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Advice needed for recently DX with GL 4+4

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Posted 4/2/2019 2:40 PM (GMT 0)
I received a call yesterday from a man who was recently diagnosed with Gleason 4+4. He called me because my name is on a reference list from UFPTI as a former Proton patient. He has a very keen interest in having Proton and, while I had a good experience with my treatment, I am encouraging him to consider other forms of radiation before he decides.
He had an MRI at a local facility in a small town but doesn’t know what kind of equipment was used. He was told his cancer had not spread outside of the capsule. You and I know that a report like that is not definitive, especially if not done with mp MRI and interpreted by an experienced radiologist. Personally I would be reluctant to have surgery as a 4+4 regardless of what the MRI said, but I’m sure many here might disagree. It didn’t come up in my conversation with him because he is opposed to surgery anyway.
He is near the UNC Medical Facility with offers many forms of radiation including SBRT. I suggested he talk with someone who can discuss the pros and cons of each before he decides. He plans to make an appointment at UFPTI to consult with them on Proton. They will not advise him on other choices, so I think he should visit UNC first. From discussions on HW it seems a lot of men with Gleason 8 have had brachytherapy plus an external dose with good success.
I think he should have a discussion with a doctor who can advise him on these different choices. What specialty would he look for? If he chooses someone who specializes in SBRT he may not get an unbiased opinion. Likewise, a Brachytherapy specialist may favor that approach over others. Should he consult with a MO perhaps?
Posted 4/2/2019 5:34 PM (GMT 0)
Sounds like you've given him good recommendations.

Like so many of us, we want to rush into a single treatment mode without doing our research into other treatment modes.

While proton is good, at 4+4, SBRT+HDR would be a good option to look at. Keep encouraging him to get other opinions.

But if he goes with proton, it would likely work, even if it wouldn't be my choice.
Andrew
Posted 4/2/2019 8:39 PM (GMT 0)
Thing is, the majority of practitioners in any field will recommend what they know best. Rare is the subject matter expert--in any endeavor--who will acknowledge that their (friendly) competitor may be better than them. This applies in all fields, not just medicine or used cars.
Posted 4/3/2019 3:11 PM (GMT 0)
I am somewhat limited in total PCa knowledge being a new kid on the block but.................
Given the 4+4, if that is born out by a 2nd, It would appear to me that a single therapy would be a bit dicey. That said though if the cores taken where numerous with only a few with a small volume then maybe. But certainly a large number of positive cores with high percentage of PCa would seem to demand a "multi" treatment approach.

SBRT and Brachy could be a very route to take. There are others as well.

Hoping this person gets the word and accepts it. INVESTIGATE.

Roger
Posted 4/3/2019 5:08 PM (GMT 0)
Yes, those are all solid recommendations.
I believe that the AUA would considers this patient 'high-risk'.
See
https://www.auanet.org/guidelines/prostate-cancer-clinically-localized-guideline

and the guidance is
• Clinicians should recommend radical prostatectomy or radiotherapy plus ADT as
standard treatment options for patients with high-risk localized prostate cancer

Personally, I would not favor surgery, but I may be biased and didn't go to Med school.

Post Edited (Sr Sailor) : 4/3/2019 11:23:09 AM (GMT-6)

Posted 4/4/2019 9:49 PM (GMT 0)
If he's adverse to surgery, then IMRT + brachy boost (plus ADT) could be a very good treatment. But it would be good for him to first get a second opinion on his biopsy slides from Epstein...if he lucked out and was downgraded to a G7, he may not need the multi-treatment.

FYI, I was initially diagnosed as a G8 and I went the other way--to a G9. In my case, I was considering surgery as if my second reading came back as G7, but decided against it as a G9.
Posted 4/6/2019 11:35 AM (GMT 0)
As a solid G7, I went for the trifecta. It almost worked.........almost.
Posted 4/6/2019 12:12 PM (GMT 0)
I'm a G8 survivor. I had the robotic surgery back in 2009 without nerve sparing which obviously caused permanent ED.
Looking back, and seeing all the advances in radiation results I may have chosen another path. My Urologist told me that back in 2009, they didn't do radiation after surgery unless the PSA started to rise. He told me that if my surgery was done today, he would have followed my surgery with radiation for those with Gleason 8 and above.
Posted 4/9/2019 5:16 AM (GMT 0)
I would definitely do surgery. I was a Gleason 4+4 and I had surgery. I had a world renowned surgeon who had done thousands of surgeries and I had full continence within a month. Used Viagra for first 8 months to get an erection but don't use anything now. I was pT2 with a focal margin. Ductal Adenocarcinoma GL 8. PSA has been <0.02 for a year now. Lowest level local lab can detect. Surgery was the way to go. Glad I did it and moving on with my life.
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