John Hopkins down grade

Hello All,I had my first meeting with with a Radiation Oncologist at the University of Chicago Medical center,this morning,Dr.Golden.Smart man,not pushy with IMRT.Went into detail with all options,surgery,brachy,sbrt,focal lazer ablation,etc..My slides were sent to John Hopkins last week for second opinion and this morn before my appt. I called JHU and the results were just sent to my Uro.I asked if they could Fax the results like now to Dr.Goldens office at UofC so those results would be there for this consul.They did.Now Im really nervous headed to his office.Just praying there are no upgrades. So my bone scan results were there also.Bone scan was clear.Quest pathology gave me a 3+4=7,a 3+4=7,and a 4+3=7,with no perineural invasion on the original pathology.

John Hopkins gave me a 3+3=6,a 3+3=6 and a 3+4=7,but gave me perineural invasion,Geez.So I was down graded,but have the PNI.In all your expert opinions,even non expert opinion, would that PNI change treatment options one way or another? Im so happy that HealingWell has been here for me.I would never of know of John Hopkins,or fileing a claim with VA.So I feel very fortunate to have all of you here.Maybe I should play the lottery tonite.So Thank You All,SemperFi

Thanks Paul65

Thanks Michael-T

Thanks InTheShop,by your signature ,are you pleased with the IGRT treatments that you received?

Thats what I wanted to hear.The RO said to explore all the options.I just hope the final choice is the right one.Thank You Andrew

That's great news. I'll help put it all in context, and then also address the big picture on PNI...


First, as a newcomer to this site, perhaps you are not yet familiar with the PROSTATE CANCER QUANDARY famous article, which is really more about PC treatment quandary. I posted this last month to another member, island time:

JackH said...

This awareness is captured in an article called THE PROSTATE CANCER QUANDARY, but I might argue it would be more precisely labeled THE PROSTATE CANCER TREATMENT QUANDARY, since one could posit that there are several other quandarys associated with PC. I'll just copy/paste directly from the article (in italics):

The quandary in prostate cancer medicine is best summarized by Dr. Willet Whitmore, former Chief of Urology at Memorial Sloan Kettering Cancer Center: “When cure is possible, is it necessary? When cure is necessary, is it possible?”

Another very wise urologist, Dr. Paul Shellhammer, once used the words of Whitmore to further explain that we know there are two kinds of prostate cancer and we hope there is a third.

1. There is the kind that can be cured, but need not be cured.
2. There is the kind that needs to be cured and cannot be cured.
3. We all hope there is the kind that needs to be cured and can be cured.


http://blogs.cancer.org/expertvoices/2011/10/05/the-prostate-cancer-quandary/?_ga=1.43698277.1529535559.1440079495

These three kinds of PC align pretty closely with the low-, intermediate- and high-risk case categories which are described in the "Newly diagnosed..." thread (hopefully you've already read that). There are some exceptions; for example, the intermediate-risk category is further subdivided into a favorable risk side and an unfavorable risk side, and many favorable intermediate-risk cases need no immediate treatment at all.

Your 4+7 put you solidly in the unfavorable intermediate risk category. Your re-classification to 3+4 knocks you down toward the favorable intermediate side, but the PNI may be the influencing factor.



PNI does seem to confer an increased risk of extraprostatic extension (EPE) of tumor. However, in a Epstein study, men with isolated EPE at radical prostatectomy had a roughly 50/50 likelihood (plus or minus about 10 percentage points depending on Gleason and margin status) of biochemical recurrence-free (BCR-free) survival a decade after surgery. So it's only a percent of a percent risk that PNI indicates BCR. Therefore, with specific regard to surgical treatment options, the increased risk of EPE posed by the presence of biopsy PNI should not serve as a contraindication to RP.



My layperson's opinion, you are in the Shellhammer category that "needs to be cured and can be cured." With respect to the method of cure (treatment), PNI does provide at least some incentive to look at non-surgical treatments.


good luck

Congrats on the downgrade! You're still considered "favorable intermediate risk" with or without the PNI. That means surgery, SBRT, LDR brachy monotherapy and HDR brachy monotherapy are all on the table for you. You have to visit with experts in each of those - there's no such thing as "one stop shopping" with prostate cancer treatments. Everyone (including me!) has an opinion, but you really can't get the whole story until you've met with each specialist.

- Allen

Thanks for welcoming me to your family. Does that mean I can take the car?

The RO is quite incorrect that HT is the only option after an RT failure - SBRT and focal BT (either HDR or LDR) and focal cryo have been used if the recurrence can be found within the prostate or the prostate bed.

You may be a good candidate for FLA, but I would not recommend it outside of a clinical trial. To be a good candidate, the index lesion - presumably the one with GS 3+4 - would have to be in a place away from the neurovascular bundles, the rectum, the urethral sphincter, and the bladder neck - preferably in the anterior part of the prostate. This study on HIFU focal ablation and commentary are just out; there's no reason to suppose that outcomes would be much different for FLA:

Focal Ablation Targeted to the Index Lesion in Multifocal Localised Prostate Cancer: a Prospective Development Study

Keeping an open Mind about Novel Concepts for Management of Prostate Cancer

As you can read, 20% were found to have a significant focus of remaining cancer within the year, and 43% had some detected residual cancer at 1 year. So essentially, one is on active surveillance after treatment, but without the ability to use PSA at all as an early detection tool - a lifetime of targeted biopsies. What kind of SEs are attached to re-treatments is unknown. As far as the SEs go, they're not bad, but they're not zero. Erections were preserved in 77% and pad-free continence was preserved in 92% at 12 mo. 5.4% had to have TURP for urethral strictures at the bladder neck. Of course, one year isn't nearly long enough to draw conclusions.

By comparison (see links in my signature) with SBRT 7 years after treatment: erections were preserved among 71%, there was no urinary incontinence, and 1.7% had TURP for stricture or laser coagulation for bleeding. 11% of all the intermediate risk men had a biochemical failure within 7 years of treatment, but only a quarter of those were local failures. The cancer control was better for men with GS 3+4 than for GS 4+3, of course.

It's a much better use of the RO's time to devise the treatment plan. When that's done, it's programmed into the computer that runs the linac. The technician just stands by to make sure that all goes according to plan. The plan is the what you have to have trust in. The machines do what the plan tells them to, unless someone interferes.

- Allen

Tall Allen said...

The RO is quite incorrect that HT is the only option after an RT failure - SBRT and focal BT (either HDR or LDR) and focal cryo have been used if the recurrence can be found within the prostate or the prostate bed.

THIS!

...and again...

THIS!

YOU already know more about the WHOLE landscape of treatment than that RO... whom I will take unto the car park and give a fine and mighty kicking for you... just give me the word!



Opinions do vary as to its added benefits but pencil Proton Beam is also worth a sniff... as there do appear to be some potential upsides in some cases.

As an aside, one thing I've come to appreciate is that in some cases some wives don't always fully appreciate how intimately intertwined a man and his sexuality actually are. Naturally some push hard for the 'highest' cure rate at any cost, of course they do, they love us to bits (thank God) and want us there forever... but at what cost (to us)? Sometimes I think is pays to pinch yourself, reflect and reflect upon that question; everything in life is about compromise and weighing risks and benefits. I think that this ultimately points toward the fact that opinions, from guys here, wives, lovers or visions of giant white rabbits are only that... opinions. Ultimately the decision belongs to the man inside you and everything that makes that man tick. Everything... No two of us have the same values, attitudes or needs.

My opinion... look real close at those Brachy options, they seem to fit your situation very well and I base that upon never having met you and the handful of posts I've read on the internet!!!

From what I've seen of your approach to this whole situation... you don't have it in you to make a bad or ill considered decision... you'll get it right, it's just who you are.

...now to the car park.

Post Edited (Paul65) : 12/9/2015 6:23:17 AM (GMT-7)

Drs Walser and Sperling are the other well known focal folks 03... but I don't see how focal helps you... because you know you have some PNI and freezing or cooking a nerve strikes me as much the same as driving a scalpel through it? My experience with Dr Walser is that he's a straight shooter so probably worth a conversation.

Thanks Bozolidat,my main question in my brain with the unknown path of PCI ,in your opinion does RP,surgery,post-op pathology offer the best clues as to what lies ahead as far as EPE,EPC ?

OK,and Thank You Michael_T,who in the Chicago land area specializes in Cyber-knife,SBRT,and BrachyTherapy.As my University of Chicago annex near me does only IMRT,I will also inquire at the big Uof C downtown,Chicago,about 1 hr drive.Maybe I will ask DR.Google also.All help is very much appreciated to get me the best possible Dr.in each of their fields.

0311, keep in mind that the Index Lesion theory is just a theory, not a proven fact. There is as much evidence against it, as there is evidence supporting it. My guess is that it occurs in some men but not in others. We don't yet know how to sort out which is which. That's why I think focal ablation should only be done in the context of clinical trials until we have learned more about it.

Brian Moran is one of the top LDR brachytherapists. For HDR, I'd recommend Alvaro Martinez in Detroit. I think someone here used the CyberKnife Center of Chicago for SBRT, but I don't recall the RO there.

Paul65, PNI doesn't mean that the neurovascular bundles, which run around the outside of the prostate, have been infected. There are small nerves within the prostate capsule itself that can show signs of cancer, and it's thought that the cancer can escape more easily when they're infected.

- Allen