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4+3 and 97 PSA — considering treatments now

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Posted 10/25/2021 5:59 PM (GMT 0)
As I mentioned in an earlier post, my father-in-law, 73 years old and in otherwise good health, was diagnosed with PC about a month ago. 6% of one core was 4+3 and another core 3+4 at 67%. No adverse findings at this point. He has met with a Uro who recommended RALP and he has appointments scheduled with a radiologist and a different uro at the same hospital. Also he will be seeing a uro and a radiologist at MSK in the coming days. MSK will also be giving him a second opinion on his biopsy slides. I’ll be joining him at his radiologist appointment at MSK. Based on what I wrote above, do you have any thoughts on a treatment path for him? From what I’ve read here and elsewhere, a triple play might be worth investigating, surgery may be an option, and SBRT probably isn’t. I’m far from an expert on the subject, so going into the appointment with him on Nov 9th with some general ideas of realistic treatment options would be helpful. Thanks.
Posted 10/25/2021 6:35 PM (GMT 0)
Paul,

If the scans show nothing unusual or concerning, monotherapy may well do the job for him. It's good to get MSK to take a look as well as whoever is primary back home.

At 73, I recall the words of one famous prostate surgeon who said that he would only perform a prostatectomy on a man over 75 if he brought both parents to the consultation. That is a valid statement here, as well. He's intermediate risk, so the need to weigh the downsides of aggressive treatment such as 'triple play' against his QOL at his age.

Again, if his scans show everything is where it belongs, then I'd think one of the radiation monotherapies, such as SBRT with a short course of ADT would be an excellent treatment for him.
Posted 10/25/2021 6:41 PM (GMT 0)
Paul, with a PSA of 97, I would not be surprised if there was more going on than just those 2 cores of intermediate risk cancer. For that reason, combined with the fact that while he is "only" 73, he is not 53, leads me towards some form of radiation, which specific one is beyond my pay grade
Posted 10/25/2021 8:02 PM (GMT 0)
I agree
Posted 10/25/2021 8:30 PM (GMT 0)
Your father-in-law's PSA indicates there may be something other than prostate-confined PSA going on.

Djin
Posted 10/25/2021 8:44 PM (GMT 0)
I'm assuming his radiology appointment is for bone scans and a CT scan? Maybe an MRI too?

A PSA of 97 as noted is high, maybe with a high probability of mets. If that's the case, he's likely looking at palliative treatment of Lupron + one of the second line ADT medications.

Somehow I feel like there may be some missing information.
Posted 10/25/2021 8:46 PM (GMT 0)
I think the focus at this point is determining what's driving that very high PSA before making a treatment decision. Has he had a post biopsy PSA to verify the high PSA or is there any history of the very high PSA?
Posted 10/26/2021 5:50 PM (GMT 0)
Appears to be very high risk and most probable Mets if the PSA is due to PCa. That coupled with his age should clearly rule out surgery. How is his health otherwise? Radiation can be used and often would be after a failed surgery for most men in this risk category. What have the scans shown? What is the estimate of his prostate size? Does he have a history of extreme BPH that could explain the super high PSA? I am guessing he doesn’t have any prostate history as no one would allow the PSA to go so high without a bx or search for the reason. Is this his first PSA in a while? What prompted it?

If it shows to be localized, the most effective treatment would be HDR brachytherapy paired with external beam radiation like IMRT-IGRT including the pelvic lymph nodes, and ADT in the 12-18 month range. If significant local spread and or distant Mets are found then clearly no surgery and perhaps might even take radiation off the table. I can’t imagine a situation of mono-therapy HDR or SBRT that would be used with such a high PSA unless the reason is other than PCa. Has anyone started ADT? Or even suggested it? With that PSA and a positive dx it is a near certainty.

I just re-read your original post that didn’t mention the PSA. In your subject of this post you report 97 PSA. Is that correct?
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