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Another G6, What's Next?

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Posted 9/20/2013 5:40 PM (GMT 0)
Hello brothers... I guess I'm in the club now. I have a great medical support team. My uro has done 1700 RP procedures... I think he told me the last 700 have been robotic (which he now prefers). The RO seems very competent although I don't know his credentials. They've told me my best options are either RP or seeds. I'm 'locked in indecision' or 'researching my options' depending on the day. I've ordered a second read on my pathology from John Hopkins. I've been fairly calm about the whole thing so far... not really sure why. The current question I have is 'What are the implications of a high % of cancer found in a core?' I've got a 60% and a 70% as you can see from my signature. Intuitively you know that higher is worse, but why? Jim R
Posted 9/20/2013 6:00 PM (GMT 0)
Welcome to the club. Sorry you have to be here, but you found the right place.  Sounds like you're taking the right tact by being calm through this, and that's the right thing to do in your case. Getting a second read was a fantastic move as well. Start by reading the "newly diagnosed" thread at the top of these threads, lots of information there.  With your stats, you don't need to be in a big hurry to make a decsision.  You may also be a good canidate for Active Survellience as well.  There are a number of things to consider when making your choice.  For surgery, you've made the right first step by finding out how many your urologist has done, the next step is to find out what his record is as far as side effects and to come to an agreement on what he means by incontinent and impotent.  there are a bunch of guys who've used seeds on this site with great sucess and I'm sure they will weigh in soon.  I just finished a round of SBRT (Cyberknife) and have been very pleased so far.  That's an option too.  Educate yourself as much as possible first and then you can ask the doctors the right and most meaningful questions to you.  You have to be your own advocate.  If there's anything I can do to help, don't hesitate to email me (the adress is in my profile).  Good luck and continue to stay calm.  Read as much as you can about treatments and side effects.  With your stats you should have a lot of options and a great chance at sucess.

Mike

Post Edited (MikeM53) : 9/20/2013 12:09:14 PM (GMT-6)

Posted 9/20/2013 6:02 PM (GMT 0)
Hi MOWOG- I was also a Gleason 3+3 with a high probability that everything was contained in my prostrate.....I just wanted it out....gone, aloha, see you later....!!!!

My choice and I would do the same thing, the same way, all over again....

Good luck to you...we are all here to help you out....ask lots of questions...with a Gleason 6...things will look good for you in the long run..

Cheers,

Curt
Posted 9/20/2013 6:40 PM (GMT 0)
Welcome.
The base is towards the bladder and seminal vesicles , if I remember, which can be confusing.
With that much cancer in 2 cores, I'm thinking you should have treatment.
What size is your prostate?
Seed radiation sounds reasonable. I had cryo / freezing for a Gleason 7.
You are likely to live more than 10 years without treatment if that gives you any perspective. Good luck.
Posted 9/20/2013 7:00 PM (GMT 0)
Jim,

I'm sorry to hear about your diagnosis. You seem calm and collected, which is a good thing. You didn't mention your stage, but if it was T1b or T2a, you'd still be classified as low risk. That means you have lots of options, and time to interview several doctors to find the treatment that suits you best. Your options include surgery, SBRT, HDR brachy (temporary implants), LDR brachy (seeds), IGRT/IMRT & proton (pencil beam & standard). I investigated all of them before making my decision, talking to about 6 doctors and spending 6 months on it (I'm worth it!).

Jim R said...
The current question I have is 'What are the implications of a high % of cancer found in a core?' I've got a 60% and a 70% as you can see from my signature. Intuitively you know that higher is worse, but why?

Statistically, it's an independent risk factor for recurrence. The bigger the tumor has grown already, the more likely it may be to extend beyond the prostate and possibly spread. There is controversy over what to label as an "insignificant" tumor. Some label it as less than 4 mm in length, so when it is more than 50% of a 1 cm core, it is over that.

You can use a nomogram like the one below to estimate your statistical risk. If you check the box on the bottom that says :"Would you like to enter additional details?" you can see how the cancerous core length affects your risk.

Memorial Sloan Kettering Pre-Treatment Nomogram
Posted 9/20/2013 7:22 PM (GMT 0)
Jim, I'm really sorry about your diagnosis but welcome to HW. You seems to be going about this the right way, i.e. getting yourself educated, getting a second reading on your slides and considering all options.

You might consider reading Walsh's "Guide to Surviving Prostate Cancer" and Scholz' "invasion of the Prostate Snatchers". Between the two I think you will get a broad perspective on our disease.

With what we know about you, it would appear that most any of the treatments should cure you. I would suggest that you take a measured approach and discuss you options with experienced specialists across the various disciplines as Allen suggested. There are men (and their loved ones) on this site who have experience in almost every treatment possible so be sure to ask anything you want for our non-medical perspective.

Good luck and let us know how we can help.

Jim
Posted 9/20/2013 7:47 PM (GMT 0)
Hi Jim R., - YOU ASKED: "The current question I have is 'What are the implications of a high % of cancer found in a core?' I've got a 60% and a 70% as you can see from my signature. Intuitively you know that higher is worse, but why? Jim R"

MY REPLY: Statistically, the more you find, the longer it has had to spread within the Prostate and the more likely it has had the opportunity to progress and the less likely that it is to be indolent or insignificant. But this refers to the overall % of Cancer found in the sampled tissue not to the individual sample, which is more a matter of chance in directly hitting a "tumor".

Since 12 samples is todays preferred Standard, each INDIVIDUAL sample represents a a very narrow, relatively small in volume (18 gauge needle size) piece of tissue that is "randomly" obtained, but done so in a very specific pattern, taken from specified locations within the Prostate. So how much is found in an individual sample is directly related to the "luck" of squarely hitting the center of a cell grouping, rather than hitting a glancing blow on the side of the same grouping. Those "direct hit odds" increase as the size of the malignant groupings reflect a greater percentage of the area being targeted.

This is why, roughly, 30 to 40% of "clinical" Gleason Scores are upgraded as higher "pathologic" grades are found in post -surgical specimens where the entire removed Prostate is available for examination. That is why "p" Grades are considered so much more accurately reliable than "c" grades. Unfortunately, Pathologic Grading is only available to those having surgery as their treatment choice.

I hope this explanation helps your understanding. Happy to answer any other specific questions. - [email protected] (aka) az4peaks
Posted 9/20/2013 8:23 PM (GMT 0)

MOWOG said...
Brothers,
Thanks for the replies. RobertC, I don't know the size of my prostate... can't find that information in anything I've received so far. Tall Allen, I'm a T1C (I'll update my sig), and try the nomogram with the updated details. Thanks. Jim R

MOWOG posted the above on a new posting but it appears he wanted it here as part of this thread. Jim/Tud
Posted 9/20/2013 8:33 PM (GMT 0)
Thanks John... This gives me another piece of the puzzle. Jim R
Posted 9/20/2013 11:07 PM (GMT 0)
Hello MOWOG

I too would highly recommend "Surviving Prostate Cancer", get the new 3rd revision if you can, still the
best one volume primer on all things PC. There are other good books, but if you are only going to read one, I say read the Walsh book.

With your specs, I would lean toward seeds, the "cure" ability would be as good as surgery, and you would stand less of a gamble with either incontinence or ED. When I was dx in 2008, I had wanted seeds but didn't meet the criteria at the time. In my case, I had open surgery - which failed fast, and later salvage radiation, which also failed fast. For me, the cancer is no longer curable.

Keep calm like you are doing, that's half the battle. I was kind of stoic about the entire PC thing, as for me, PC was the 4th major cancer bout that I had dealt with in about a 9 year period at the time I was dx.

Good luck, we are here for you, which ever path you choose.

David in SC
Posted 9/20/2013 11:34 PM (GMT 0)

Tall Allen said...
Jim,

The bigger the tumor has grown already, the more likely it may be to extend beyond the prostate and possibly spread. /quote]

OK, it's on these details that I get confused. I've followed the lengthy discussions stating that G6 PCa (the kind of cancer in my 60% and 70% samples) has not been known to travel outside the prostate. Can someone clear this up for me? Jim R

Posted 9/20/2013 11:45 PM (GMT 0)
Mowog -- your numbers are very similar to mine except I had 12-12 positive and I was a 3+4 G7.  my highest percentage core was also 70% and my PSA was 6.8.

the fact is there's no way you can no for certain you are a gleason 6 except to have surgery.  a high percentage of cases are upgraded after surgery.  I would be hesitant to do brachy alone in your case.  with what I know now i'd either go with a combination radiation therapy or surgery.  good luck in whatever you decide.

ed

 

Posted 9/21/2013 7:10 AM (GMT 0)
You're right that the GS6 tumor itself probably doesn't metastasize, there are several bad things that may still happen:

• the tumor can grow into the surrounding tissue (extraprostatic extension)
• the tumor can undergo EMT, and then metastasize
• the tumor can invade the seminal vesicles, the perineural area and spread from there
• There may be undiscovered Gleason pattern 4 and 5 that is already there
• Gleason pattern 4 and 5 may emerge from the same source, which may form part of a metastatic tumor
• There may be cancer stem cells that form new higher grade tumors

None of those things will necessarily occur, but they may occur. Larger tumors and multifocal tumors increase risk.
Posted 9/21/2013 1:05 PM (GMT 0)
While it is only a rough indicator, I think I would use the average lifespan of close male family members (father, uncles, brothers, grandfathers) as a rough guide of how to proceed. Most men diagnosed with prostate cancer will die of something else - usually heart disease. If the males in your family are lucky to make it to 75 and you feel quite good right now (other than the trauma of a cancer diagnosis) why take a chance on messing up your potential last 8 years of life with the complications of a surgery or radiation? If males in your family tend to live to 95, then surgery or radiation may be more of an option.

One of the positive aspects that I find about Active Surveillance is that it is a heck of an incentive to ensure that I'm living the most healthy lifestyle possible - one that includes reducing meat, sugar and salt consumption; increasing consumption of fruits and vegetables and getting sufficient physical exercise. I don't think I would have as much incentive if I had surgery and I probably would even feel that I needed a few indulgences as compensation. It is not impossible that, if active surveillance motivates you to make some positive lifestyle changes, that this cancer diagnosis will result in you living much longer than you otherwise would have by avoiding a heart attack. Most of the lifestyle provisions for AS are the same as for reducing the risk of heart disease, which is a much bigger killer of men than prostate cancer.

That all being said, AS is definitely not for everyone and you always have to weigh the risk that you may have a more advanced cancer than a Gleason 6. But you owe it to yourself to find out more about it before committing to a decision.
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