Choices with a Gleason score 8?

The day before Christmas, my husband was diagnosed with PCa. Leading up to receiving the news, we had already assumed the worst as he was having blood in his urine. We were semi-prepared, as much as one can be. What we didn't expect is how high the Gleason score was to be.

We have spent the last week devouring all the information that we could, from this excellent site, reading Dr. Walsh's book as well as Invasion of the Prostate Snatcher, and many other web sites. Since the urologist gave us the news, my husband has had a bone and a CT scan (results to come 8 January). The urologist is also setting us up with an appointment with a radiation oncologist sometime in the near future.

I am still not totally familiar with the hieroglyphics that are included with signatures of some of the healingwell.com's posters but I have provided what I think is pertinent at this stage.

Although my husband has and continued to have cardiovascular disease, he is in pretty good shape with optimal weight, exercises regularly (including weight lifting) and is very disciplined wrt diet. Although I have read that there might be a link between heart disease and increased risk of PCa, I also have read that there seems to be a protective effect from taking statins, aspirin and having a good diet. By all accounts, he shouldn't have prostate cancer which only goes to show how statistics haven't much to do with the individual.

Given his history and age, we were surprised that the urologist recommended surgery. That doesn't seem to agree with anything that I have read, especially as we still don't know if it is have spread beyond the prostate. I realize that urologists, being surgeons, would have a natural bias towards surgery but he seemed very confident that the cancer was confined. Why he thought this will be one of my first questions when we see him again next week.

So, I am asking those on this forum who might have been in a similar situation and can provide some advice. We are keeping an open mind at this stage on his choices and continue to read as much as we can. However, my husband has a natural bias AGAINST surgery, primarily because it took him forever to recover from his open heart surgery and he doesn't believe that RP will be a walk in the park either.

He and I also agree that our priorities are quality of life. ED is the least of his concerns.

As we live in British Columbia, our health care system is significantly different than the American one, as it is government run. Unfortunately, most of the information that we have researched to date is mostly American (wrt hospitals/specialists) and wondered if there was anyone out there who can give a BC perspective (and specialists' recommendations).

UPDATE January 2014

Uro still suggesting surgery but says that RT/HT will almost certainly be required. He readily admits that radiation onocologists will favour radiation and urologists will favour surgery, with much passionate debate amongst these physicians. Interestingly, he said that, even when diagnosed with PCa, more often than not, the uro will pick surgery and the RO will pick radiation. No wonder it is so difficult for us mortals to decide what treatment to choose.

Pendulum swung slightly back to surgery after seeing the uro because he definitely did a good selling job on us. Sober second thought has the pendulum swinging back towards radiation but we still haven't seen the RO, so don't yet have all the facts on which to make a final decison.

Welcome to HW, sorry you need to be here but it's a great place to get questions answered.

The real question comes down to, is the PC confined in the prostate. That's a tough one to answer but it is possible.

There are three basic tools in the PC fighting kit, surgery, radiation and HT (hormone therapy). With advanced PC it might make sense to hit it with all three. However, I wouldn't do anything until you've talked to a radiation oncologist and received a second opinion.

One advantage of surgery is that they'd get the prostate out a pathologist will get a very good look at it so you'll know much better what is going on. Then if the surgery fails you still have the other two options open. If you do radiation first, surgery is generally not done. The cardio thing is a concern for surgery but given his fitness level, might not be a big concern.

What is a concern is the bleeding. That isn't normally associated with PC.

Hopefully the other G8 and 9 folks will come in with better information.
Hang in there and keep us updated on your progress.
Andrew

Dear French traveller
Welcome to healing well. As most will say, very sorry you had to find us but very happy you did. Prostate cancer is a very personal disease. Education in the various forms of treatment is a must. I concur that there are three primary forms of treatment but you can look at them as the three primary colors. There is another form of treatment that sometimes gets forgotten in the chatter. That would be immunotherapy. It is a real actively new form of treatments that harness the immune system to target prostate cancer cells. Provenge is the first such drug to receive F.D.A. Approval but others are coming such as gleevac and I ipilumab. I apologize if I spell them incorrectly.
You uro is most likely correct in his assumption that the cancer is organ confined. It is possible that the cancer could have spread outside the organ but judging by the number of cores that showed positive and the percentage of cancer in each core, the odds are in his favor. The Gleason 5 is troubling if the number is correct. It indicates the most aggressive of tumors. Surgery could very well be his best option for a total cure. His age does enter into the equation.
I myself had a great deal of blood in my urine. It was he reason for my diagnosis. The blood was not caused by the cance however but rather by a Uralic acid stone in my bladder. The stone formed because my urethra was not allowing my bladder to fully void. The cancer had it 80% blocked.
I would like to have had options at the time of my dx. but alas he cancer had already spread to my lungs and bones. Had I been your husbands age I may not have opted for surgery but I would have liked to have that as an option. Removing the cancer is the only way to her cured. A cure is not always necessary. I have lived 91 months with stage 4 cancer. I am doing much better today then I was when diagnosed. I am on my 4th treatment and there are several more waiting in the wings. I intend on living well into my 70's I just turned 50 last month. At the time of my dx my Psa was over 3200. Today it is 0.29 and my ct and bone scans are clear. My Gleason score of biopsy was 4+3=7 a post op pathology report may have found it to be lower or higher. Sadly I will never know. I wish you and the hubby all he best. Educate yourself and get a second and third opinion. Remember there is hope. I am the proof. Your neighbor to the south in Washington State, todd

Hello from Texas. I was diagnosed with Gleason 8 back in Jan. 2009 at the age of 67. My surgeon suggested surgery and if the follow up PSA was not zero then radiation to follow. I had robotic surgery in Feb, of 2009 and so far after almost 5 years I remain in the zero club. My PSA prior to surgery was 3.87 (low) and only 2 node out of 12 were involved. Surgery is not always the preferred treatment depending on your husband's PSA is and how much cancer was discovered in the biopsy. I suggest that you consult with a radiation Oncologist before you decide. Best of wishes.

Todd , where did you see a percentage of cancer in the 6 out of 10 cores positive. Is it me or Am I missing something. If you meant 6 out of 10 is low and somewhere you see a low %, your conclusion may be correct. I see 6 out of 10 cores as high amount not low. Tho I see no % of cancer mentioned in travelers post the psa and coupled with my definition of high volume.is high and totally agree with Tall Allens assessment. It concerns me when we willy nilly add something not there to bolster a point, that, arguably doesn't have "evidence". I'll tell you what. Read Tall Allens post and read yours. Any merit in my concern here?

That clears that up French-Traveler. Thanks. Tho I did not make a specific suggestion on treatment. I would not do surgery for all the reasons, your husband mentioned. There is something to be said about the patients own insights trumping much. The Prostate Center of Seattle also has a topnotch BT facility. A trip down there for a consult would help with any eligibility questions you may have about BT.

Tall Allen....

Can you tell me any more about the sunnybrook trial. Does the presence of bone mets eliminate you from this treatment?

I have been hearing a bit about SBRT for advanced cases but I can't seem to get a clear understanding or who is a candidate?

Thanks Tall Allen. I thought the bone mets were an issue.

Sorry for hijacking the thread for a bit there

Thanks, Bill, for your encouragement. I have found that there are many on this forum who have an amazing amount of knowledge (including Tall Allen) who are willing to share. I have since been in touch with some PCa folks that live in the Vancouver, BC area and they tell me that the Vancouver Prostate Centre as well as the BC Cancer Agency are world class and we will receive the best of care right here. It really helps to know that we can get the help my husband needs right in our own backyard.

FrenchTraveller

My stats and history are similar to your hubby's:

DOB January 1944 (age 70)
1981: prostatitis
2000-2013 BPH treated with finasteride & tamsulosin; low T treated with androgel
PSA History:
Pre 2009 0.4-.6
11/2011 2.2
8/2012 2.7
2/2103 5.5 Note: all scores were actually double these due to finasteride!
4/2013 6.1
5/2013 6.6
11/1 2013 0.1

6/2013 Bx:PCa Gleason 4+4=8 (Bostwick), 4+5= 9(Johns Hopkins), 2/6 cores, 10%, 40%, DRE neg. (Stage PT1c)
7/2013 bone scan and pelvic MRI negative
9/7/13 open RRP, Johns Hopkins, Ted Schaeffer MD PhD.
9/9/13 Pathology: 33G, both nerves spared, SVI, EPE and 4mm pos. margin at base (Gl7), Stage PT3bN0M0)
9/20/13 Foley and staples removed
Continence: one pad per day for 13 weeks, now none. ED pre and post op.
Watchful waiting until next PSA Feb 1, 2014

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I chose surgery because I wanted RT and HT as a back-up if necessary. Unfortunately, my pathology results point towards recurrence at some point. Your husband may not have local mets, therefore surgery may cure him. But only RP tells you the complete story. I strongly considered most RT before electing RP. Brachy was out due to prior urinary symptoms from BPH. I chose open RP because my surgeon said he could better determine if cancer was near nerves by feeling them so he could decide to spare them or not, which he did. Another Davinci surgeon I talked to said he wouldn't even try to spare the nerves which upset me no end.
Good luck with whatever you all decide!!

Bob

Because my husband's diagnosis only came about because he discovered blood in his urine (he avoided doctors as much as possible), he is scheduled for a cystoscopy test next week. My husband likes to imagine the worse, so he has already decided that he has bladder cancer as well. He never imagined for a moment that his CT/bone scans would be negative so he knows that he can be proven wrong.

Once we know the results from the cystoscopy test, the next key date is meeting the RO for the first time. We hope to be able to make a decision on treatment soon after, as the uro has him tentatively scheduled for RP on 3 February. We already know that, for whatever reason, hubbie suddenly wants to have surgery, he is going for open and not Da Vinci, for pretty much the same reasons as Bob explained above. From what I understand, Da Vinci is not a good option for someone with heart disease and we have confidence in the current uro, who only does open.

Lana, you obviously have travelled the same road and I greatly appreciate your encouragement and sharing your story. We are trying to take care but sleepless nights seem inevitable.

French-Traveller,
Be assured that we will support you whatever route you choose; it can become complicated-lol.
Hummbug,
Don't let the "conservative" approach that your uro took consume you mentally. It was wrong but like you said, "let it go". I wish you all the best!
Bill

Hi all,

I have been reading many of the wonderful posts on this site and find every one informative and heart warming.

Just a little update. My husband had his cystography test last week and everything looked just find, so no bladder cancer. Uro thinks that the blood in the urine is from the prostate, or could have been a burst vein but didn't seemed very concerned.

Today is our big day, our first visit with the RO. Having had several weeks to read, read, read everything there is to read, hubbie has just about decided to go the RT root in conjunction with HT. As many have pointed out, what is the point of going through a surgery when RT/HT is in the cards.

Now it is just a question of getting the details, what, when, how. As you all already know, none of the options are 'pleasant' and hubbie is most concerned with how the HT will affect his mental capacity. I guess time will tell.

Cheers,

Hannah