. I elected surgery and would do the same again, though for different reasons. If you can spend enough time to be more confident in your decision, do so. In retrospect, I let circumstances accelerate my decision and I've done much more learning after my decision than I did before.

I went in to the biopsy a bit nervous, but not anticipating anything bad. Out of the 12 samples taken, 2 or 3 were the worst pain I've felt. Then 2 days later I ended up in the hospital with a serious post procedure infection. I was miserable enough that when the biopsy results came back positive I knew any treatment I elected would NOT include another biopsy.

My surgery and continence recovery were better than typical, according to my surgeon and some of what I've read here. ED recovery is slow and behind the curve. Per my signature, PSA tests look good.

Bottom line - I got the cancer OUT. A few friends are in the grips of various later stage cancers, so I'm counting my blessings that I could take definitive action early. Second thoughts about having been over treated are not going to find fertile ground here.

Explorer

It seems like you are a perfect candidate for AS. Please read "Invasion of the Prostate Snatchers" by Dr Mark Scholz for a good reference on "low risk prostate cancer". You have years to make a treatment decision and it's not worth the possible bad outcomes that a quick decision may incurr. Take your time and investigate all of your options before deciding.
Things to know about your status:
- G6 cancers rarely matastize and are almost 100% local at DX.
-The death rate of untreated G6 cancers is 5% in 20 years.
- 70% of those entering an AS program show no signs of progression of their cancer.
- Delayed treatment has the exact same results as immediate treatment.
JohnT
JT

As you already know, there are no guarantees with anything - any of the treatments approaches, and well, anything. HOWEVER there are still facts, studies, your own PCa stats and so on that I would encourage you to use with respect to the direction you decide to take. There ARE differences in the outcomes of these choices - and certainly with AS thrown in there.

Trust me, I'm with you, incredibly similar personal stuff - I'm 5'11" 195# and carry it well due to the cardio, weight lifting, smart eating and in general staying unbelievably physically active - and the LAST thing I wanted to do was potentially give all (or some) of that up! Way back when I remember trying to "wish myself" into being a candidate for AS - but went after all of the details and realized that would be a mistake - so then I decided on the treatment I did because of all of the above. In your case I really believe you're a candidate for ACTIVE Surveillance. At the very least, it sure doesn't sound like you're ready or committed to surgery - you can always hit the "cancel the appointment" button and collect yourself. . . .

It's tough brother and I (we) all feel what you're going through. The best we can do to help you is to continue to offer our own experiences and information to help put you in the right place - then it's your call - but again remember there are no "do-overs" once you commit to a treatment.

AlmostRetired,

From what you have told us you are a good candidate for active surveillance. It is a serious, sensible, grown-up way of deferring the decision about treatment selection and timing until you have more information. If your head is spinning then you could do AS for a year or so to see which way your head is pointing when the spinning stops.

Bear in mind that AS does not mean stepping away from the problem. It is an alternate method of engaging it. You would be committing to frequent testing, occasional biopsies, and a small but non-zero possibility that you and your doctors will find something that requires immediate action and makes you wish you had pulled the trigger sooner. You would be balancing that against years -- possibly many years -- of freedom from the side effects of aggressive treatment. Some treatments have fewer side effects than others but they all involve risks of side effects that are worse than the minor risks and annoyances of an annual biopsy.

Almostretired said...
Another thing....I've read that Gleason 6 cancers generally do not matastasize, but isn't it also true that they really do not know if it is a true G6 until the take it out and do a post-op pathology ? So I could actually be 3+4 or even 4+3. The uro told me he was "reasonably sure" he hit the nodule during the biopsy, but another uro told me it was possible the needle just glanced the edge of the nodule and missed some of the cancer.

Bottom line is, there really is NO decision I can make at this point that will give me peace of mind. There are just too many unknowns. Part of me says "get the darn thing out and get it over with", and another part of me is saying "wait and have another biopsy". But if I wait, what then ? I feel at age 53, I will have to do SOMETHING eventually. And how can I live with this indefinitely, knowing I have cancer ?

I guess I'm just venting at this point. ;-) Once again thanks for all the good advice and kind thoughts.

Hi Almostretired,

You are in kind of a twilight zone with your particular situation -- although there are many PC patients who would love to be in this kind of spot.

You definitely seem to have a low grade, low risk early stage case of PC. If the biopsy results are a true reflection of the actual situation within your prostate, AS would certainly not hurt. In any case, there would seem to be NO need to rush into any final decisions.

But then we enter Rod Serling territory in that you DO have a family history of PC, including your father's own G6 that was sneaking up toward the bladder neck. This shows you that even a G6 needs to be closely checked and often treated.

I also had a family history of PC and had always promised myself that if (when) it finally knocked on my own door, I would not fool around with it and immediately have the gland removed. This promise was made by a guy who used to consider having my teeth cleaned to be a major surgery.

My case is different from yours, however, in that I had a case of BPH that made the prostate almost 4x normal size -- with the associated urination problems.

In any case, I knew that treatment was needed because I did not trust my family history. And the decision to remove the prostate was easy because it did the trick by also restoring my urination function back to teenage levels.

What kind of surgery are you scheduled for -- DaVinci?

Chuck

July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate. Right
posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Catheter out in 7 days. No incontinence, occasional minor dripping.
First post-op exam 2/13/12, PSA <0.1.
Semi-erections now happening 14 months post-op.

If I thought I could go thru this and not be wearing pads in a few months and could have good sex again, I would go ahead with the surgery.
If I thought that I could have gone thru surgery and not have continence and ED issues, I may have done it too, but my research told me that was unlikely.