Active Surveillance after 2nd Biopsy?

I thought the second biopsy would be 12 months after DX? Seems like your AS coordinator waited 2+ years? 7 3+4 with a PSA 12 is a tough call on AS. I am sure you will get arguments for and against treatment here! Let's see what some of the veterans and mods here have to say?!

To each his own, my PSA was 5.8’ with 5 percent PC. Gleason was 3.4. I was however 68. I sought treatment. Did not want PC to leave the pocket. Good luck.

I understand your reasoning. I am just getting increasingly critical of the treatment necessity, with all the side-effects and the large number of patients with cancer returning at a later date.

Do you think that waiting will decrease the available treatment options?

Thanks.

(a) another interpretation of the slides is not an option due to finances and being treated under the NHS in the UK
(b) apparently 25% on the left of the prostate (21 samples) were positive with 3+3 and 2x 3+4.
(c) as above. The options here are somewhat limited. The NHS will apparently only treat PC if the score is 7 or higher. I am given the option to continue AS or seek treatment.

Balingtwine-

Welcome to HW!

I fully support your decision to stay on AS. Laurence Klotz, who started the longest running AS program (over 20 years) in Canada, believes that there is no rush to get treatment until predominant pattern 4 is detected. With your template mapping biopsy, you have very good assurance that there is no GS 4+3. I also agree with you that the additional risk is quite small. While it's true that the risk of systemic progression is 3-fold greater in those with favorable intermediate risk PC compared to low risk PC, the absolute risk is still very small (3.5% 10-yr risk):

www.jurology.com/article/S0022-5347(17)78036-6/pdf

What people often misunderstand is that the entrance criteria for getting on AS may be different from the triggers for coming off of AS and getting treatment. Most programs now reject PSA as a trigger.

It is likely that the GS 3+4 was always there, but was undetected on your previous biopsy and MRIs. mpMRIs aren't all that good at detecting low volume GS 3+4. Now that you know exactly where the cancer is, you can have repeat biopsies to monitor progression safely.

Genetic test?

Probably, another reason to continue on AS. Only one cancer case (grandmother) in the wider family.

I am attaching the presentation referenced by ASAdvocate below. I also saw a similar recent presentation given in 2017 by Dr. Jonathan Epstein concerning his recent research and observations concerning increased risk for G(3+4) regardless of percentage of pattern 4.

https://www.urotoday.com/video-lectures/advanced-prostate-cancer/video/778-embedded-media2017-06-02-13-54-01.html

Both of these presentations are getting factored into my decision towards treatment. Have been trying to add my signature but in event I am unsuccessful I have 4 cores positive 3 G(3+4)'s and 1 G(3+3)

Face to face, Dr. Bal Carter at JHMI, told me not to consider AS, and I had one G3+4 core, at between 5 and 10%, depending on whose pathology report I choose to believe. FWIW.

Please note that of the 3 bio-marker tests mentioned above by TA, the Decipher one is specifically designed for POST surgery progression estimates.

prostatmarkerstest-grid2018 (1).pdf

Good luck to you!

garyi said...
the Decipher one is specifically designed for POST surgery progression estimates.

Decipher does both - on whole-mount prostate tissue post prostatectomy, and on biopsy cores pre-treatment.

Balingtwine, Your case (a low risk G6 PC becoming an "intermediate risk" G7 PC) has historically been one of the more difficult to decide the treatment. This is because intermediate risk patients have anywhere from 2-70% chance of recurrence after treatment, a very wide range, regardless whether you choose surgery or radiation.

In 2012 at Memorial Sloan Kettering (MSK), researchers decided to try to separate the "favorable" vs "unfavorable" intermediate risk patients. The idea was not whether to treat but the intensity of the treatment. I know you are trying to decide whether to treat, but the MSK analysis is still relevant as you will see below. The simplest definition of unfavorable intermediate risk is if you have more than one intermediate risk factor.

From what you have written, you have two intermediate risk factors. You have PSA > 10 and Gleason 7. This puts you into unfavorable intermediate risk already and even if you treat now, statistically you already have a higher chance of recurrence. To me, regardless of what the entry/exit criteria are for AS, you are already unfavorable intermediate risk and not treating now could shorten what is currently an excellent - 99% - chance of not dying from PC in the next 15 years.

Which brings me to the next point. It's not clear what your worry is when you say you haven't seen anybody without problems post treatment. If you are talking about side effects, then yes. However, if you are talking about cure (as defined for example by no recurrence in 15 years), then no, if you treat now, you have an excellent chance of cure. I, for one, am willing to trade a few side effects for better assurance of a longer life. Do realize that if you read this forum a lot, you are reading posts from many who have had more problems with side effects than normal. Most, whether radiation or surgery, simply don't post anymore because they are don't have side effects that bother them enough to post.

I think you are reducing future options if you plan to postpone treatment. While prostate cancer can be slow growing, yours - with Gleason 4 - is potentially no longer slow growing. As an unfavorable intermediate risk, you should carefully weigh you decision to wait in consultation with your doctor.

If there is anyone you should listen to here in this case, its ASadvocate. He has been a big proponent of active surveillance, is very knowledgeable about it, and as he just said if he were you, he would treat.

Here is a link to an article I think you might find useful

www.cancernetwork.com/oncology-journal/favorable-vs-unfavorable-intermediate-risk-prostate-cancer-review-new-classification-system-and-its

My two cents are about risk. Being younger and having a small amount of 3+4 I believe the odds are against me.to stay metasasis free for my lifetime. My decipher score supports that. So it came down to treat now with higher probability of.cure or delay and maybe be fighting a larger battle. I also studied the treatment options and decided HDRBT is the best for me. Thanks Denis

Balingtwine,

Your question to start aggressive treatment is definitely a hard one to answer. If my home natural application stops holding down the progression, I'll have to exit AS and make the same decision.

My thoughts, stick to the facts of the available data. Don't let the "possible" SE's drive the decision. You are talking about either being alive or being dead. I would take one of the genetic test to add aggressiveness data to the assessment process.

Because your GS is >6, core volumes greater than 20%, and, a PSA >10. I would think a alarm should be going off in your head (a lot of smoke = Fire in the building).

So, what will allow you to sleep at night. If you pass up doing the treatment now, can you accept the possible consequences of waiting to long.

The best of luck in your decision. The crystal ball on this crap doesn't work well.
_________________________________________________________________

SEP 2017: PSA 3.8
NOV 2016: PSA 3.7, Biopsy (12) cores Benign/Negative
JUL 2016: Bone Scan (NEGATIVE)
APR 2016: PSA 3.7

OCTOBER 2015 (Dx)
Age: 59
PSA: 3.0 elevated to 3.5 in (6) months
3T-MRI: (1) lesion identified
Fusion Biopsy Results: Lesion cores benign, addtional (12) cores = (1)5%
Pathology Summary: Grade Group 1 (G6:3+3), 2nd pathology verification
Clinical Stage: T1c

PCa Treatment: "Active Surveillance" + "Home Natural Cancer Treatment"
Risk: Undetected Cancer Progression
Risk Likelihood: LOW

My Story: https://www.healingwell.com/community/default.aspx?f=35&m=3528051