New Here--Looking for advice

If you go with RT, make sure you discuss the prognosis for your LUTS with your RO in conjunction with the planned total dosage and the size of the radiation field.

Djin

My urinary and sexual function were both very good prior to SBRT. I did have some of the typical burning sensation when urinating during treatment and lasting about two weeks that did not require medication and resolved on it’s own. Other than that minor issue and very little ejaculate everything else is the same. Since I did not have LUTS it’s certainly worth discussing with a RO.

Surgery to remove a prostate is brutal and you do lose one of your urinary sphincters that can play a major role with bladder control later. The information gained with surgical pathology may have limited value and the risks of complications for a 76 yo guy should be considered. HoLEP is worth investigating and maybe the gold standard today for BPH issues.

Djin, Great point since biopsy only samples a small part of the prostate. No doubt that surgical pathology provides some additional and valuable information about the tissue that was removed. Unfortunately it doesn’t provide any guarantee about what was left behind. Far too many men have experienced failed prostatectomy even after the margins and lymph nodes appeared ‘clean’. The question becomes one of weighing the value of surgical pathology against the risks of having surgery. I believe far too many men choose surgery when radiation treatments would be a better choice. BPH issues become another factor in the choice of treatment.

Terry's Cellar said...
Djin, Great point since biopsy only samples a small part of the prostate. No doubt that surgical pathology provides some additional and valuable information about the tissue that was removed. Unfortunately it doesn’t provide any guarantee about what was left behind. Far too many men have experienced failed prostatectomy even after the margins and lymph nodes appeared ‘clean’. The question becomes one of weighing the value of surgical pathology against the risks of having surgery. I believe far too many men choose surgery when radiation treatments would be a better choice. BPH issues become another factor in the choice of treatment.

Fortunately, most men have a choice between two treatment paths and two men with identical PCa statuses can make differing choices and be happy. All I campaign for is an informed decisions based on one's specific status. Neither option will catch the case where distant micrometastases have gone undetected, probably long before diagnosis. RT has the advantage that it can treat micrometastases in regional nodes from the outset, whereas with RP you wait for BCR unless there is persistent PSA and.or the path report's adverse findings consel adjuvant. PSA-a blunt tool at diagnosis--after surgery becomes an exquisite metric

However, I came to this from the smaller cohort of very high-risk men. I had no guarantees that my primary treatment would end at surgery, a point my uro/surgeon made clear to me when we were discussing treatment options. However, my post op path report (and Decipher test) showed me that high-dose RT plus two years of ADT--the upfront alternative to RP after my G10 (5+5) biopsy--would most likely have been overtreatment for me. Of course, it remains to be seen how I will fare in the coming years, but the same would hold true after a successful RT+ADT choice). This is why I emphasize the importance of one's diagnostic status. Many men with similar diagnoses do not have my outcome: they will need RT +/- ADT after surgery.

My history of BPH and evidence in favor of having caught my cancer early weighed heavily in my decision for surgery. I would have paid a pretty penny to have known at the time of my TURP that I would be diagnosed with PCa a few years later: one surgery with a chance to cure both conditions with the luxury of a crystal ball. (At the time of my RP, my prostate had grown back about half of the 60 g removed at my TURP; BTW, many men need a repeat treatment for BPH).

Djin

Post Edited (DjinTonic) : 1/4/2023 2:40:16 PM (GMT-8)

Thanks everyone.
I received second opinion on biopsy from Stanford. Essentially same as original report but substantially lower percentage of area that is pattern 4. All Gleason scores same--one 3+3 and rest all 3+4. PNI, cribiform pattern 4, and possible extraprostatic extension. My MRI and my PSMA PET/CT were also iindependently reviewed by Stanford. Opinion was "PSMA PET/CT showed PyL binding within left peripheral zone of prostate and no activity to suggest metastasis".
I am don't want surgery if I can avoid it. I am meeting with a Stanford urology radiation oncologist tomorrow to go over options.
I am not familiar with terms HoLEP or LUTS. Can someone point me in the right direction ?
Also, Dr. Scholz of PCRI refers to "teal patients". Is that another way to describe Group 3 Pca ?

centralPAdude said...

They were able to look at the pathology of your TURP at the time, correct? Came back negative?

Definitely--tissue removed in TURP is always sent to pathology. Yes, mine came back negative, just like all the many other biopsies I had over a 20+ year period! The majority of cancer lesions form in the outer part of the prostate (the cortex); the tissue removed/zapped for BPH treatment is that around the urethra, where--if I remember correctly--lesions develop in only about one-third of cases.

After my TURP my uro upped my schedule to 6-months visits. I had one or two more negative biopsies after that (for rising PSA) until my last, which found 2 lesions. Of course cancer may be developing for years, perhaps decades, before it's diagnosed. My cancer involved only 5% of the prostate. My last biopsy was triggered by a new nodule felt on DRE. Ironically, the nodule turned out to be benign, but that same biopsy found two lesions in other zones (2 of 14 cores were positive).

If my cancer was caught early, I credit my extremely vigilant uros, especially my current doc, who did my successful TURP and RP. I never hesitated or questioned advice that it was time for a another biopsy: when my uro said jump, I jumped.

Djin

Post Edited (DjinTonic) : 1/4/2023 4:52:20 PM (GMT-8)

Hi JAW21. It looks like you are getting expert, honest treatment advice! AFAIK, SBRT studies are at about the 15-year mark. Radiologists title them "long-term" studies, but a urologist will scoff at that. The optimal dosages and fractionation regimes are still being worked out.

Djin

Thanks for the good feedback. It helps my confidence going forward.

It seems to me that Dr Qian is too pessimistic about SBRT long-term results.
As Djin pointed out 15-year results are available for SBRT; by that time, you will be 91...

I received my latest PSA (6.9) which is down from 7.9 two months ago. The Decipher test result was a big dissapointment. My score is 0.83 which puts me in the HIGH risk group (actually 94th percentile). This correlates to a 7.1% 10-year risk of metastasis with radical therapy (RT or RP). 15-year mortality risk from this prostate cancer is 9.5%. My RO recommends Hormone Therapy and EBRT.
If the RT is not successful or there are metastases down the line my RO indicated surgery would be problematic after RT (but may be possible) and the same area could not be radiated again, so that would mean immunotherapy or chemo I guess. On the other hand, my understanding is if I have RP there is still RT as a fallback if needed. My further understanding is with RP I would not require ADT and I would get PSA feedback relatively soon that would indicate if the surgery was successful.
The side effects from RT and Hormone Therapy versus surgery are tough for me to weigh.
What bothers me most is the Decipher score of 0.83 which tells me my tumor(s) are potentially very aggressive. While no sign of metastases showed on my PSMA PET/CT, the Decipher score causes me to not be optimistic that the initial treatment (be it RT or RP) will result in long term avoidance of further cancer.
I'm going to talk to my surgeon again and see how the Decipher result affects his opinion.
Am I being unreasonably pessimistic or is the Decipher score a fairly big deal?

Jim

I can understand that your Decipher scores weren't what you wanted to hear. But if you flip them around, you have a 90.5% chance of still being around after 15 years, which is really pretty good if you think about it. Plus, that assumes that treatments don't get more effective over that time frame. While this isn't a slam dunk for you, I'd approach this with the overall knowledge that your initial treatment is quite likely to work.

As to radiation/surgery thing, In the event that radiation didn't work, it's likely that it's because there has been spread beyond the prostate. So i'm not so sure that the fact they can't do surgery after radiation would be an important point in your decision making. I'd focus more on which treatment and set of SEs that you think you'd be better able to tolerate.

Concerning Decipher score (genomic testing), is there evidence linking Decipher score to BCR?

Rockin@57 said...
Concerning Decipher score (genomic testing), is there evidence linking Decipher score to BCR?

Yes, since one's Decipher risk correlates with chances of recurrence, and recurrence is suggested by a rising PSA (BCR). Decipher scoring tells you your risk category (low, intermediate, high) for developing metastases within 5 years of the test.

BCR is the return of a worrisome PSA (0.2 and rising) after your PSA has been undetectable (<0.1) following one's primary cancer treatment (surgery or radiation). BCR doesn't always lead to clinical recurrence of your cancer (where it is detectable on imaging), but most men who aren't elderly choose to have some form of salvage therapy if they have BCR after primary treatment. (BCR can also occur from local recurrence in the prostate bed without metastases.)

So an increased risk for metastases implies an increased risk for BCR: mets are always associated with an increase in PSA, which, if your PSA was undetectable, begins with BCR.

Note that low risk does not mean no risk; and high risk is not a guarantee of having mets.

I'm not sure I'm answering your question, so feel free to ask more.

Djin