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Posted 6/5/2024 11:48 AM (GMT 0)
Hi Folks:

My daughter's father-in-law was recently diagnosed with PCa and has reached out to me for advice. I'm pretty sure what I want to tell him but am seeking your collective wisdom as well.

Here are his stats. 73 years old in good health. PSA is 9. 13 sample biopsy with 5 samples positive at Gleason 6 (3 +3). 4 samples with 10% cancer, 1 sample with 75%. Biopsy report confirmed by second opinion. PSMA test shows no spread beyond prostate. No nodules on DRE.

What say you?

Thanks,

Jim
Posted 6/5/2024 12:02 PM (GMT 0)
I’d next ask what his PSA history was, and suggest a genetic test of the biopsy material. Also, prostate size to get PSA density.
Posted 6/5/2024 12:20 PM (GMT 0)
Any idea of prostate size and PSA density? BPH issues? Family history? Family life expectancy?

The PSA of 9 is problematic since it could be above 10 next time which is not the area one wants to be at, maybe not.

My Dad started his PCa adventure around that age and made 96 with same treatment as you, brachy, and later recurrence in late 80’s with ADT for 1-2 years, heart was his main problem, PCa a nuisance in comparison.

My thought would be easiest treatment possible with least side effects as waiting is getting to the point of not being prudent. HDR, no ADT? Kick the can down the road for 10+ years and see if something else is more pressing if PCa starts causing problems.
Posted 6/5/2024 2:39 PM (GMT 0)
I'd just add that in weighing the pros & cons of RP vs RT for treating localized PC, his age is not a factor against surgery. See also

Localized prostate cancer in older patients: Radical prostatectomy or radiotherapy versus observation (2024 analysis of 13 studies involving 284,066 patients)
Posted 6/5/2024 2:40 PM (GMT 0)
I might be wrong, it's been a while, but seems like a PSA of 9 is pretty high for a G6. So my question would be is something else lurking in there? Was his biopsy, MRI Guided?


In either case, I think action is warranted, what action depends on his mindset and his priorities. I think the best you could do is lay out all the upside and downside of both surgery and radiation, but either way, I would treat, with that PSA and 5 of 13 samples positive.
And no, if his preference is surgery, I don't think 73 is too old, assuming no major comorbities
Posted 6/5/2024 2:45 PM (GMT 0)
Regarding the PSA, I suggest a further breakdown to estimate the tumor load and take some steps to isolate the cancer amount and any progression as measured by PSA. Of benign prostate tissue and of all the Gleason grades G6 expresses the most PSA by volume. Several years ago renowned prostate cancer oncologist Dr. Steven Strum estimated that, on average, G6 expresses about 4 PSA per cc of volume. He also estimated that a completely benign non-infected and non-inflamed prostate expresses about .066 PSA per cc.

So, if the person’s healthy prostate at age 73 is say 40 cc, then it would express about 3 PSA. Then the remainder would be the tumor(s) 0f 6 PSA divided by 4 equals 1.5 cc. That is slightly more than the volume of a garden pea. However, if the prostate is inflamed or there is some infection or enlargement by BPH, then the prostate expression would be greater and the tumor estimated size smaller.

Based on this, I would personally embark on a good AS approach. I would also accelerate my PSA testing to quarterly to determine the rate of increase, if any, that would allow a better and more timely measurement of risk. Further, I would consider using Avodart to shrink the prostate and reduce any prostate expression of PSA in order to isolate the cancer expression of PSA and determine any trend progression.

I see nothing in his present dx that would indicate the need to begin PCa treatment, certainly not surgery, but I would clearly step up the surveillance. I certainly would not wait a year for another PSA test.
Posted 6/5/2024 4:35 PM (GMT 0)
Thanks for your comments. Re some of the questions you have raised:
1. He doesn't know his prostate size but his doc characterizes it as "normal". He has no known history of BPH and no BPH symptoms.
2. PSA history has been in the 3-4 range during recent annual tests. Recent test was 9; test was not repeated.
3. No known family history. Family life expectancy in normal range.
4. Biopsy was MRI guided and 5 of the samples were from "suspicious area".

I think he is leaning toward AS right now.

Jim
Posted 6/5/2024 5:30 PM (GMT 0)

Tudpock18 said...
Thanks for your comments.
...
I think he is leaning toward AS right now.

Jim

The best (strictest) AS programs have a PSA of <10 as an entry requirement and bump people off--recommending treatment--for those in their program whose PSA climbs over 10. I think most wouldn't accept men with 4 or more lesions or bilateral lesions (if the latter is the case here). Of course, you can do AS with your own uro following any published (or personal) protocol, although my uro calls some of them "loosey goosey." The risk with non-rigorous AS is that by the time your PSA, biopsies, or scans are of concern, your PCa may have progressed. There aren't too many men who "fall through the cracks" of AS, but ideally you always want to treat before your cancer has progress to the metastatic stage.

Djin
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