when to stop active surveillance

My uneducated advice would be to find another urologist immediately, if not sooner. You've had a doubling of the PSA reading over the past couple years and that would probably end the idea of AS with most good uros.

Gleason 6 is low risk prostate cancer. Gleason 7 goes up the scale a bit to moderate risk. While it is hopefully curable through surgery or radiation, it is nothing to waste any more time on with continued watching.

Another thing to consider -- in an appreciable percentage of cases (about 28%), the aggressiveness and extent of PC turns out to be HIGHER than estimated by the biopsy. This is a statistic based on the post-op pathologies of prostates removed during surgery.

Even with a Gleason 6 biopsy report, it's still somewhat of a roll of the dice that it is NOT a higher Gleason grade than indicated.

So I would definitely see another uro for another opinion -- preferably a highly experienced (perhaps even an older) person because your current uro sounds a bit nutty to me.

Good luck to you!
Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
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.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, PSA <0.1. PSA tests now annual.
Semi-firm erections now happening 14 months post-op & VERY slowly getting a bit stronger.

None of us can replace the advice you get from a professional. I've seen the most educated proponents of AS on this board state that a G7 would typically disqualify one from AS. I've seen Dr. Scardino state the same in a paper in which he was recommending AS for G6.

A second and third opinion can't hurt you.

Good luck. Sounds very curable.

My uneducated advice would be to find another urologist immediately, if not sooner.

^^^^^^^

if you are a G7 with a PSA of 4.7 I would definitely do the above.

ed

 

I would find another doctor asap. Gleason 7's can be tricky fellows to deal with, and I would not be comfortable telling someone to stay on AS with any verified Gleason 7's in you.

Get another opinion at the least. I am all for AS when the criteria is correct and safe.

Good luck as you sort this out.

david in sc

Jert,

I was on AS with a PSA of 4.3 and one of 12 samples at G6. This was considered to be 'insignificant'.

Roughly 2 years later, my PSA was 6.1 with 15 G6 samples and 1 G7 sample out of 60. This was now considered to be 'significant' and in need of treatment.

Not sure if that helps, but somewhere in there, I crossed a line in the mind of my oncologist.

Thanks for the imput from everyone. I purposely did not mention that my urologist is the one I was sent to for a second opinion, and who is the guru of active surveillance at UCLA. I am "only" 65, 62 when diagnosed, but I am obviously getting more nervous than I was when first diagnosed.

A G3+4 is not as aggressive as a G4+3 as the primary cells, the first #, are more aggressive.

The NCCN clinical guidelines for prostate cancer 2010 recomend AS for those with a 10 year or less survival.(Edit: with a Gleason 3+4=7)

In the April 2013 US Too prostate cancer hotsheetthere is an article on Page 5 "Clues found to Prostate Cancer Upgrading which states "eligibility for AS required a biopsy Gleason(GS) less than or equal to 6 and a PSA level equal or less than 10 ng/ml. For men older than 70, the criteria consisted of a GS equal or less than 3+4 and a PSA level equal or less than 15. Men had a repeat PSA every 3 months for 2 years and then every 6 months thereafter. Scheduled follow-up biopsies occurred after 1 year and then every 3 years until age 80."

That said,
Also as a patient of this doctor who I highly respect, it seems to me the fused biopsy capability and significanty increased ability to detect cancers is more advanced than what is generally currently available, so it "may" be possible to monitor at a more aggressive levels of cancer.

Since the PSA is an indicator, the biopsy is the main piece of information

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Post Edited (hopeful and optimistic) : 5/2/2013 8:08:47 AM (GMT-6)

Dec 2012 Interview with Dr. Klotz http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=799211&sk=&date=&pageid=7

Tall Allen, I have been reading your comments about sbrt at the cyberknife patient forum with great interest...............Thank you

Avodart
I’ve done a lot of research on whether or not to take this drug.
When I was first diagnosed four years ago, I saw a prominent surgeon at UCLA who recommended AS
for me. He managed my case for a year. I brought this drug  to his attention. At that the time the only
study was among men who were not diagnosed. He told me he did not think the drug would be effective
since I already was diagnosed.
During the next four years I questioned several doctors who specialize. As you would guess the opinions
were mixed (they tended to favor not taking the drug).
Lately new information has been published the Redeem study and the John Hopkins study with differing
viewpoints.
I spoke with my now AS doctor, who tends to favor taking the drug. His thought was that since Avodart
shrinks the prostate in size it would be appropriate to prescribe in that case. My prostate is small, so no
drug…..I imagine that if I asked to be put on the drug he would have complied. (To be honest I like to
take less, not more drugs).
……………………………
The protocol for the AS program where I am being treated is initial biopsy, biopsy after one year, (those
two were negative), then another one after two years…my next one will be in June 2013, 6 weeks from
now. Generally I go on with my life, working on being positive, and I have succeeded, however I am
always apprehensive before any test, especially the biopsy. During the last two years my PSA rose
somewhat, not at a great rate, but significant….I evaluated the doubling time at the Sloan Kettering site.
My doctor is not very concerned, he focuses on the biopsy. I also spoke with a very experienced doctor
about this who also was not concerned, he said that quick increased happens from time to time. (To
be honest I am now slightly apprehensive.) At any rate I will have the biopsy very
soon that will tell the story...I hope for the best).
……………………
During the last four years I’ve had time to research possible treatment opinions if necessary. Right now I
am interested in having SBRT, a different treatment than what my first choice had been, surgery. I’ve
done some research, not as much as you by a long shot. One of my friends was diagnosed about six to
eight months ago. I was his advocate, and visited several doctors with him. With him, I met Dr. K. a few
times, the doctor who did your SBRT. My friend elected to have his SBRT with him. So far he is doing
well, his PSA dropped three months after treatment; his next PSA is scheduled for June.
I have upmost respect for Dr. K. however, I wonder about Novalis versus Cyberknife. I have family in the
New York area and am able to see Dr. Katz. I wonder Allen, if offline you can give me an opinion of
which way to go, if I am faced with a decision between the two best doctors of SBRT.

A gleason 3+4 is not as aggressive as quincy17 says. But any time you have a 4 or above in the mix, it may not take long for the 4 cells to over run the 3 cells. The "latest" protocol" seems to be to treat or consider treatment based on the highest grade. I , myself, believe in that protocol. The placement of the tumor, in my view, does indeed play a prognostic role also though. I wouldn't be worried, but I would not be doing AS anymore either. I would not take that risk, because the only person that has nothing to lose is the uro, and a possible gain in reputation, stature if , he is right. You on the other hand, have something to gain if he is right ,but unlike him have something to lose if he is wrong. You do not need to be a guinea pig, unless you choose so, much like the 1st few patients of the Da vinci surgeon, etc.

hopeful, I agree with one of your points. biopsies (unless they are saturation type) are so random. it took 3 of them to find my cancer, and when it was found, there was a lot of it. my uro at the time said that the typical 7-12 core variety are like sticking needles into a loaf of raisin bread, just because the needle doesn't find a raisin, doesn't mean it's not raisin bread.

I often wonder, if I had had a saturation type on my first pass, it would have found my cancer more than a year sooner, and perhaps I would have been in better straights than I currently am. Especially since my PSA record was showing such rapid acceleration, having gone from 4.x to 16.x in a little over a year.

david