Just left MD Anderson consult...not what we expected

Sorry about the upgrade, but better to know than not. Not really sure about the utility of another biopsy - it won't change his G8 for the better. If he has G8, he has it. With him being G8, I like the RO's proposal for "triple play." Not clear to me why G8 would exclude SBRT - maybe those experienced with that can comment.

Clearly the combination of brachytherapy, EBRT and ADT is the best for you. Like me, your risk level points to a very high probability of surgical failure and then needing radiation salvage. This is the worst combination for negative side effects. Proton is no advantage over photon, thus most insurance will not reimburse for PCa.

I have read that many docs will use SBRT with G7, but not beyond. I don’t remember seeing SBRT with brachytherapy. With your high risk situation you should ask your docs about also radiating the pelvic lymph nodes. IMRT is fine for the external beam for the prostate and wider coverage for the nodes.

If you are concerned about waiting, I would see nothing wrong with starting the ADT. They will probably want you on it for a month or so before starting radiation. Like mattam I don’t see why you would have another biopsy. Have your slides been read by Epstein at Johns Hopkins? Is that where the second read is from? If not, I would suggest it.

it's clear to me they don't know what he's got.

Send the original biopsy slides to JH.

https://uoflphysicians.com/blog/2018/11/06/cyberknife-may-reduce-side-effects-of-prostate-cancer-treatment/

The above article indicates the patient eligibility for SBRT. It claims Gleason 7 (3+4) with <50% core involvement is the upper limit. I had Gleason 7 (4+3) with 60% of core involved and both the surgery and radiation doctors said I was not a candidate for SBRT so had surgery. Maybe the limits shown in this article are not followed by all those in the field(?)

JNF said...


I have read that many docs will use SBRT with G7, but not beyond. I don’t remember seeing SBRT with brachytherapy. With your high risk situation you should ask your docs about also radiating the pelvic lymph nodes. IMRT is fine for the external beam for the prostate and wider coverage for the nodes.

I am a GS 9. My treatment plan. Was a triple play of ADT, low dose brachy and SBRT in 5 fractions. Check my signature for my up to date results. And I hope they stay that way

I'd send the slides up for a second opinion.
The triple play is a good choice,
but alcoholism hasn't been proven an effective treatment for anything.

Andrew

Neither of us see any real value in getting a third opinion on these particular slides. The cost is completely a non issue. Another reading won’t change our coarse of action. Our plan was always to get another biopsy. We want another biopsy even more so now. All of the doctors we saw today were scratching their heads at this huge discrepancy in pathology readings. Hubby will likely end up choosing surgery. He is only 51. Dr. Ward said at his PSA level (4.8 at time of biopsy, 6.something today) that he doesn’t believe it has spread. I asked him if it had spread outside of the prostate would it change his recommendation of surgery and he said no, it would not if he is indeed 4+4=8.

Think carefully about surgery. At 51 your husband should have plenty of years of sex ahead of him. Surgery is more likely than RT to result in ED. Surgery followed by RT is still more likely to produce ED.

For each different procedure and treatment you should only accept the assessment of a board certified specialist for that treatment. Do not let the surgeon talk about radiation as he is not the board certified specialist. Just like you do not ask the plumber about the electricity problem just because the plumber happens to be in the house.

Has the surgeon run the MSKCC nomograms to indicate probabilities of surgical treatment success? If so, what do they tell? If not, why not? have you run them? With high risk like you surgical success drops off quickly because the surgery can not cover as wide an area as radiation can. Simple physics and no doctor’s opinion or your hopes can change that.

Your husband’s young age in no way precludes radiation treatment, after all radiation treatment is a gold standard in many juvenile cancers. And of course the surgeon will matter of fact rush to radiation as a way to salvage a failed surgery regardless of the patient’s age. This is not a knock on surgeons, it is just what happens. Radiation after surgery most always results in the worst combination of negative treatment side effects. Simply more treatment damage that is inflicted. Again, just simple physics. And please do not let anyone tell you that he will have a high probability of a radiation induced cancer down the road. Several studies show that the probability is equal to the probability of dying from complications from the surgery. The current high tech radiation therapies pose very little probability of radiation induced secondary cancers.

Based my nine years of direct experience with my own, and hundreds of other men with PCa, here is what I would be doing. Send the slides to Epstein. See a number of other doctors even outside the MDAnderson group. When I was diagnosed, within two weeks I had assessments from three surgeons, two radiation oncologists and a medical oncologist. I considered surgery, both open and robotic; permanent seed brachytherapy; High Dose rate brachytherapy; External Beam Radiation therapy; combinations of surgery and adjuvant radiation, combinations of radiation therapy and ADT; and drug only ADT. Only after the assessments did I make a determination. If you do anything less, in my opinion you will shortchange yourself. You see from my signature that I used the combination of radiation and ADT. All three surgeons said no to surgery because they all knew the probability of surgery being curative was extremely low. After nine years my PSA remains undetectable and I have no negative treatment side effects. For me, this approach and treatment has been completely successful.

You only get one chance at the initial primary treatment. But you hopefully will live a very long time with the outcome. Make very sure you choice is the very best you can make. And remember surgeons, or any doctors, don’t live with your results. You are in charge, not them. They work for you, not the other way around. Thankfully there are many great practitioners that specialize in PCa in urology, surgery, radiation oncology and medical oncology. And thankfully there is no one institution that has all the best. You have many great options. Take a little more time to get direct, specialist assessments from unaffiliated professionals before making your decisions.

star0210 said...
Neither of us see any real value in getting a third opinion on these particular slides. The cost is completely a non issue. Another reading won’t change our coarse of action......

But it might increase your sense of urgency, and speed up a treatment decision.

My surgery consult with MDA did not go very well. I had their pathologist review my slides and they upgraded me from a 3-4 to a 4-3. I inquired what quadrants changed and they provided me with the charts. I was a novice to this all but I had to inquire why most of the affected quadrants seemed to be different from my original charts....
Oops!! They had provided me with an analysis using a different guy's chart.... NOT MINE. Needless to say I was pretty disturbed that they could make such a big mistake. I went with the initial surgeon that I had interviewed with Memorial Hermann instead.
But I did go back to MDA for SRT and everything is good so far.
I agree with the others.. Get a second/third opinion from Epstein/JH.

halbert said...
Star, we would encourage you to consult with the Radiation oncologists and get their take--don't accept what a surgeon tells you about the risks and benefits of radiation therapy. Particularly if the G8 is confirmed, surgery may or may not be curative. Also, there is a variety of PCa that doesn't put out a lot of PSA--at least one guy in here had very high G scores with PSA less than 10.

Hang in there, you're doing ok, MDA is as good as it gets, they know what they are talking about.

We did consult with a RO while we were there. Dr. Tang. He looks 12. Lol
But I really liked him. He suggested EBRT with two years of HT and a brachy boost. I told him I was surprised he wasn’t pushing proton since MDA just spent a gazillion dollars on a new Proton center. He said nah...he’s not a proton pusher. I asked him about SBRT and he said not appropriate for my husbands case if he’s G8. We told him we really wanted to avoid HT and he said if he’s G8 there was no avoiding it.