Need some Advice

Hi:

I am Avi from New England area and my parents are back in India. My dad is a healthy 71 year old (walks and exercises everyday-takes medication for BP and nothing else), and he had some pain over the weekend and went to see the Dr. After some tests, he came back home knowing that he has prostate cancer with Gleason Score 9 (4+5). This is a shocker since he is the healthiest among us all! I have read up on what the scores are. His CT Scan results came in today and unfortunately, his Dr/Urologist is on vacation until end of the week. The wait is killing me (being so far away from them during these times!), so was wondering if you could go over the results below and kindly let me know from your experience what it means and should I be alarmed? (I don't have his PSA results)

Ga68-PSMA accumulation is seen in the following regions (SUV per BW).
1. Lesion in the median lobe and rest of the prostate parenchyma SUV: 116.0
2. Bilateral external iliac and obturator lymph nodes SUV: 120.4

PETCT:

1. Prostatomegaly with prominent median lobe causing bladder base indentation.
2. PSMA avid enhancing lesion involving the median lobe and rest of the prostate parenchyma, predominantly involving bilateral peripheral zones with pericapsular extanrion and infiltration of the seminal vesicales (I>R)-suggestive of carcinoma prostate.
3. Bulky PSMA avid bilateral external iliac and obtrurator lymph nodes-metastatic.
4. No obvious metabolically active PSMA avid skeletal metastases.

Thank you,

Avi.

Hi Andrew:
Thanks for your time and help. I have asked them for the PSA values. Does the scan results that I typed earlier say anything about cancer having spread out of Prostate and into other organs? This scenario, I believe, is the "worst" case, am I right? In case it has indeed spread then would it mean his life expectancy decreases drastically? I am sorry, this feels very surreal and just the word cancer brings in so many bad thoughts.
Thank you,
Avi.

In my opinion, he already has all the information he needs to make a good decision. Yes, it has spread outside of the prostate to the pelvic lymph nodes. But that doesn't mean it's not still curable. The good news is that it has not spread to his bones (which would be incurable).

His best hope for a cure is radiation to the whole pelvic area with a brachytherapy boost to the prostate and about 2 years of androgen deprivation therapy (ADT). This has high cure rates in such cases.

I don't think that surgery would be a good choice. If he has surgery, they would have to cut very wide, with high risk of lasting incontinence and loss of potency. They would have to follow it up with radiation anyway, giving him the worst of both world. And it is very hard to ensure that all the pelvic LNs have been removed. Even if they do, there is a high risk of lymphocele and lymphedema.

So the next steps would be:
(1) He should get a shot of hormone therapy very soon to stop any further spread.
(2) He should talk to a radiation oncologist who specializes in brachy boost therapy.

Welcome to the group. Sorry that you are here but you could not ask for a better group of people.

There is good news and not so good news. It is advanced (bad news). But there is good news. First, it is not in the bones (very good news). Second, while it has to be treated, it does not have to be treated today. I was G 8 where it spread to my pelvic lymph nodes. In my case, they caught it early enough to have surgery. (Note, many people would not agree with surgery. I had to argue with the surgeon who thought surgery would not be the beneficial.) This was followed by two years of hormonal therapy (Lupron), which I am 9months into and 38 rounds of external radiation to my pelvic area.

In your fathers case, it may be to advanced for surgery. Please note, many men do better not having surgery. Quite often the cancer is spread during the surgery, and the side effects are not fun. It seems like hormonal therapy and some sort of radiation treatment(s) is in order.

Knowing the PSA will also be of help. First there are some rare forms that do not raise your PSA. Second, it can act as a benchmark.

Please know that with treatment there is a very strong chance that you dad will live a very long time.

Avi,
I agree with others that your father does need treatment - most likely a combination of radiation and androgen deprivation therapy. Surgery is unlikely to add benefit and would add needless side effects. I can also assure you that radiation therapy is nothing like chemo -- side effects are typically minimal. I had salvage radiation 7 years ago - 36 treatments over two months. Some people experience fatigue as a side effect, but I had none of that. In fact I worked full-time throughout my treatments - albeit as a tech writer able to spend my workdays at a desk. My only side effects were urinary urgency beginning about half-way through treatment. This would happen when I'd first stand up, nothing I couldn't control, and within a minute or two would return to normal. This returned to normal about a month after treatments ended. about 8 months after the completion of treatments I began having some occasional rectal bleeding from radiation proctitis. Most people don't get this. Mine was not severe and gradually returned to normal over the next 8 or 10 months without any treatment.
Jim

Hi All:

I finally received an email from my dad's Dr. He clarified that the Gleason Score is 4+4, PSA of 44.1 (I think!) and T3N1M0 staging. Today he administered a shot of Degarelix/Firmagon shot to my dad and asked him to wait for a month. Post one month he will do an urine culture and give another shot of Degarelix. Below is his email and it has way too many technical jargon and hence hoping you could help me with your experience and thoughts on the treatment procedure the Dr has charted for my dad.

"In view of a large gland causing complete urinary obstruction, he would probably benefit from LHRH Antagonist therapy with Degarelix which acts quickly and therefore controls the disease early.

This will also facilitate early removal of his urinary catheter.

I plan to continue 3 such monthly doses of Degarelix and reassess his disease response.

If there is a good response to the treatment, I would probably contemplate Radical Prostatectomy keeping in mind his large prostate gland and Urinary Obstruction.

There is a very high chance that he will require either Adjuvant or Early Salvage Radiation therapy following Radical surgery. This is called Multimodal treatment which is a new and evolving concept in management of high risk localized and locally advanced prostate cancers.

If at the end of 3 months, his disease response is only moderate and surgery will seem challenging, I would consider getting IGRT on him (Radical Radiation).

If he goes through the path of radiotherapy, he will require to continue the hormone therapy as well for up to 2 years duration.

I would be happy if he gets a chance for cure with both Surgery and Radiation as this approach would maximize his chances of cure whilst not compromising his Quality of Life significantly."

Thanks again for your time and help!

Hi All:

I just wanted to drop in and give an update w.r.t. my dad's situation.

History:

Back in March my dad got diagnosed with a Gleason Score 4+5=9 PCa. He has taken 2 doses of Degarelix and has been on catheter ever since. He is 71 years old.

Update:

Two attempts to remove the catheter has been unsuccessful since he has a very tough time to pass urine while he is off catheter. So the Dr. will be doing a Cystoscopy and a TURP surgery next week and see if they can remove the blockage. He is saying that if everything goes well then my dad should be off catheter OR else he will be on catheter the rest of his life since the bladded might have failed (he said something about a pipe through his stomach or something like that). So hoping for the best as my dad hates being on catheter and not being able to go out as frequently as he used to. The only good thing about his HT is that the prostate size has reduced drastically (from 148grams to 51 grams), but he still has issues passing urine. Re: the future treatments to deal with PCa, he said he will give my dad another dose of Degarelix and then a month later will put my dad on Radiation Therapy. He basically ruled out surgery given that the cancer has spread out of Prostate. When asked about the Survival Rates, he said it is too early to comment on that and we will know based on how he reacts to Radiation Therapy.

Questions:

I am leaving for India in a couple of days to be with them. I wanted to know if there are anything to watch out for during these 2 procedures and also, based on your experiences do you think my dad will need me when he undergoes radiation therapy? Kindly let me know if you can think of anything else that might be useful.

Have a good day!

Avi.