Recently diagnosed - PSA 15.1 with only 1 core positive @ 3+3. At 44yrs old - any thoughts?

Quick update, had my Cysto 2 days ago, it was normal.

The urologist entered the Cysto test and immediately asked me if "I had gotten another urologist" ... and was confused on who ordered the Cysto.

After the test he and I discussed options.

He again encouraged me to strongly consider RALP.

He told me that he strongly believes anything other than surgery would be a mistake, including a focal laser approach, as the long term re-occurrence rates have not been verified, and we have a chance to "cure"... and should take that approach... also, he said that radiation is just not appropriate at all for someone who is 44.


Also, he told me directly that any additional testing is not warranted, including the MRI. He doesn't think a MRI is going to impact the decision at all.


He also said that performing this surgery for him wouldn't "make him any richer" ... but with my G3+4 now as opposed to the original G3+3, he believes it's even more justified to move quickly for surgery.

When I asked him about the cancer in the R-Apex, he said it was not a concern, and that when he operates he takes out as much as possible...

That left me wondering, do doctors have different approaches to RALP? Are there different approaches to how much of the prostate they take, or how they test during the surgery for postive margins? ... he said he didn't test normally during the surgery...

He also said he would not be able to tell me if he could save the nerves or not... he said sometimes they peel off easily like a onion ...

Anyways, next up for me:

3T mpMRI on 9/12

Visiting Urology department at MD Anderson on 9/15

Sending MRI results to Laser Focal Ablation team after MRI on 9/12 to see if I am a candidate or not.

Zzarth

I'm glad the cysto was clear.

I agree that you need an mpMRI if your choice is FLA. One of my big questions about it is how does one tell if it was successful? With surgery, we get an undetectable PSA; and with radiation, it may take awhile, but PSA eventually goes very low. Given your elevated PSA, what is a good drop? Obviously, it won't go to undetectable, but if it goes down to, say, 4 or 5, is that good? And if it goes up, when is it a bounce and when is it biochemical failure? All this stuff hasn't been figured out yet. I'm not saying it's bad, just that I don't know how you'll determine success. Do they do another mpMRI-targeted biopsy of the ablation zone in a year? Anyway, it's all very good stuff to ask about when you meet.

I make it a policy never to ask doctors about therapies outside of their field of expertise. They don't usually know, but that won't stop them from giving an opinion. I'm glad you're moving forward undetered and continuing your investigations.

Did you ask the Uro if he takes frozen sections with a pathologist standing by? That's how they know how wide to cut. The right apex is the riskiest place for a positive margin, so I think you are right to ask:

Wrong to be Right: Margin Laterality is an Independent Predictor of Biochemical Failure After Radical Prostatectomy.

Zzarth said...
I don't think I would be happy with a result that left any detectable PSA level... with FLA is that not possible? ...

No, that is not possible with FLA. Neither is that possible with any kind of radiation therapy. If you need that assurance, you should go for surgery (if surgery is successful). Any therapy that leaves healthy prostate tissue behind, like focal ablation or radiation, will leave a source of PSA. With radiation, we have enough years of experience to know which nadir values are prognostic for cures. But it can take years to reach that nadir (it took me 5 years to get down as low as 0.2). We also have enough experience with radiation to know that nadir+2 is prognostic for a recurrence. We don't yet have enough data on focal ablation to have such benchmarks.

Let's say, for example, that your prostate is full of BPH tissue that is churning out a lot of PSA, or that you have relapsing and remitting prostatitis. That will not stop with focal ablation. Hopefully, the PSA from the index tumor will be eliminated, but that still leaves all the PSA coming out of all the other BPH and inflamed cells. We have no way of knowing what that value is. There is also PSA coming out of any foci of cancer outside of the ablation zone, and we don't know what that value is. Then, if the ablation of the index tumor was incomplete, there may be PSA coming out of there, and we can't distinguish that from all the other sources of PSA. So you can't really gauge focal ablation success with PSA. What you have to do is have periodic biopsies to make sure the cancer isn't progressing. Effectively, you are on active surveillance for the rest of your life. Now certainly, after a few years of no biopsy-detected progression, you would have greater confidence that the focal ablation was successful, and you can delay further biopsies.

Zzarth said...
@TA -- if you were me, what would you do? ... :)

But I'm not you, so I could not possibly answer that. No one can except you. The things that are most important to you are unique to you. That's why I list that as a question to never ask doctors or anyone else. Take your time, do your due diligence, and eventually you'll be able to answer that for yourself.

Sorry about the diagnosis, I was 48 with a PSA of 14.7 and a 3 + 3 biopsy. I did do the surgery route and 2.5 years later I am good. You've gotten a lot of good advise here, I'll echo that if you get surgery go with someone that has 1000's of procedures under their belt. Learn about incontinence and post surgery sexual changes. Its not the same... The better the surgeon the lower the risk for the post surgery SE's

Best of luck and if you like I'll be happy to talk about the pre and post surgery experience

Pat

Zzarth-

An mpMRI is not the same as an MRI. An mpMRI is used to find areas suspicious for cancer after a first negative biopsy. The point of it is to help target another biopsy.

I know some Uros like to look at a regular MRI to help plan where to cut, but most just leave those decisions to when they get in there with the the microscope (if robotic) so they can actually see it (which is much better detail than they get with an MRI, or actually feel it (in the case of open prostatectomy). Sometimes, especially when the DRE is positive, they might want to see if they can identify ECE (in which case surgery would be futile or at least questionable). For the ones that like to see an MRI, I don't really see the benefit -- maybe it helps them do the surgery faster.

No one can tell you with certainty if they will be able to do "nerve sparing" on you. They can only gauge that in advance from the biopsy results - if the positive cores are near the neurovascular bundles, they might doubt they can spare the right or left or both bundles completely. Also, "nerve sparing" is a relative term - sometimes when they get in there they find that they have to cut wide into some but not all of the neurovascular bundle.

It's not just the neurovascular bundle. Perhaps more important is how much of the urethra they will be able to spare. At the base is the bladder neck; at the apex is the urethral sphincter. They control continence. If they get in and find a lot of cancer in those places, they will have to take out more. They won't know this in advance, even with the best MRI.

Every Uro has his own way he likes to work. I do think that frozen sections are important, although many Uros don't do them. If you want to know how any particular Uro's technique is different, you should ask him.
They may have different ways of stitching up the anastomosis. and different techniques for "nerve sparing."

I remember asking a couple of uros if, when they got in there, if they found that the neurovascular bundles or the bladder neck could not be preserved, if they would stop the prostatectomy, close me up, and send me for radiation. They laughed, of course.

Zzarth - just a few thing...
One of the reasons i chose surgery was the opportunity to see my PSA go to undetectable quickly, and stay there, and not have to be concerned with any bounces 6 onths after treatment. But thats me, I'm a bit of a high strung dude (understatement)

Secondly, like Tall Allen, i would want a surgeon who does a frozen section before closing up. My surgeion, Tewari, who has done over 6000 RALPS, does so, and in my case, the frozen section showed positive margins, so he cut wider, and retested, until he got negative margins. Had he not done frozen sections, i'd be at higher risk for recurrence.

Last, yup, every surgeon is different. I saw Dr Samadi, who said (through his NP) that he doesnt do MRIs before surgery, he believes they are only for Drs who dont have a plan (i thought that was ridiculous, but thats just me). Tewari, on the other hand, equally experienced, insists on an MRI prior to surgery, to plan things out.

Getting advice from a urologist about whether to have surgery is like asking a car salesman if you should buy a new car. When I was researching treatment options, I looked at the doctors as salesmen, each trying to sell the type treatment that they had invested the time and money in gaining expertise in. It was up to me as the consumer to evaluate the pros and cons of what each doctor told me and in the end make up my own mind on what to do. My age and pre-treatment situation was similar to yours. After a lot of research, I opted for HDR brachy treatment at UCLA. Two years out, I still feel that I made the right decision. HDR may or may not be right for you, but you owe it to yourself to at least research it so you can make an informed decision.

radonc.ucla.edu/prostate-cancer-brachytherapy

I first learned about HDR during a consult with Drs Turner and Lam at: /www.prostateoncology.com/
They were a good source of unbiased information. I say unbiased because they do not offer primary treatment, so they have no incentive to steer patients towards one type of treatment over another.

Post surgery ED is one of those variables that is very, very hard to predict. The results are truly all over the map. Some men don't have any issues at all. Others are done in that department, permanently. It's truly individual, and there doesn't seem to be any clear indicator to suggest who might be lucky or unlucky.

The skill and experience of the surgeon certainly makes a difference. As does the specifics of the individual case. Things like whether EPE is present or known before surgery. Some surgeons will say that sometimes the nerves 'lift right off', and other times they are more difficult to release.

The best answer to the ED question is, I guess, is to acknowledge that there is a risk, a very real one, that you're likely to experience some level of ED post surgery, how much and for how long is unknown and unpredictable.

Thanks Halbert & Hawaii-Guy

I've now been to a large handful of surgeons, doctors and even oncologists that say the same thing "They highly recommend surgery due to my age and situation."

The underlying tone is that Radiation at my age is risky, however, I have looked and looked and I can not find any hard research that links brachytherapy with with any type of radiation-induced secondary malignancies.

Does anyone know if this is purely a theoretical concern or do these doctors have some data to backup their fear?

After more research and reading posts like Tudpock's I'm starting to lean towards HDR myself.

Zzarth

I agree with Michael_T that the risk of second malignancies is very low. Here's an article about it:

Radiotherapy-induced second primary cancer (RTSPC) risk is low and may differ by radiation technique.

I would guess it's about the same as the risk of surgical instrumentation spreading the cancer.

As for age, the same considerations apply for surgery or radiation -- younger men are often healthier and tend to do better - less impotence and less urinary difficulty. And they recover more quickly.

In the olde tymes, when radiation doses were too low (because the machines were less accurate), radiation was often not curative. So it was often given to older men who had limited life expectancy - they assumed the radiation just slowed it down and the side effects were generally less. Both external beam and brachytherapy have vastly improved oncological outcomes since the 20th century. SBRT began in 2003. Urosurgeons don't keep up with specialties outside their own. No one does.

"So I'm not sure what they mean here... why would the nonogram be different for Radiation-- anyone know what they mean?"

Lots of reasons:
• Nomograms are based on a retrospective analysis of patients at specific institutions, and men given radiation (of various kinds) may have completely different disease characteristics than men who chose surgery (usually those choosing surgery are younger, lower stage, lower grade, etc.)
• This nomogram is only based on patients having prostatectomies at MSK, by among the best, most experienced surgeons in the world. The skill of seed brachytherapists are almost as important.
• Radiation outcomes are heavily dependent on dose, actually on biologically effective dose, which is why results may be very different at different institutions and for different radiotherapies.
•They are different therapies - for surgery, extension outside of the capsule is a big deal because they are only removing the capsule. It's less of an issue for radiation because they treat outside of the capsule.
• Only a randomized comparative trial can be used to compare therapies, and this has never been done. The ProtecT trial will give some data, but it was done using substandard radiation. I'm guilty of making comparisons nevertheless. (see table at the following link)

pcnrv.blogspot.com/search/label/proton

Nomograms are accurate about 70% of the time, typically. Just use it to give a general idea of expected outcomes - your individual set of circumstances may change it a lot.

I just re-read one of your posts about the discussion with the urologist pushing RALP saying that radiation is inappropriate for someone your age. My question to him would be..."so if the surgery fails, you would certainly not recommend salvage radiation as you firmly and unequivocally state that radiation is wrong for someone my age. What would you suggest I do if the surgery fails?" Of course the uro is then going to say "well that is different and of course we would suggest SRT and........." To me that very typical explanation exposes certain professional hypocricy.

Well had my MRI done today ... and my PSA tested on the 13th.

My PSA came back:

% Free PSA: 7.3

Free PSA: 1.17

Total PSA: 16.1

... I guess this is not a huge difference, at least it seems to have gone down from 18.0, but not a significant change.

Off to MD anderson this week with my MRI disks!

Zzarth