Standard protocol for Gleason 8 recurrence?

hi all, i'm not sure if this question even has an answer, but i have some concerns with how my dad's urologist handled his PSA recurrence and i just want to know if what he did was "right"/standard or if it was careless. it's not to take him to court or report him or anything like that, it's more about making him aware so this doesn't happen to his other patients, and hopefully it can be something he takes into consideration.

my dad had PSA recurrence in january 2016, after stopping lupron in june 2013 - he had started lupron and radiation in 2010 after RP failed. his PSA went down to 0 i think a few months after lupron was started.

so i actually have 2 issues:

1. surgery failed and the doctor waited around 7 months to begin any type of treatment. PSA post-surgery was around 2 (pre-surgery was 4). 7 months later he began radiation and hormones. is that normal to wait so long with a gleason 8?

2. when recurrence began in jan 2016, the doctor didn't do a scan or anything, and waited until october 2016 to do another PSA test. he told my dad the PSA was "undetectable" and "nothing to worry about". the PSA had gone from 0.04 in january 2016 to just over 1.0 in october 2016. the doctor still did no scans and no treatment, telling my dad there was nothing to worry about


now, i can understand this for a gleason 6, but a gleason 8?? the doubling time is so fast and not doing a scan just seems so careless. of course, that whole time my dad's cancer was growing and he ended up having to get emergency spinal decompression surgery in feb 2017 because he had a bone met that was encroaching into the spinal canal. it was only at this stage that the doctor began treatment (the bone met wasn't discovered by the urologist, but by the emergency room doctor)

i know there is no point looking back, but i just feel like if he had taking action sooner, even got a scan, we could've got that met when it was still tiny and easier to blast. now it's radioresistant and again encroaching into my dad's spine. the cancer also seems to be spreading (we are waiting to find out for sure about this)

my dad was lucky enough to only have one met for over a year, despite the fact that his PC had mutated into the neuroendocrine type (we're still hopeful there is only the one met but the latest scans/bloodwork showed some suspicious findings), i think it was probably controllable at an earlier stage but i think since it's been disturbed via surgery it has now started to spread around to other places too.

anyway...just wondering if this is the normal action that the urologist should've taken, or whether i should talk to him about it and ask him to be more attentive to future patients? is this a urologist that can be trusted with gleason 8-10 patients? he also never got an oncologist involved, aside from during radiation.

Lee - I'm so sorry to learn of your recently discovered metastasis, especially so long after your RP. I know that really changes the whole picture. And it's a LOT different when it is YOU that has the cancer, not someone else. I'm surprised that there are no uro/mo/ro specialists in your area. Memphis is a big city.

One Lee to another, I wish you the best in this. So did the Provenge seem to be of any benefit at all?

Your Urologists job was finished when his first after surgery PSA came back 2.0 From here on, he was working outside his job description..The specialist needed at this point is a Medical Oncologist...he would have ordered scans, that met on your Dad's spine would have been found and it could have been treated and controlled or stopped by a Radiation Oncologist. MANY urologists try to hold onto their patients for far to long..They just don't have the training to be messing with ADT and metastasized cancer..But they hate to send you off to a Medical Oncologist and lose all that money....Just my humble opinion...

Hi RobLee,

Let me clarify my previous post regarding "specialist" in Memphis area for PCa. We do have an very good cancer clinic, West Cancer Clinic, but all the Doctors except three are listed as Medical Oncologist only. The other three treat PCa, but are not specialist in that area. I am sure they could treat me but I opted to stay with my Uro group whom I felt was equally versed in the disease.

Regarding my urologist clinic I go to, Conrad-Pearson which is highly rated Urological group in this area. Dr. Eber, who I now see, heads up "per say" the area of their clinic that treats advanced PCa patients. He is not a medical oncologist but a urologist that is very well versed in PCa. ( at least I hope so)

The nearest city and Medical Center that has both medical oncologist and urologist that "specialize" in PCa is Vanderbilt In Nashville.

thanks annie! my dad's urologist wasn't a urology oncologist, just a urologist (though i know there are good uros out there who treat cancer very well!) but unfortunately this one wasn't on the ball. i read his reviews and so many people have been saying the same thing about him i guess it's too late though to look back and regret. i just wish he'd done a scan! right now we're with a medical oncologist who specialises in PCA and he is really great. i think in ontario at least, we are still allowed to go with a med onc with PCA if we want (my dad started seeing him as soon as the bone met appeared) but in our case, one was never recommended and at the time, i didn't realise we could go to one with a GP referral or ask for one. in fact, we didn''t know med oncs even existed!

in my dad's case, he had continuous HT for 32 months - we had actually agreed with the doctor that it was gonna be IHT but for some reason he didn't do that. my dad's PSA went to 0 very quickly once HT started so i'm still unsure why he was given hormones continuously for 32 months with no break. apparently, this mutation he has can result from overuse of hormones and some recommend IHT to decrease the risk of these types of mutations.

i do want answers from the uro but i know it won't help my dad - i'm just more concerned that he doesn't do this to other patients.