2nd opinion biopsy with questions

High-Dose Rate (HDR) brachy and SBRT are similar in several ways. Whether one is preferable for a case such as your husband's should be discussed with radiation specialists. You both have some time to learn more.
I have never seen a case that combined HDR brachy with SBRT. However, for higher Gleason scores either therapy can be combined with IMRT and/or ADT (androgen deprivation therapy).

My history shows a combination of SBRT + IMRT + ADT, but this therapy was 'experimental' (and for a Gleason = 9 case).

Please do continue studying the various options for your husband and take into consideration the expertise of the radiology team.

Based on Gleason score, your husband is still favorable intermediate. Typically, at that risk level you would have either SBRT or HDR brachy as a mono-therapy, but it's certainly something to ask the RO about. You would also want to ask if ADT is recommended as part of the treatment. Good luck to you!

Lucky1313 said...
Thank you Sailor, F8, and Michael. If any of you wouldn't mind answering, what made you choose HDR/SBRT over the other? They both seem like viable options and so interested in what you have top say.

i was referred to a radiation clinic that my uro worked with. the brachy doctor was something of a rock star. he used cesium seeds so no HDR for me. i don't think SBRT was a thing back then but these days it would be at the top of the list for me

Lucky1313 said...
Thank you Sailor, F8, and Michael. If any of you wouldn't mind answering, what made you choose HDR/SBRT over the other? They both seem like viable options and so interested in what you have top say.

Like you and your husband, I was new at all this and unaware of HDR brachy. But I had heard of SBRT because I live in the greater Washington DC area and Georgetown U Medical Center ran frequent ads about its radiation oncology center emphasizing SBRT. After my diagnosis (by my urologist) and the usual tests I called the center and was asked to come in for an initial evaluation by the center director (Dr Collins). After looking at the prior tests, he came up with a ('triple play') plan that looked good to me. Because all of this took several weeks, I had time to look up Dr Collins' qualifications. Turned out he had around 100 refereed papers related to radiation oncology. Moreover, he turned out to be very personable and enthusiastic.

As mentioned, I only learned about HDR-brachy afterwards; ignorance may have been bliss for me! Moreover, it turns out that there are not many highly qualified practitioners of this therapy.

Sidenote: My urologist (bless his heart) advised strongly against surgery (because of my age and Gleason score) and recommended conventional brachy (with seeds) followed up by 40 IMRT sessions with ADT on top. In other words, another 'triple play', but a more conventional one.

Best wishes with the decision process!

Post Edited (Sr Sailor) : 1/26/2023 5:35:12 PM (GMT-8)

My take on the biopsy information is that three things point to increased risk that the cancer has already locally breached the prostate capsule: (1) PNI found at biopsy; (2) the apparently wide distribution of the cancer throughout the prostate; (3) the large percent cancer most of the cores themselves.

For this reason, I would discuss with your docs the potential value of a Decipher test on the biopsied tissue to have a better idea of the risk of the 5-year risk (low, intermediate, or high) of metastasis of your husband's cancer.

Looing at the distribution of metastasis risk for all G7 (3+4) men according to Decipher scores across pathology staging:

pT2 (Prostate confined): Low: 56% / Int: 22% / High: 22%
pT3a (Extraprostatic extension): Low: 45% / Int: 23% / High: 31%
pT3b/pT4 (Seminal vesicle invasion or worse): Low: 24% / Int: 25% / High: 50% (Reference)

(Of course men choosing RT have to estimate their pathological staging from their diagnostic workup and imaging results.)

Given the relative low percentage of Pattern 4, let's assume that the risk that the actual Gleason score would be upgraded to G7 (4+3) is relatively small. The numbers become worse if you look at the risk distribution for G7 (4+3)

As one would expect, the chance of being high risk skews upwards at the seriousness of the adverse findings increases. The bottom line is that even though G7 (3+4) disease is in the Favorable Intermediate risk group, I would ask my RO whether the total radiation dose (or perhaps even the RT modality) needs to adjusted accordingly if the Decipher score is high risk for metastases.

Frankly, given that about 22% of even prostate confined 3+4 men are high risk for mets, I would want a Decipher test for planning RT dose and modality in any case. The days of thinking low Gleason score automatically equates to low met potential and non-aggressiveness are over.

Djin

F8 said...
true but in this case and many other cases (mine) you need to treat a larger area than just the gland, and in the case of SRT there is no gland

The OP's condition looks suitable for HDR Brachy, since it appears gland-only. Also, HDR can target extracapsular extension and seminal vessel invasion. It gets combined with external beam radiation quite a lot.

Good reading from my Pennsylvania sites

University of Pennsylvania hospital

Competition down the street at Fox Chase

I'm not a candidate myself, unfortunately, since I had a HoLEP procedure, but I did the research.

You definitely need someone who is good at it, like choosing a surgeon.

Lucky1313 said...
...My husband is still working full-time, but I have more time available for researching, so I do my thing during the day and then we discuss what I've found each evening (he looks into things too, but just doesn't have the luxury of time that I do, plus isn't as obsessive as I am - Ha!)...

Hi, Lucky1313. have you heard the book The Key to Prostate Cancer : 30 Experts Explain 15 Stages of Prostate Cancer by Mark Scholz? this is a great book that will help explain prostate cancer, explain in more depth the many treatments that your hubby's doctor would recommend to him and the many ways to manage hhis health after treatment.

Hi Lucky,
Your husband's case sounds similar to my husband's case. His dad passed away from prostate cancer so the family history was there. His doctor started checking him with a DRE starting at age 40, but he never checked his PSA level. He saw a different provider in May of '22 and a PSA level along with other labs (cholesterol, etc..) was drawn and the PSA was 4.6. The only other time his PSA was drawn was in a wellness exam/lab draw for work and his level was 1.6 when he was 43 or 44. I suspect that he would've been diagnosed with prostate cancer in his late 40's, had his primary care doctor been checking his PSA levels as they should've been doing with the positive family history. Anyway, a 12 core biopsy in July'22 showed 10/12 positive cores that were all 3+3 = 6 with one 3+4 = 7
He had a RALP in November '22 and his post-op pathology was consistent with the biopsy ... 34cc, total tumor volume was 20%, gleason 3+4 = 7 with 5% of the whole tumor volume that was pattern 4. Negative margins, negative for EPE, negative for LVI, negative lymph nodes, and + for PNI. He's doing well post-op, has been fully continent since about 2 weeks after the catheter was pulled. The neurovascular bundles were spared on both sides, but he is experiencing the expected post-op ED issues. He's hopeful that he will have a good recovery on the ED with time and we recognize that it is very early in the recovery process. His 6 week PSA was undetectable and his 3 month PSA is coming up in the next week. He's recovered well and is feeling good! He went to a center of excellence and had a surgeon that has performed >4000 Laparoscopic prostatectomies so we both felt that he was in very skilled hands. He started doing kegel exercises about 3 months prior to his RALP, which I'm sure was incredibly helpful in his excellent post-op urinary continence recovery. My husband felt that the RALP was the best treatment choice for him and I support his decision completely.

As you are both already doing, be sure that all of your questions are answered before making a final decision on treatment. Wishing you all the best as you both navigate this unfortunate diagnosis! As wives, our experience is different than what our guys go through, but we are there to support them and walk in step with them as they go through treatment. Feel free to ask any questions from a wife's perspective!

Once his surgery was scheduled, all of the nervousness and what-if's were still there, however there was a sense of calm in knowing that the treatment was scheduled. Every step started a new set of worry though, waiting for the pathology report, waiting for the 6 week PSA, waiting for the 3 months PSA, etc... I've learned so much by reading on this site and am so grateful that forums like this exist.

I'm sorry you and your husband are going through this, thinking of you and hoping that you will both feel the sense of calm as you decide on the route of treatment!

Hi Joinedtheclub,

So happy for you about the undetectable PSA, and hope that you always see the same with every test going forward. It must be a big relief to see that result!

After meeting with the RO, we then met with another urologist at the same appointment. Then we had a phone consultation with another RO this week (specialized in other radiation treatments). Anyway, long story short, we have decided on SBRT combined with 6 months ADT. He got a Lupron shot yesterday (Friday) and SBRT will be scheduled for approximately 6-8 weeks from now. It's a relief to finally have made a decision and start the process of actual treatment.

Again, congratulations Joined - do something special to celebrate the occasion!

Joinedtheclub said...
Hi Lucky, my husband's 3 month post-op PSA check was undetectable at <.01 - we're very happy and hopeful that an undetectable result is the only result he'll ever see going forward. How did things go with the RO? Wishing you both peace in your decision and most importantly, a successful treatment outcome!

Thanks F8. I appreciate your posts on this board (not just this thread).

We narrowed it down to SBRT or IMRT with BT boost and went back and forth between those 2 options. I think they are both great options, so hoping this works out for us.