New Member - Intermediate Risk - Decision on Therapy

Welcome, just heading to bed and saw your post. You will get a number of responses in the early morning since prostate people get up early for some reason.

Please note that you have plenty of time (few months) to fully evaluate your situation and treatment options based on your diagnosis. No need to go with the first doctor that proposes a solution. Your testicular cancer should not be related other than general location but those are questions for your urologist.

Where are you located would be my first question? At the very least, you will will want to visit some radiation treatment doctors (radiation oncologist or RO in prostate speak) for the other side of prostate treatment options and possibly a respected cancer center at the state university or major medical institution that would hopefully give you a more balanced evaluation.

Take it slow and learn as much as you can before making any decisions.

Be sure to make an appointment to see a radiation oncologist before committing to surgery. Frankly, I don't think much of statistics from a surgeon on the percentage of his patients with different side effects. If he operates only on people who shouldn't be treated, then he'll have low side effects. If he treat patients with more serious problems, he'll have more side effects. Unless you know who he has operated on, his statistics don't tell you much. I think you should pay more attention to the rates of side effects generally for surgery compared to radiation. At 60 you'll have a long time to live with any complications such as ED or leakage, so choose wisely! Do your research!

Thanks again guys, I will definetley make an appt at Henry Ford. I was actually interested in laser focal therapy and even called an office in Houston. They advised I would need an MRI which was not covered under insurance before an ultrasound was performed, so I had to go that route first. In metioning this to the Urologist he didnt say absolutely it wouldbe an option but stated my amount of cancer is pretty significant. So here are some more details in that regard. The 4 samples with cancer are (G,H,I,J). The % is much higher in someof the samples than I had indicated earlier going from memory. The cancer is grouped on the left side. So thanks again and if you have any further it is most welcome and appreciated.

Summary: Positive cores 4 out of 12, highest Gleason grade 3+4=7 (ISUP Group 2) , PSA 5.74 ng/ml, DRE: normal T1c.
According to NCCN guideline this tumor would be considered intermediate risk.
Speculated TNM stage= T1c N0 M0.
Perineural Invasion is identified.
No Extra-prostatic extension is identified.
Gleason 4 ranges between 0% and 40% of the tumor in these cores.
Cribriform pattern 4 is present.

A. D. E. F. K. L. Prostate Biopsies(RA, RLM, RB, RLB, LB, LLB):
Benign prostate tissue
B. Prostate Biopsy(RLA):
Benign prostatic stroma, no prostate glands are present for evaluation.
C. Prostate Biopsy(RM):
Atypical glands present suspicious for adenocarcinoma (ATYP)
G. Prostate Biopsy(LA):
- Adenocarcinoma of the prostate, Gleason Grade 3+3=6 (ISUP Group 1). Tumor length 1 mm involving: (5%)
H. Prostate Biopsy(LLA):
- Adenocarcinoma of the prostate, Gleason Grade 3+4=7 (ISUP Group 2). Tumor length 9 mm involving: (60%)
I. Prostate Biopsy(LM):
- Adenocarcinoma of the prostate, Gleason Grade 3+4=7 (ISUP Group 2). Tumor length 17 mm involving: (30%
patchy)
J. Prostate Biopsy(LLM):
- Adenocarcinoma of the prostate, Gleason Grade 3+4=7 (ISUP Group 2). Tumor length 9 mm involving: (40%
patchy) Perineural invasion is identified.

Expert opinions on focal therapy (FT) vary considerably, some advocating that it should be used only in the setting of a clinical trial and not as standard of care. Those in favor of its selective use, say it's best suited when there is a primary larger ("index") lesion of low or intermediate risk to be treated and just a very few other, very low risk lesions.

I don't know how many times FT can be done (or the expense) if the untreated (or new) lesions require treatment in the future.

While FT could solve one's PCa issues, it seems to me one is collecting sources of anxiety: only partial treatment of one's cancer, the psychological anxiety of AS with future imaging and biopsies, the worry about needing future treatment, and, possibly, having to make a decision on that treatment and going through it.

Djin

MI...Sorry to have you join us but glad you found us. I don’t believe you’re a candidate for AS; however, a lot of treatments are likely to offer a cure. It’s a little overwhelming at first wading through the different radiation options but it’s important to do so. You may wish to reduce the number of radiation options to avoiding meeting with each specialty but I encourage you to at least understand each and interview those that seem to have a fit.. This forum is an excellent place to start and you’ll find questions very welcome. Keep in mind each of us is just a data point of one in our personal experience. The best treatment decision is an informed one. I also always recommend seeking out the very best practitioner and team for whatever choice you find best for your situation. Keep us posted. Terry

Hi M1 and welcome. Sorry you have to be here but we will help where we can.

Your diagnosis, while still cancer, is not all that bad as diagnoses go. With a low intermediate cancer you are likely to be cured by any of the mainstream treatments the first time out so I would recommend you also think about potential side effects. I was only 2 years older than you when I was diagnosed and I know that cure was first and foremost but I also wanted to make sure I lived out my golden years both continent and potent...and I have.

These are the things I would suggest to you:
1. Send your biopsy slides to Dr. Epstein and JHU. He is the expert and you can have confidence that you have the best possible pre-treatment assessment of your cancer.
2. Get educated. The sticky thread at the top of our forum is designed for newly diagnosed patients and people have told us that it helps. There are tons of books on our cancer but three I would recommend are Dr. Walsh's, "Guide to Surviving Prostate Cancer" (more of a surgery bias) and two books by Dr. Scholz, "Invasion of the Prostate Snatchers" and "Keys to Prostate Cancer" (more of an anti-surgery bias). You need the broad perspective beyond what you will get from your urologist and you must be your own advocate.
3. Get multiple opinions from different docs. See an experienced RALP surgeon, i.e. more than 1000 procedures. Also see some radiation specialists...LDR Brachy, HDR Brachy and SBRT are all likely to give you the same cure odds as surgery with a better chance of avoiding onerous side effects.

We don't have many members who have used focal therapy on their cancer since prostate cancer tends to be multi-focal. So most of us have gone for the whole enchilada. But there have been some who have done this successfully. One is Ziggy9 who doesn't post here anymore but I you can search for him and send him an email; I'm sure he would be glad to share his experiences.

Good luck. Stick with us and ask any/all questions. We are here to help.

Jim

Hello Guys, Back again. I mentioned my cancer samples were sent to Utah for more thorough study. This test is called a Prolaris. The results are that I am a candidate for active surveillance. I am not sure this is the right path, but at least it takes some heat off for awhile. I am certainly going for a longer life than 10 years, but it helps put this cancer diagnosis in perspective. I dont see a way to upload my report so Ill try to explain. The results indicated a 10 year prostate cancer DSM (Disease Specific Mortality) of 2.2% with active surveillance, and a 10 year Metastisis (METs) of .7% with single modal treatment. My Prolaris molecular score is 3.2. This is a measure of cell proliferation, independent of clinical variables. I hope this is enough information to weigh in on these results. Thanks and any feedback is appreciated.

Hi M1, I would get more expert opinions if your are serious about AS, but I believe you are a poor AS candidate for these reasons:

1. Most published AS protocols at major institutions that allow G7 (3+4) allow just one low-volume core -- you had three such cores in three different zones, one with a high percentage tumor (60%) to boot!

2. Perineural invasion (PNI) found at the time of biopsy is correlated by many -- but not all -- researchers with a higher risk of adverse findings being present, as confirmed in those men who go on to RP and have their entire prostates examined. (As many as 80% of men who do surgery have a finding of PNI somewhere in their prostates; however seeing it at the time of biopsy, when only a tiny amount of tissue is sampled, is taken as a sign that it has been there longer and is more extensive.)

3. The presence of cribriform pattern 4 is another finding associated with a poorer prognosis and even alone may be reason to rule out AS and seek treatment.

Prostate cancer with cribriform pattern: Exclusion criterion for active surveillance? (2020)

"Following the 2014 International Society of Urological Pathology meeting, a rapidly growing body of evidence by several researchers has been demonstrating a poor prognosis in association with cribriform morphology"

Update and optimization of active surveillance in prostate cancer in 2021

"The pathologist must identify the cribriform or intraductal histology on biopsies in order to exclude these patients from AS, in the same way as with patients with alterations in DNA repair genes."

4. Regarding metastatic potential, it's encouraging that your Oncotype genomic test came back low risk. However, (a) prostate cancer can advance locally with non-metastatic growth into adjacent tissues, and (b) genomic tests done on biopsied tissue can miss lesions with a higher metastatic potential (just as they can miss lesions with a higher Gleason score than any found). Or, even if your biopsy did capture a "worst-case" lesion, the genomic test may not have sampled it. In fact, the Decipher Prostate test (a competitor of Oncotype) clearly states on its reports that results done on biopsy tissue correlate with the same person's results done on post-RP tissue 70% of the time, which means, of course, that 30% of the time it doesn't (the reason again being either that the biopsy missed a lesions with a higher met risk or that neither of the two different tissue samples Decipher tests captured the worst case lesion).

I'm only suggesting you do due diligence and research these topics with regard to AS and your diagnostic workup results before making a decision. If you do begin AS, be sure to have your confirmatory biopsy within a year, as the best AS programs advise.

Did you get a second opinion on your biopsy pathology? Have any of your docs told you that you are an AS candidate?

Djin

I have to agree with DJin that you are probably not a good candidate for AS. The amount of Gleason 4 present and the cribiform pattern would make me seek treatment if I were you.

I would suggest that you look at SBRT/Cyberknife radiation. It has very impressive non-recurrence results for intermediate risk men.

M1 - Another resource that may help your understanding of PCa, only a few paragraphs on AS but the rest is good information.

https://www.pcf.org/guide/prostate-cancer-patient-guide/

I have the engineer’s curse as well where the optimum solution is never achieved due to time constraints so you make a decision with full knowledge that you don’t have enough information. My Dad (also engineer) wondered if I was studying to go to medical school when I was running things by him. Just do what you have to do then proceed full speed ahead.

M1, gotta agree with the others re the doubts on AS. Move forward and get all of your options covered...you need to get some RO appointments on your schedule....ones that specialize in HDR Brachy, LDR Brachy and SBRT.

Jim