Cribriform & Decipher results - determining monotherapy or combined therapy recommendations

Hi, been lurking a little while since subdenis was kind enough to point me over here.

Sorry, this is so long, but trying to be thorough in providing info that will help solicit your useful feedback. Before all the detail, the question I'm trying to determine is:
Can I effectively treat my G7 (3+4)/T1c cancer with a monotherapy?


We went to see Peter Carroll at UCSF. We had already decided against surgery, so we were basically seeing him to get his opinion on whether we could safely do HDR as a monotherapy or if we required combination therapy.

His recommendation was that combined therapy would work fine in my case, but if we wanted to do monotherapy, he'd feel more comfortable with that being curative if he could further characterize the Grade 4 portion of my biopsy. Specifically, he talked with us about:
1) a slide review and ensuring that they had a good characterization of the pattern 4 cell subtypes - specifically if I had abnormal cribriform (i.e. expansile cribriform) histology.
2) doing the Decipher Prostate Biopsy test

The purpose of both to further characterize my G7 (3+4) to see if the 4 portion of it is more aggressive and therefore require combination therapy - and if not, to agree that a monotherapy could be effective.

*to expand on my info in my signature, for the 6/12 cores that had involvement:
LM - G7 3+4, 15%
LLA - G6, 5%
LLM - G7 3+4, 20%
LLB - G7 3+4, 25%
RLA - G7 3+4, 5%
RLM - G6, 15%
The targeted tumor: LMPZ X 4 cores: G7 3+4, 45%

Search of the forum brought up a very similar scenario with the same doctor. Tall Allen posted a response there which said:

"..Cribriform used to be part of the Gleason pattern 3 diagnosis, but was elevated to Gleason pattern 4. Thus, a man who used to be GS 3+3 is now GS 3+4. It can only change a diagnosis to high risk if 95% of the tumor was now Gleason pattern 4 (including cribriform), which is not the case here. The ISUP change actually lowers the risk level of both GS6 and GS7 diagnoses by the Will Rogers Effect."

So, that confuses me because then, at least for the cribriform portion, I don't really understand the purpose of what Dr. Carroll is getting at. Dr. Carroll said:

When you look at pattern 4 cells that are different histologic cell subtypes, these histologic cell types correspond to aggressiveness. We would be looking to see if there is cribriform or expansile cribriform histology which corresponds to higher aggressiveness. If there were expansile cribriform histology he would recommend combination therapy vs monotherapy.

I would prefer to do monotherapy - HDR (or SBRT - which after reading more here and researching independently, I'm now thinking may be just as effective as HDR but less invasive). However, his comment is that you don't want to undertreat this. He was also sensitive that we don't want to overtreat it either.

Bottom line: The results from the secondary BX review specifically detailing cribriform histology and the Decipher test would be the determiner for his recommendation of whether we could stick with monotherapy or whether we needed combination therapy.

After considering Tall Allen's comments, unless someone wasn't accurate in reading the slides, I don't see how this focus on expansile cribriform would change anything. Unless, the type of cribriform sort of further stratifies the grade 4 into normal G4 or more aggressive grade 4 (maybe that was the point Dr. Carroll was making?)

If it does come back with Cribriform, I would expect those portions would already be classified as G4 and I would still be G7 (3+4) Favorable Intermediate. And NCCN treatment recommendations would include "LDR Brachy alone..if test results suggest the cancer hasn't spread far."

Now, granted, I'm talking HDR or SBRT instead of LDR Brachy, but Dr. Carroll didn't really make the distinction and actually recommended HDR over LDR and said either HDR or SBRT would be fine if a monotherapy was appropriate. (he did caveat that he wasn't the RO, but felt that the RO's recommendation would be highly influenced by this "further risk stratification" by looking for certain cribriform structures or getting a high Decipher score.

Thanks for feedback!

Welcome to posting mode.

You've done some great research there. Do wait for the re-read. Reading the slides can be a bit subjective and based on the experience of the pathologist reading them. If you get similar results you can be more confident in them.

You'll want to get the RO's opinion, but I would think you'd be fine with a mono-therapy. SBRT is showing great results (only five treatments), but unless I'm missing something I don't see why LDR wouldn't be an option. If you have one form, say HDR, you can always followup later with a bit of SBRT later if needed.

Keep us updated on your research,
Andrew

Oh yeah Stanford RO said Cyberknife isn’t there yet ..he said he wouldn’t recommend it to his worst neighbor...

Sounds like you have done your due diligence and have a plan in place. Good luck to you as you move forward and let us know how it goes. My apologies for a slight edit to your post; I removed the name of the doctor who was disparaged in the now deleted post of another member.

Jim

Jack,

Thank you for your thoughts.

Part of the reason that I’m pursuing being treated at UCLA is that the two therapies I’m potentially comfortable with: SBRT (for which Dr. King is a nationally renown expert) and HDR (for which Dr. Demanes is well-regarded) appear to be well run there.
I actually called the Brachy dept and tried to get a consult but they were going to connect me with a less experienced doctor. And they didn’t follow up. Given that I was still awaiting test results, I let it go.

Do you know if Dr. Demanes is still fully involved there? It appears from the website that he has taken a step back and I wonder if anyone on HW has been treated by him within the last year or two.

Also, since SBRT is essentially a less invasive version of HDR, I’m strongly leaning towards that and that we’ll have confidence and a scheduled treatment path forward following next week’s appt with Dr. King.

As far as multi-mods therapy, from my few posts here, you can see that the choice between multi-modal and monotherapy is very important to me because the increased risk of SEs can be significant.
So I’ll do it if my RO convinces me that it will significantly increase my cure rate. But I’m not going to layer on another treatment just to get a little more insurance. The long term risks of effects of that for GI, GU and ED are not worth it to me.

Thanks for all the support here. I read ravenously here and really appreciate the expertise, the sharing of experiences, and the kindness extended to all members.

I think its a good application of the rules...and I have been guilty of that rule violation...my self(duh?)...some may feel its a step backward...but in my view it is a step forward( it being a revisit to rules)...HW is not a vacuum...having said that(yep...always a but)...the spirit of words should always be followed where it is understood...to the extent...that spirit does not undermine its own self....tricky stuff...alphas and omegas...btw ...did ya hear the one about...



My view only...back to the thread...even tho hijacking is not a violation of any rule other than in the eye in the sky...to my knowledge...all views can be understood to have the potential to wonder