Doc Not Happy

I agree that another opinion isn't a bad idea and also that PSA testing at 3 months rather than 6 would be a good thing. But other than that I don't agree with your uro's pressure for surgery. In my -- non medical -- opinion, surgery or other treatment may come sooner or later, but based on what you have told us, you have time, maybe lots of time, to wait and then decide what is next.

I was once involved in a major employee rights legal case with backing from a non-profit legal group and a major law firm on my side and a Fortune 100 company on the other side. I learned then that lawyers--at least the lawyers I had then--with all their expensive oriental rugs and harbor-view conference rooms--like to give you your options as they see them and then sit back and wait for your decision. I wish more doctors worked this way.

IMHO, you are in charge, whether you want to be or not. There is always a doctor or lawyer on the other side of the argument. You need to make them substantiate their recommendations with something -- their personal experience over x cases, published studies they care to cite, something new and promising they have discovered that no one else yet believes or trusts -- whatever. But then you have to take charge and decide. I wish there were black and white answers or nice logarithmic tables against which we could plot our measurements, but in my experience it has never been that simple -- and PCa is just one example among many of the messiness of navigating our way through life.

If I were in your position I'd stay with AS, at least for a while. But I could be dead wrong. And so could you or your doctors. Best of luck whatever you decide to do.

Jim

Squirm-

Low Risk is currently defined by NCCN as PSA <10 and Gleason Score≤6 and Stage T1-T2a. They recommend AS as an option for all such men unless the life expectancy is less than 10 years, in which case they recommend watchful waiting/observation.

- Allen

GeetarMan,

I didn't know the size of your gland. Glad to hear it's small. Mine was three times that size. You ought to be in good shape.

Hello
I didn't read all the posts in this thread but... If you can do AS/WW safely then by all means do it. I wish I had the choice. None of the invasive treatment options are treatment, they are a compromises. Just be careful that you don't wait too long.

I hope that you have a long healthy life of AS/WW with no further progression

Pat

PeterDisAbelard. said...
I came across this again while I was looking for something else.

Can Single Positive Core Prostate Cancer at biopsy be Considered a Low-Risk Disease after Radical Prostatectomy?

If I understand the paper (and that is very much an open question) it suggests that low-volume single-core diagnoses are so often wrong, especially for men with large prostates and/or high PSA scores, that they should not be relied on for AS qualifications, or at least should be used with special care.

This kind of study resonates with me because my biopsy report, based on a single, low-volume core, was wrong in every respect.

Just something to think about.

I faintly remember reading in Quest where Catalona stated:
"In anywhere from 15 to 30 per cent of the patients, when you remove the prostate, you find out it was a lot worse than you thought," Dr. Catalona said in a telephone interview from Chicago.

http://www.drcatalona.com/quest/quest_spring09_6.htm

Squirm,
Low risk is defined as psa less then 10, psa density < 1.5, no more than 30% positive cores, no core greater than 50%, G6 or less.

Squirm-

PSA doubling time is not a very reliable indicator for initial risk stratification because it is affected by so many other things. I've seen one study that demonstrated it is not very useful for AS. Where PSADT becomes valuable is after a recurrence following surgical or radiation or hormone therapy failure.

The one derived measure of PSA that is used in risk stratification is "PSA density" which is PSA/prostate size. If it is .15 or less and there are only one or two positive cores and less than 50% involvement in any core and the other conditions of low risk are met, then it is considered to be "very low risk" cancer. According to NCCN, the only difference in treatments for "low risk" vs "very low risk" is that, for very low risk, if life expectancy is 10-20 yrs, AS is the only recommended option, whereas if life expectancy is >20 yrs, AS is one of several recommended options.

I've never seen anything about PCA3's usefulness in AS. It is approved for helping to decide if a second biopsy is warranted after a negative biopsy. I'm not sure how it might be useful once one already knows that cancer is present.

- Allen

Geetar, We have similar stats but I am a little younger and had 1 core 23%.  I wasn't planning on AS but wanted to do as much research as possible and get a few Dr.'s opinions.  Two years has passed and I have taken two more biopsies and MRI's expecting to see some progression.  Fortunately these additional test hasn't  identified any more cancer.  Two oncologists at Memorial Sloan Kettering agreed AS is a good choice.  I am ready to be treated when the time is right and there is evidence of progression.  There is no guarantees, but we can get hit by a car tomorrow.  Quality of life is important to me.  

I was told I was low risk initially, but post surgery (using NCCN guidelines), I turned out to be Intermediate Risk because of the tumor staging.  It's hard to fit into any one of these perfectly. 

http://www.nccn.org/patients/guidelines/prostate/files/assets/basic-html/page43.html

 

Squirm said...
I faintly remember reading in Quest where Catalona stated:
"In anywhere from 15 to 30 per cent of the patients, when you remove the prostate, you find out it was a lot worse than you thought," Dr. Catalona said in a telephone interview from Chicago.

The article goes on to quote some suspiciously low rates of impotence and incontinence for Dr. C's patients but his statement about 15 to 30 percent upgrading is fairly well supported by independent research. What the Brazilian paper I linked to states is that a disproportionate number of those under-diagnoses occur in men with large prostates who are diagnosed with a single low-postitive-volume core in their biopsy. My take is that if you don't find much cancer in your sample it is perhaps unwise to rely on the tiny bit of tumor you get to examine for an assessment of aggressiveness. It could be (usually is) that not much was sampled because there's not much there. But it can also be true that you mostly missed the tumor and the small amount of tissue recovered by nicking the edge of the tumor may not be enough to accurately characterize it.

It seems to make common sense (at least to me) that missing PCa in a large prostate is easier than with a normal sized prostate...simple math. However there are various additional tests, e.g. CDU, that can significantly assist in the identification of the cancer.

Jim

JT, Tud, Ms Bird,

My comment was made in the context of a thread started by GeetarMan whose urologist doesn't seem to be much into AS. If GeetarMan wants to do AS he should find a facility where they do lots of AS and are good at it. The fact that GeetarMan has a single low-volume core on which his dx is based sounds like it should be reassuring but, in point of fact, it slightly increases his risk, compared to a man with a higher percentage of the core involved, or a second core. He needs to be sure he finds a doctor who can, as you said, John, mitigate that risk. I'm just suggesting that he be sure to keep the "A" in his AS.

One solution to the "finding a needle in a haystack" problem with enlarged prostates is to take Avodart/Proscar to shrink it. Sometimes it has the opposite effect, rendering the cancer undetectable. This may be because it has shrunk the cancer as well, which would be a good thing. It also resets PSA to a new baseline level that is more sensitive to cancer progression because it reduces the PSA effect of BPH.

- Allen