it may be time to end AS for me

Yeah, that's a tough call for sure. I can arguments on both sides of that one.

The only thing that would push me towards surgery now is the PSA rate of change - the curve seems to be getting steeper. It's that doubling time that would worry me. Don't think you can ever guess that perfect window. You've had a good three year run.

Surgery is a good option and you'd likely do just fine after.

With all the support you've got there, might be time to pull the surgery trigger.
Andrew

DanO, you obviously have a tough call to make. From your posted stats, the last PSA test was in August...did you consider getting a PSA test now to see if the August reading was an outlier? Also, if I might ask, why are you rejecting all types of radiation -- it would seem that your case is ready made for one of the types of brachytherapy.

Good luck,

Jim

Jim, I am not rejecting radiation outright, only as primary treatment. My doc's office provides both so he would benefit financially from either therapy. However, he indicated a higher level of recurrence after 10+ years compared to the primary surgical option. Also, I have seen some of the damage from radiation therapy that gives me pause. I know that would likely not be the case with me, but I am just uncomfortable with that mode of treatment.
I did consult a rad/onc 3 years ago, and he suggested IMRT instead of brachy, but also said that surgery was probably a better option due to my age/life expectancy.

tooyoung, yes, my doc offered the genetic test you mention, but cautioned that it is not without ambiguity. The option is on the table. I do wonder about the cost? My insurance would probably not cover that.

be well..

Hi Dan... you made it three years on AS... that is great! To continue AS is certainly an option. But what would be your tripping point? To me, that is one of the dilemmas of AS... picking a trigger. If a trigger is not picked, then you are continually in eval mode after every PSA, biopsy, DRE, etc. and it can be easy to talk ones self out of treatment.

Sounds like you are clearly thinking through things and have a wonderful and supporting family and friends network.

Best of luck on whatever you decide!

Dear Dano,

Since you are man who is only 50 years old, continuance of AS with a Gleason 3+4=7 is not appropriate.

It may be a nuiance between the 3+3=6 and 3+4=7 score. You can have a gene test if you so wish. As a senior I had one, and I did not have to pay; this may be applicable to you as well, I really don't know.

I strongly suggest that you have a T-3 MRI to confirm that there is no extracapsular extension .

Also as a benchmark and for the future consider a bone density test(DEXA), a testosterone test and an ECG

Mikla said...
Hi Dan... you made it three years on AS... that is great! To continue AS is certainly an option. But what would be your tripping point? To me, that is one of the dilemmas of AS... picking a trigger. If a trigger is not picked, then you are continually in eval mode after every PSA, biopsy, DRE, etc. and it can be easy to talk ones self out of treatment.

Sounds like you are clearly thinking through things and have a wonderful and supporting family and friends network.

Best of luck on whatever you decide!

You make an excellent point, thanks Mikla. I do find myself wanting to push reset.

be well..

Uh…definitely not such an "easy" decision, zampilot.   This is undoubtedly why Dan0 has written, “it may be time to end AS.”   3+4 cases (the low-end of intermediate-risk) are the true “ grey area ” of when immediate aggressive treatment may or may not be needed.   The Gleason score alone is not the sole indicator.   There are other case characteristics which AS protocols may consider, too.   When all case characteristics are considered together, AS protocols are increasingly supportive of a subset of favorable-risk 3+4 patients staying in the program.   There is not a one-size fits all solution for all AS patients, and this should be apparent from what Dan0 has reported from his discussions with his physicians.   For the sake of possible future readers of this thread, it is appropriate that this point be clarified…not as Dr Casey’s position (hahaha), but the broader perspective of what is common in Active Surveillance care protocols.   There is much to consider and weigh…

zampilot said...
... but it wasn't for me, and I wasn't concerned about what someone's study claimed.. Get rid of the PCa or it will kill you.

That's fine. 

Nobody is going to tell anyone else what to do (at least I'm not going to).  It is helpful for some men to gather facts and make an evidence-based decision; others have made it clear that they want to make, or have made, a decision based on other critiera.  It's all good.

Reusing one of my teenage daughter's favorite sayings, "You do you."

But you are absolutely incorrect about there (not) being a range of intermediate risk cases.  The amount of Gleason pattern 4 has been shown in multiple studies (apparently you don't pay attention to those) to have a significant bearing on the seriousness and long-term outcomes of PC cases, and is the key basis for considerations of splitting "intermediate-risk" cases into a more- and less-favorable spectrum.

Mikla said...
For me, I keep falling back on the NCCN Physician Guidelines as it is the collective input from 23 of the most respected cancer centers.

I would do the same.

They are excellent guidelines.  And I've seen with my own eyes how doctors treating cancer cases at one of our nation's top Comprehensive Cancer Centers use the NCCN Guidelines as guidelines....I'll share my experience...

My wife had cancer.  Over the span of her treatment, she saw many doctors.  Her primary oncologist literally carried the physician's version of the NCCN Guidelines around in his lab coat pocket.  (In her case, it was the Kidney Cancer NCCN Guidelines.)  During several of her office visits, he pulled out the Guideline and showed it to us, and said, "this is what the Guideline says."  Often we followed the Guideline's recommendation, but it could not possibly address all of the case characteristics of all cases.  In some situations, we discussed the Guideline, and discussed why it may be appropriate to depart from the Guideline.  As her doctor pointed out (paraphrasing), "it's a guideline, not a rule."

The more- and less-favorable "intermediate risk" cases are an excellent example of how this applies to the NCCN's PC Guidelines.  As you pointed out, all three (AS, surgery, radiation) are recommended options for intermediate risk cases, but in practical application AS is less recommended for the less-favorable 4+3 cases (in fact, I cannot think of instances when AS would be recommended for 4+3 cases; WW yes, but AS no), and more recommended for the 3+4 cases, while the other individual case criteria must (should) also be considered.

Note, Mikla, that PROS-3 says "Gleason 7", not 3+4 or 4+3.   You were "somewhat correct"... 

But I agree with your general point, Mikla, that in the absence of addtional considerations, one would do well to follow the Guideline.

Post Edited (Casey59) : 11/22/2013 12:28:54 PM (GMT-7)

When I was first diagnosed I was all about AS, figuring no reason not to get 5-10 more good years before dealing with all the potential SEs. But my WIFE was frantic, and my doctors were not supportive. Turned out they were right, I think. But it's a tough call. So hard to be sure.
Good luck!
Mikey