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Intro, candiate for AS?

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Posted 2/8/2020 2:20 AM (GMT 0)
As a 62 YO, my PSA has bounced between 6 to 9 over the last 10 years. At 8.2 I had a clean biopsy, but now at 9 I have a new PCP who suggested an MRI. The results were "PIRADS 3 - Intermediate (the presence of clinically significant cancer is equivocal)". So I had a 12 sample biopsy which yielded two cores at the right apex with 70%, 75% of each core cancerous scoring a 3+3=6 Gleason at the local path lab. I talked with local oncologist who suggested Brachy, and a local surgeon who of course suggested robotic PR. We sent the slides to JH and went there for a second opinion and to see if AS would be an option. The JH path lab rated the two cores a 3+4=7 and as such they do not recommend AS (although they acknowledge that others do recommend AS with this Gleason Score). We have additional scheduled appointments with a JH oncologist and a JH surgeon for more opinions.

So, does anyone have experience with AS at this level? I'm reading this forum and others and find it hard to normalize everyone's results/side effects as the technology is changing so quickly that long term studies don't seem particularly relevant and everyone starts from a different place.
Posted 2/8/2020 2:47 AM (GMT 0)
AS is probably not the best idea from what I have read with a couple of high percentage 3+4’s. The good news is probably any treatment should provide good results for eliminating the problem so you have that going for you. You probably do not have to hurry too much so you can read a PCa book and visit a few doctors to help make your decisions. Sometimes the forums are more confusing than helpful when it comes to making treatment decisions and there seems to be a study that says anything you want it to say if you look hard enough. You are doing the right thing seeing a number of doctors and JH is a good place to go for evaluation.
Posted 2/8/2020 2:50 AM (GMT 0)
Hi and Welcome to the Forum! Yes, some AS protocols allow for a G7 (3+4) core (I didn't know that any allowed two G7 cores). I personally would not do AS in your case, but if you are seriously considering it, I highly suggest a genomics test, like OncotypeDx or Decipher Biopsy, to ensure you are low genetic risk for metastases. BTW, JH has one of the strictest AS protocols. Your percentages of cancer in your G6 cores might even disqualify you from their program.

Djin
Posted 2/8/2020 2:51 AM (GMT 0)
As you can see from Johns Hopkins acknowledgement, there are differing opinions regarding AS with G7(3+4).

I would be inclined to not screw around when pattern 4 cells are involved, especially with 70-75% of the two cores being cancer. Put another way, i'd say go with JH recommendations and treat, dont do AS.
This stuff is highly subjective, so others may disagree.
Posted 2/8/2020 2:52 AM (GMT 0)
I would have qualified for AS with my original G6 dx... Glad I went the treatment route as it has been a very tough and pesky G6 to corral... smile

pasayten
Posted 2/8/2020 3:06 AM (GMT 0)
If it were me I wouldn't roll the dice on that one. In fact in 2015 they hit a single core of 3+4 @ 25% and that pushed me over the edge. Naturally, all of us have different risk tolerances. And no 2 situations are the same. Based on the outcome of my treatment - I'm glad I did it my way. I had one doc reference some Canadian study that recommended AS for certain patients w/ 3+4 given limited conditions. But it wasn't enough to change my mind. Treatment is no fun regardless of type. The best you can do is speak with professionals to get their opinions, read the research and if you're a believer ask the Almighty for guidance - then let the chips fall where they may. But the FINAL decision rests with you.
Posted 2/8/2020 12:34 PM (GMT 0)
As others have said, it's possible to do AS with your diagnosis but...I personally would not do it either and would opt to treat now. IHMO surgery is overkill for you and it seems that LDR Brachy (seeds) or SBRT would be excellent solutions.

Jim
Posted 2/8/2020 1:20 PM (GMT 0)
I have to agree with the others that some type of treatment is necessary. I’ve always used the criteria of two cores with 10 percent Gleason(3+4) as the threshold for leaving AS.

If going to JH, talk with Dr. Pavlovich about the new TULSA-PRO treatment. I understand that he will be opening a second clinical trial. The first one generated a lot of interest among low and intermediate risk men.
Posted 2/8/2020 2:29 PM (GMT 0)
You are a young guy....eradicate the critters. Sure its a month or two of inconvenience no matter how you deal with it, but you can now decisively deal with it.
Posted 2/8/2020 3:56 PM (GMT 0)
Welcome to HW. Just wanted to pop in and say hi!

You've gotten some great info already on this thread.

Do keep us updated with your progress.
Andrew
Posted 2/8/2020 7:08 PM (GMT 0)
The others have already given you a lot of good advice, so I will simply speak from my own experience.

I was 68 at diagnosis, having had gently rising PSA for some years. When mine hit 5.69, I had a 12-core template biopsy, which showed 3 cores with low percentage of 3+3, and one core with low percentage of 3+4. With "only" one core at 3+4, I may have been able to go the AS route, but decided that for me, any grade 4 cells meant I should/would treat.

I did a lot of research, mostly about my treatment options (and there were quite a few of them), but also about the immediate impact of each treatment and their side effects. The immediate impact of surgery drove me to choosing radiation, as I had already had several significant surgeries and my cardio and I felt that another would bring too much risk. That decided, I researched the efficacy of various radiation therapies, where they were offered, how they would impact life during treatment, and, most importantly, their known side effects. Ultimately, I found that a couple of radiation methods would have similar efficacy, so I chose my ultimate treatment based upon its side effects.

I won't bore you with "what" I chose, or the specifics of what was important to me, as your situation will be your own. I am only counseling you about "how" I chose my path. I can go into a lot more detail if you want, but just the thought about there being several valid treatment choices for your Gleason score, and that you may be able to choose based upon side/after effects is what I wanted to impart.
Posted 2/8/2020 7:09 PM (GMT 0)
Hello Y-a-me,

After my MRI came back with a PIRADS 4 lesion, I had a 15 core biopsy resulting in a Gleason 3+4. My disease is in the mid-upper sections of the left side only. Second opinion reading of slides read by JH found 10% pattern 4 disease only in the lesion and all other positive cores, 7 out of the 15, were 3+3. This was an overall downgrade from the initial reading by the local hospital pathologist. My URO, who completed a fellowship for AS, stated that because of my low percentage of pattern 4 disease, I technically could consider AS. He did recommend that I get gene testing first, so my tissue samples were sent out for an Oncotype test. Those results tipped the scales to "go directly to treatment" for me. My score was a 37 out of 60, and AS should only have been considered for scores less than 20. My highest PSA level was about six weeks before my biopsy at 4.9.

If I had been diagnosed with two positive cores at 70/75%, located in the apex, I wouldn't have even bothered with the Oncotype test. Right now, I assume you are a candidate for mono therapy treatment. I know I would regret waiting for it to become a 4+4, or worse, requiring a multiple treatment approach. I might also want to know about the possibility of disease extending out of the organ from the the apex area before strongly considering AS.

You are asking all the right questions. For me, the information I received from this site was/is invaluable. As is frequently stated, continue with your research. Eventually, you and your doctors will decide on the best course of treatment for you. GOOD LUCK!
Posted 2/8/2020 8:29 PM (GMT 0)
Welcome to our club--it's good here, really. Yeah, with a couple of 3+4 cores, you're probably not an AS candidate so....the next steps are to have the consults with the specialists. Surgery, any of the multi-flavors of RT are likely curative for you at this point.

They will probably want some additional scans just to be sure there isn't anything nasty going on, and then--you get to make a decision. For me the key balance point(s) for the decision come down to your personal assessment of the various risks, your degree of difficulty related to the different options (I elected against the 40 treatment EBRT because I didn't want to spend 4 hours on the road every day for 6 weeks)--that was because of where I lived at the time.

In the end, you'll know what the right choice is.

Oh, get yourself a big accordion pleated folder and a spiral notebook. Take it to all appointments to take notes and write down questions. Get copies of all the reports, information sheets, etc. It helps to have someone with you to take notes.

Come back often with your questions and insights, we'll answer as best we can--or, if you need talking off the ledge, we'll do that too.

Hang in there....you'll look back at this as a bump in the road of life.
Posted 2/14/2020 4:44 PM (GMT 0)
I don't think AS with 2 cores 3+4 with high involvements.
Posted 2/14/2020 6:41 PM (GMT 0)
AS might or might not be an option, but if possible, personally that would be my 1st choice. Being actively monitored, you won’t miss your window of opportunity to get treated when it becomes necessarily. This all depends on your tolerance risk and your own priorities. In the meantime, your QoL won’t be affected at all. In 2016, I was diagnosed at 51 with 4+3 with 1 core positive out of 12 and total of 12%. . I had 55% of 4. No one wanted to accept me in AS. Brachytherapy was not an option because of TURP 3 months prior. Wanted to avoid RP to all means but per my wife pushing I ended up with RP and very bad SE.
MK
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