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Posted 11/14/2015 2:01 AM (GMT 0)
Hello everyone,

My 59 year old dad was just diagnosed with prostate cancer.

Pathology : Adenocarcinoma Gleason 3+3 in 1 of 12 biopsy samples. Positive biopsy sample was 18 mm long and only 2.5 mm contained adenocarcinoma Gleason 3+3 cells.

PSA: 2.4

He was being worked up for BPH and the transrectal ultrasound showed a little nodular area so biopsy was performed.

Anyways now I'm lost. His urologist said this is extremely mild and no treatment is needed at this time. He does not want to over treat. As only 1 of 12 biopsies was positive for the lowest grade cancer. Also the PSA is low. He recommended surveillance for now because my dad is otherwise healthy and quite active and side affects of prostate surgery can affect lifestyle. He recommended follow up in 6 months. My dad eats well and works out regularly. This is so crushing to him.

I'm thinking about sending the biopsy to a pathologist that specializes in prostate disease. Also I want him to get a second opinion from another urologist as well as a radiation oncologist.

Is there any targeted therapy such as localized cryoablation that would be considered in this case?

Please let me know your thoughts. Thank you in advance.

Post Edited (Novembeard) : 11/13/2015 7:22:08 PM (GMT-7)

Posted 11/14/2015 2:20 AM (GMT 0)
Novembeard, with 1/12 positive cores at G6, that's about as low grade as it gets. Certainly you can send the slides of for a second opinion (or your Dad can, you can't) to Epstein at Johns Hopkins or Bostwick Labs.

Active Surveillance is certainly a viable option based on his numbers. There are many threads in here that discuss AS, and others will bail in with more comments. Here's the important question: how does your dad feel about it? What is HIS position?
Posted 11/14/2015 2:22 AM (GMT 0)
I agree with your Uro. G6 is pretty much the minimum grade of a slow growing cancer. His PSA, at his age, is pretty much normal, and only about 15% of that core is positive. While I'm no medical professional, he seems like an ideal 'Active Surveillance' candidate for the time being. Please, while you're understandably worried, don't make the rush to overtreat. A G6, with only one core positive, only 15% of core, and a normal PSA isn't any where near an emergency. Take your time.

My 2nd biopsy was a G6 also, but in 2 cores on each side, low involvement like your dad's, and my top Hopkins doc told me that I'm a '1' on a 5 scale as an immediate threat. In fact, I would've been on Active Surveillance if not for my bilateral issue, which made me ineligible for the program at Johns Hopkins.

2nd opinion....Are you looking at having him go through a second biopsy? NOOOO!!!! If you want to have his results checked elsewhere, inquire about sending his slides for a second opinion at either Hopkins with Dr. Epstein, or Bostwick Labs.

IMO, a radiation oncologist isn't even in the game at this point. Relax, breathe easy, and know your dad is FINE!

PS. Where are you located?
Posted 11/14/2015 2:45 AM (GMT 0)
Located in SF Bay area. Close to Stanford. In fact his urologist trained at stanford in the mid 90s and most of the docs in the medical group he goes to are Stanford trained. So I know they are on their A game.

What about the follow up recommendation of 6 months? Sounds like a long time. I was hoping more like 3 months. Also at followup should we expect a repeat biopsy? What about the saturating biopsy I've heard other men having, like 40 or 50 biopsies rather than the standard 12?
Posted 11/14/2015 3:04 AM (GMT 0)
Novembeard, there are two sticky threads at the top of the first forum page. A lot of your questions are answered there. Prostate cancer is slow growing, and so it is unlike most other cancers. 6 months is the normal Active Surveillance time frame, and sometimes they do another biopsy then, and sometimes they don't. Each institution has it's own AS protocol.

I presented with 3/12 positive cores, and my Uro told me "you have six months to decide what course to take"--and my family history has PC and prostate disease all through it. He'll be fine. You need to slow down and take a few deep breaths.
Posted 11/14/2015 3:19 AM (GMT 0)
After getting the slide read by pca expert. tho as you say Stanford is no slouch, listen to your doc... hook up with AS expert and do that . 6mos is fine , if you want 3 mos Im sure you will be accomodated. Your fear and anxiety is totally based on lack of knowledge. If you knew how minor a case your dad "appears "to have you would be whistling with joy, not shaken with fear. The " appears" will disappear with a confirmation from your experts. On a AS treatment plan it should stay that way for a good 10-15 years, anecdotally and maybe for ever. Don;t do any thing radical. Your dad is is an excellent place. Stanford, U of SFO Make sure your Dad read these posts. Has your dad exhibited traits of crushdom as you say. If so tell him he should,t be. The worst part of this for folks like your dad diagnosed with indolent cancer is fear, certainly not the the smidgin of cancer that probably win;t going anywhere. fwiw
Posted 11/14/2015 3:22 AM (GMT 0)
Anyone on these forums done AS for several years? Seems like everyone here gets treated....
Posted 11/14/2015 3:28 AM (GMT 0)
In 6 months the Uro will give him another DRE and another PSA. Don't expect another biopsy then, or you would've been told that. It would make no sense though until another PSA reading is obtained. You can ask your Uro about a PCA test if you'd like. You can Google it. Actually, of all my tests other than my higher than normal PSA3, it may have been the best indicator. But seriously, you're way too worried about way too little at this point.

BTW, we're on the East Coast, but my wife's cousin is in Oakland.
Posted 11/14/2015 3:48 AM (GMT 0)
Hi Novembeard,

I am sorry you have found yourself on this site. I am 10 years younger than your dad and was diagnosed in May with intermediate PCa and a low PSA The whole thing is overwhelming, I didn't sleep much as I consumed as much information as possible in the early weeks. It does get better.

There are focal alternatives which will only improve in time should your dad need it down the line. Check out the "Inspire" site which has numerous threads on this subject. UCLA is conducting trials with focal laser ablation. I had FLA last week at the University of Texas and have experienced no side effects. I wish your family the best, as you become more educated I hope yournconcerns will subside.
Posted 11/14/2015 4:02 AM (GMT 0)
Novembeard,

If you and your dad want to learn a lot more about low risk prostate cancer and the risks and benefits of an AS program, read"invasion of The Prostate Snatchers" by Dr Mark Scholz, a well known prostate oncologist.
Your doctor seems to be spot on. Learning more will help understand his recommendation and also what your options are.
Posted 11/14/2015 4:13 AM (GMT 0)
You will not usually find that many on these kind of sites as they for the same reason there are less success stories on cancer sites than not . You see the majority{ an intuitive opinion} deal with their cancer and then get off of cancer forums so you never hear about them.
Posted 11/14/2015 4:41 AM (GMT 0)
In the longest running clinical trial of Active Surveillance, half the men have not yet required treatment after 20 years. In the best AS programs, as at Stanford, they require an mpMRI-targeted follow-up biopsy within a year. It's a greta idea to get a second opinion on the biopsy slides from Bostwick or Epstein.

Yes there are several kinds of focal therapy available (but I'm pretty sure his insurance won't cover it, and it can take several treatments with constant monitoring for recurrence), but none have the assurance of no side effects the way Active Surveillance does. And I don't think any of them have treated significant numbers of men with more than a couple of years of follow up - it is still in an exploratory phase. That's another argument for Active Surveillance - it can give him time while new therapies are proved. If he wants to be an innovator, there are clinical trials he can get into.

I think halbert asked a great question - how does your dad feel about it? All of us have loved ones who, out of deep concern, have questioned our decisions, but what we all need is validation and support. It's really important to examine the baggage we all carry about the word "cancer" to see if it really applies and is useful to our current situation. The loss of control is the hardest thing to cope with. I think it's often a good idea to "do" something - even if there's no real evidence it can help, as long as it doesn't hurt. One can exercise more, eat healthier, maybe take a statin or a daily aspirin (with doctor's advice) - anything that helps us feel we're actively fighting the disease rather than passively accepting it.

Your father is fortunate to have your loving concern.
Posted 11/14/2015 4:39 PM (GMT 0)
Just adding my welcome and that you've got some great advice already in this thread. There are several men here that have been on AS for some time--and a few that started on AS and had to move off of it--hopefully they'll be around soon.

Good luck to your dad and glad to see you out there advocating for him!
Posted 11/15/2015 12:06 PM (GMT 0)
Novem,
Your dad does indeed appear to be an excellent candidate for AS. The great thing about AS is that it is the only option that assures you of zero side effects. If, as in my case, the cancer becomes more significant, other options can be considered. I was able to do AS for only two years, but as you've read, others have been able to continue much longer.
The very best to you and your dad.
Posted 11/15/2015 4:49 PM (GMT 0)
Novembeard,

I have been on AS for almost 4 years. In addition to a semi-annual PSA test, I have also been keeping track of any possible significant PCa with annual 3T mp-mri. I also took a PCA3 test.

If I were your father, I would have his biopsy sent off to Dr. Epstein at JHU for a second opinion (he downgraded mine). I would also have a 3T mp-mri done to make sure that the biopsy did not miss any more significant PCa.

Good luck.

Posted 11/15/2015 8:37 PM (GMT 0)
Thank you.

I will look into sending the biopsy for second set of eyes on it.


PCA3 test, what does that tell you exactly? I understand it is a blood test to help detect prostate cancer, but how accurate is it and what is the sensitivity and specificity?

Definitely will look into MRI as well.
Posted 11/15/2015 10:41 PM (GMT 0)
Novembeard,

The PCA3 test is a gene-based test carried out on a urine sample. The urologist massages vigorously the prostate before the urine is collected. According to the website www.pca3.org, recent studies indicate that the PCA3 Score may also differentiate between significant/aggressive and non-significant/indolent cancer. You can read more about the test at the website.
Posted 11/15/2015 11:01 PM (GMT 0)
Novembeard,
My stats are almost identical to your Dad's, you can see my signature below. I'm just a couple years younger than him.

First get that second opinion on those slides, for sure.

I opted for AS and I am so very glad that I did. Your Dad is going to be fine.
Posted 11/15/2015 11:04 PM (GMT 0)

Novembeard said...
Anyone on these forums done AS for several years? Seems like everyone here gets treated....

Almost 2 years for me.
Posted 11/16/2015 1:42 AM (GMT 0)
No,
If I had that pathology I'd get a spot PSA every year. Perhaps a re-biopsy in a year.

I'd confirm the path with a second opinion, then live life large for a long time!!!

Hero
Posted 11/16/2015 2:13 AM (GMT 0)
Your doctor is doing right by him to recommend active surveillance.

If it will make you and your Dad feel better to get an expert to tell you what they think is best contact Prostate Oncology Experts in Marina Del Ray, CA. They are pretty universally well thought of.

Duke Bahn, in Ventura, Ca is noted for picking up treatable cancer with a Color Doppler Ultrasound when it hasn't been otherwise picked up on biopsy.

Pretty much, the only reason to not do Active Surveillance in your dad's case is in the event that your dad's mindset (not yours) is not suited to AS. If the worry would be more detrimental to their quality of life than the potential side effects, which are very real QOL issues.

You have a lot of things you can do to put your or your fathers mind at rest. Get a PCA3 test. Talk to Prostate Oncology Experts, run a color doppler ultrasound by Duke Bahn.

There are no absolutes. People tend to "want it out." Problem is they want it out without incontinence or erectile dysfunction, or other issues. Getting it out has real risks. Those real risks are more concerning that a few cancer cells to many men.

We all have some level of cancer cells in our body. Your Dad is highly likely to die of something other than Prostate Cancer. Why risk incontinence, erectile dysfunction, colon other potential side effects.
Posted 11/16/2015 1:37 PM (GMT 0)
Just wanted to add my support for AS.

I was diagnosed 12/7/2012 at 57 and my urologist recommended RP. I decided on a second opinion and went to Brooks at Stanford. It was the first time I heard the words "active surveillance". It's been almost 3 years on AS and you can breathe. The advice in this thread is accurate and the information I got from the group 3 years ago helped me tremendously. I'm currently on the AS program at UCSF.

An update: My last biopsy result was 2:21 at <3% done in 11/2013. My last endo-MRI this past June was clear. I am waiting right now to see if it is possible to skip the upcoming biopsy scheduled for this Thursday.

My point in sharing is that while I was coming to grips with my condition emotionally, the advice here helped confirm the professional input. For me, I am comfortable with AS given the ability to accurately monitor. But it is a program that you must be diligent about to keep peace of mind.
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