Second Biopsy, Gleason 8. Treatment?

Happy Thanksgiving. Just got results of my 12 core biopsy. Four of 12 cores have cancer, two from right base Gleason 4+4 (10 mm of 28 mm) and two at left base 3+4 (6mm of 30 mm). DRE normal, PSA 3.3.

First biopsy three years ago showed minimal Gleason 3+3 (ordered after PSA rose above 5).
I'm 66 in good physical shape.

Next step CT scans etc. to check for spread.
Question: Assuming cancer has not spread yet, what's your treatment of choice?
Thanks much, SailingBob

Bob,
Have the biopsy slides sent to Epstein just to be certain. On HW we always encourage members to speak to specialists in their field of practice. Don't get radiation advice from your Uro/surgeon and don't take surgery advice from a radiation oncologist. There are several sub-specialties for RT. Have consultations with practioners of each of these therapies. Then, you are better prepared to pick the treatment that suits you.

There are guys who have strong biases for treatments - usually based on the side-effects of the treatments. The "cure" rates for all the available treatments are about equal.

Good luck and Happy Thanksgiving.

Agree with all three posts above.
As far as I am aware, HD-brachy isn't practiced by many. Low-dose brachy with seeds and SBRT are alternatives.
Hope that the scans will bring you 'good' news, considering the alternatives.

Sorry about your latest results--and just in time for the holidays. Agree on the need for a second opinion on your biopsy slides--particularly as a G8. I was also initially diagnosed as a G8 and my second opinion knocked me up to a G9. At that point, I definitely knew I was in the high-risk camp and planned accordingly. But I also could have gone the other way and been re-classified as a G7 and that would put me in the intermediate risk group. You definitely want to know what you're dealing with.

As to treatment, you'll want to check out all your options. If you have surgery, the higher risk you are, the more likely you are to need radiation as a back-up. In my case, that led me to jump straight to radiation--specifically, HDR brachy and IMRT (with ADT thrown in). Where are you located? We may be able to suggest some docs for you to see.

BTW, my diagnosis was also on my second biopsy, leading me to believe the first biopsy missed my PCa. (First one was completely negative.) But even if that was the case, seven years later I'm doing fine with a low and steady PSA and no real SEs. Chances are you will do well also.

Bob,

Welcome to our club. I'd agree with the recommendation for a second opinion. Beyond that, one of the best places in the US for PC treatment is Swedish Hospital right there in Seattle. There are several guys who have been here who got treated there.

I'd look at SBRT--which is a combined treatment with seeds and external beam radiation--only 5 treatments over 2 weeks.

Bob

Your numbers are almost identical to mine at diagnosis.

I was treated with ADT, IMRT, LDR seeds

Great advice from the previous posts.

Good luck

Al

Also UW/Seattle Cancer Care Alliance.

Great advice. I was leaning towards surgery...have the robot scheduled for early February. But, the rationale for seeds plus high beam radiation are compelling. The immediate after-effects of surgery, the catheter for a week, don't sound like much fun. Well, bone scan and CT scan later today. If those show spread I guess that will make the decision for me.
This week I've been listening to the music of the late Warren Zevon, and reading "Being Mortal" by Atul Gawande. Both highly recommended, even if you don't have cancer.
Again, thanks to all of you for your insights, advice and compassion.

Bob, I'll endorse the opinions of several on this thread namely, (a) get Dr. Epstein's take on your pathology and if confirmed a G8, (b) a double dose of RT depending on the specific protocol of your RO. With an aggressive cancer there is a good chance that surgery may not get it all, leaving you with radiation anyway and the resultant side effects of both.

Good luck,

Jim

SailingBob said...
Great advice. I was leaning towards surgery...have the robot scheduled for early February. But, the rationale for seeds plus high beam radiation are compelling. The immediate after-effects of surgery, the catheter for a week, don't sound like much fun. Well, bone scan and CT scan later today. If those show spread I guess that will make the decision for me.
This week I've been listening to the music of the late Warren Zevon, and reading "Being Mortal" by Atul Gawande. Both highly recommended, even if you don't have cancer.
Again, thanks to all of you for your insights, advice and compassion.

you asked and not a single person recommended surgery and you can add me to the list. I would NEVER chose surgery for prostate cancer unless there were some reason I could not have a radiation treatment, and in your case I would be looking at triple play. my recommendation is act quickly -- don't get caught up in a bunch of stupid tests that will only delay treatment.

and speaking of warren zevon here's a quote that applies to me!

“I might have made a tactical error not going to a physician for 20 years. It was one of those phobias that didn't pay off.”
-- Warren Zevon

I chose surgery after considering all the options. The bone scan was neg, the CAT scan neg, the MRI didn't indicate any progression outside the prostate. I didn't like the radiation option due to putting the gold chips in the prostate, injecting some kind of jell between the nut sack and butt to push the colon away from the prostate, and the testosterone reduction treatment supposedly making me tired for a few months, and then having I think 28 treatments.....all of this with still after effect possibilities......ED, incontinence, and possibly bowel problems. Everyone comes out of all these treatments differently. Just because one person does well with a particular treatment doesn't mean another will fair the same. My main reasons for going with surgery, if the cancer has not gone outside the prostate, were get it out of me with minimal chance of it spreading later, and if it does radiation is still available. They can also remove lymph nodes for biopsy during the surgery to see if any spread there, which of course you can't do during radiation treatment. If radiation is the treatment choice and it doesn't get it all, surgery is probably ruled out as secondary treatment. I was also in very good physical condition so the medical staff felt I was best suited overall for the surgery option, even pushing 73. The catheter was a hassle for 12 days, and after it was removed I had severe incontinence for about 2 weeks but now, 9 weeks after surgery, I'm dry except when I exert myself so I wear a pad to the gym and other exercise and hope it continues to improve. I have ED which also hopefully will improve but I guess this comes with any treatment. I had soreness in the area between my nuts and butt hole, like riding a bike too long, for about 4 weeks and also developed a urinary tract infection which they treated with antibiotics. The facility where I had my surgery brought in a Divinci single port robotic surgery machine early 2019 which they used on me....only one small (3/8") slit lower right ab and a 3/4" slit below the navel for prostate removal, no drain tube. I never had pain from the actual surgery. I went home that evening. First post op PSA 0.01. I guess I would go the same route again.

With a G(4+3) man having surgery, ten year studies have shown a recurrence rate of 35 percent. That is much higher than the results for intermediate risk men reported by the two advanced types of radiation, SBRT/Cyberknife and proton beam therapy.

Also, incontinence is rare among RT patients.

If surgery is difficult after RT, that is misleading, as there are several non-surgical salvage treatments available should there be a recurrence after primary radiation.

I'm happy to read of surgery patients who were satisfied with their choice, but I've also read way too many negative accounts.

Surgery may be a good choice especially if you have poor urinary function, have a compellingly need to either get it out or see significant value in a having a pathology report. However, surgery can be brutal and often chosen by men who only rely on the advice of their urologist. The statistics show equal cure rates for low and intermediate risk guys with either RT or RP. My urologist was ready to schedule surgery even though my biopsy showed only a small amount of Gleason 6. Thanks to this forum I found great information and started asking questions. I found it very difficult to get easily understood and/or unbiased data regarding the long term side effects for both. I watched as many treatment videos as I could find. I found no significant information that surgery either open or robotic assisted offered any benefit for my situation compared to any of the radiation treatments. The high rates (15-80%) of ED and the strong likelihood of reduced urinary function associated with surgery frightened me.

Once surgery was ruled out I focused on the various radiation treatments. My insurance would cover either the 45 EBRT treatments or the low dose ‘seeds’ and I could have either locally. The information on SBRT looked like it offered the highest cure rate with the lowest side effects; however, it involved some travel and was out of network. After several discussions with my insurance provider they finally gave authorization to go to CCI for evaluation and a second opinion. That visit confirmed my choice.

I’m just a data point of one but feel my experience is the norm and not the exception. I encourage everyone to make an informed decision regarding what treatment is best for them.