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Just got scan results---T3a

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Posted 1/13/2014 4:51 PM (GMT 0)
Hi everyone,

just an update and we would certainly love to hear anyone's advice...

Just came from the Radiologist Oncologist....Still nothing on the DRE. But the bone scan is clear (huge sigh of relief there for now) and the MRI shows extracapsular extension, but no sign of lymph node involvement. (none can be seen or felt at this point. He says its a 50/50 chance of RRP being successful...

He said we could opt for the 8 weeks of Radiation with Lupron and Casodex for 2 years or we can speak to the surgeon about the RRP.

He has been diagnosed as a T3a. G8. PSA 12. (has dropped from 15 3 weeks ago for no apparent reason)

Anyway, he was very nice and gave us his cell phone and email and said not to take any more then a week to decide... so I have put in my second call to the surgeon, who we want to speak to (asap!) regarding his thoughts on RRP, and how soon that can happen---but as of now he has not called back. (please remember that there is no option for a second opinion here---this is a one shot deal for a Urologist/Surgeon.)

We're leaning toward surgery, even though the RO is saying the final outcome will be the same...I'm a little wary of that because I know that after Radiation the surgery will no longer be an option.

Any thoughts or advice are greatly appreciated!!!

Thank you!

-------------------------------------------------------------

Age: 57

Dx: Jan 14

PSA: 12 (ish)

G8 (4+4) 8/12 cores + from 20-90%

T3a

DRE: Normal

Cancer located in frontal Apex.

Bone scans- clear for now

Posted 1/13/2014 5:29 PM (GMT 0)
Ashely,

I have not followed your first post so am not understanding your relunctness to have a second opinion or finding another surgeon who will call back!

Just to share: read stats below. My husband was 53 when Dx. His lymph nodes were clear as well, but after haveing RP his PSA was never undectable. We were told to try radiation but after research we felt his PCa had already escaped the capsule to his spine. There is no clear answer as everyones journey is their own.

I will share that often bone scans show no lesions until there is significant

size mets. Good luck with his journey, and know we are all here to be of support.

BOOGEE

Posted 1/13/2014 5:40 PM (GMT 0)
Hi Boogee,

Thank you for your response. Trust me--its not from NOT wanting a second opinion....we live in St. John's, NL and unfortunately, there is incredible waits, (I'm talking an avg of 2 years to just get a consult with ANY specialist)...so the urologist we got, (by calling in major favors) is the only one available---none are taking new patients, and the normal patient has to fly 2-4 hours away just to get seen in a timely manner...

I have been dealing with Johns Hopkins in Panama, where they actually respond to me and email back within hours. Its such a wonderful concept pretty much unheard of here...but hubby really wants to stay here if at all possible as we have 2 young children and he own a business here....so we're kind of between a rock and a hard place...

 

Posted 1/13/2014 5:52 PM (GMT 0)
I understand that you are working through the Canadian medical system. I live in Australia so I don't know how that would work in Canada but the Canadian posters here seem to have options about doctors. Perhaps they will chime in. It is important to find and use the best doctors that you can get to get the best outcomes.

If your husband is a T3a and with the cancer in the apex it would make sense to me to go down the radiation path. Your chances of getting by with just surgery are low. The approach of having radiation in the back pocket makes more sense to me if you are pretty confident that the surgery will be curative. If it was my husband in your position I would probably go for HDR brachytherapy with IMRT. Perhaps given the Gleason score I would consider HT in conjunction with this. The cancer as you describe it needs the big guns and the best doctors you can find.

I wish you all the best. This is a tough time for you and your husband and I know that this is not what anyone wishes to have.

Regards,
An
Posted 1/13/2014 5:57 PM (GMT 0)
Hi Ashley,

My husband's stats were somewhat similar. We consulted with several doctors and it seems the urologist/surgeons push surgery and the radiation oncologists radiation. We decided on surgery, partly to get a clearer idea of what the situation was via pathology.

I know making the decision is stressful.
Posted 1/13/2014 6:20 PM (GMT 0)
Ashley- It's really hard to find any consensus on the best approach in any situation with this disease. It's particularly hard with high risk, cT3a cases. I understand MRIs are not very capable of showing lymph node involvement unless it's significant. Also, they aren't necessarily as sensitive as one would like. So, there's more of a chance of missing something, but if the MRI shows something then it's quite probable it really is there. In other words, a false negative is more likely than a false positive.

My diagnosis was pretty similar, though at G9 5+4 and an extra indication on MRI (neurovascular bundle involvement in addition to extracapsular extension). My urologic oncologist, a very practiced and leading surgeon, was very soft on doing surgery in my case. He said he would do it, but it have to be a "wide excision" and had a low chance of being curative. My RO agreed, and we ended up doing radiotherapy and HT.

With an aggressive G9 (and G8s act fairly similar), an ineffective surgery would have to be followed up with radiation anyway. That gives the risk of both surgery and RT side effects. It made more sense to me to go with radiation first, further supported by some of the recent studies showing that modern radiation protocols can be quite effective. (Tall Allen has provided links to a number of such studies).

Now, for sure a lot of people will say, "Roll the dice!", and go for the surgery. It can be effective, and obviously it often is.

It's not something anyone can decide for you. As you gather information (pretty quickly), you'll likely find increasing comfort with one of the treatment options. All you can do is gather the best information you can, weigh the decision against your preferences, and go.

Time will tell whether it was a successful decision or not, but there's no going back. Once you pull the trigger, just be confident that it is your best path and try not to second-guess yourselves.

I think the mind game can be as big a foe as the disease.
Posted 1/13/2014 6:31 PM (GMT 0)
Thank you everyone...
As you know its awfully stressful. I wish there was one clear path---but needless to say there is not.
Posted 1/13/2014 6:47 PM (GMT 0)
Trying to figure out what to do is likely one of the most stressful times in this whole PC thing. Wait for test results is a close second.

The only thing I can add is that if the PC is confined to the prostate, surgery will be successful but if it's escaped or surgery doesn't get it all then you could be looking at the triple play of surgery, radiation and HT. Don't think science will give you a clear path as there are too many variables and unknowns. Sorry that's not helpful.

However, it does make sense to me to start with surgery. At least you'd get two follow up treatment paths and a you'd get a pathology report on the prostate so you'd have a better idea what you're dealing with.

Andrew
Posted 1/13/2014 7:09 PM (GMT 0)
With the scan showing ECE, cancer in the apex and psa in the 2 digits with a G8, a surgical outcome is unfavorable. With these conditions radiation would give a more favorable outcome, especially with added HT; this is an aggressive cancer and need to be treated aggressively.
JT
Posted 1/13/2014 7:19 PM (GMT 0)
See my stats below, I ended up with T3A staging also after surgery. So far all PSA test have been undetectable since surgery.

I wanted surgery for the final pathology report you get and the chance for radiation later, if I need it. So far I don't need any. My next PSA test is in a couple of days so we'll see!

Once you make your decision, don't look back, only forward.
Good luck to you both.

Bill from Florida cool
Posted 1/13/2014 8:06 PM (GMT 0)
I have had neither surgery nor radiations, so dog in this fight.

My understanding though is that the radiation oncologists prefer Casodex, then Lupron to shrink the target, but the urologists/surgeons do not necessarily want a smaller target to extract via surgery.

It seems that in your situation with the Canadian health system, the most important factor would be to take advantage of this window that only opens every couple of years.

Both approaches seem to have some merit, with surgery helping psychologically that the beast is out of his body plus providing a pathology report to increase your knowledge of exactly what he is dealing with.

Offsetting that is the potential need to have to deal with all 3 sets of side effects.

I understand he would be starting HT immediately if you opt for the radiation route, but would have to re-read old and new posts more closely to see if the radiation has to start soon due to windows of opportunity, or if he can stay on HT for a longer period and then decide.

For a different reason that is the route I am on, and the added plus is that while the Lupron shrinks the PSA and in my case the mets, we gain time to see if technology and research come up with better cures, while the side effects are more limited with HT than the radiation itself in short term.

You mentioned he has a business up North and two young kids if I recall, so stalling for time may have some merit.

As others have said, once you two jointly make a decision, go with it and do not do any second guessing. All options have merits in their own right.

LupronJim
Posted 1/13/2014 8:07 PM (GMT 0)
If you know the cancer has escaped the prostate, I don't really understand why you are even considering surgery. Radiation after surgery has worse SEs and worse outcomes than if it were just treated with radiation in the first place.

IMO, the only decisions should be which kind of radiation, how much ADT, and whether to treat pelvic lymph nodes. Combo therapy - IMRT with a brachy boost to the prostate - has an excellent track record in high risk cases, with as much as 90% freedom from failure after 5 years. Those failures that are local (most are not) are best re-treated with brachy or SBRT. 18 months of ADT (starting 2 months before treatment) is probably prudent.

My guess is that there is a high probability of lymph node invasion (LNI) because of the high stage, grade, and percentage of positive cores. A nomogram can help you decide whether the lymph node risk is worth treating. Figure 1 in the following link will help you estimate that risk.
Briganti Updated Nomogram Predicting Lymph Node Invasion in Patients with Prostate Cancer

I think he should get started with Casodex now followed by Lupron in a couple of weeks (or use Firmagon instead and skip the Casodex). This will halt the spread and sensitize the cancer to the radiation in a couple of months.

- Allen
Posted 1/13/2014 9:04 PM (GMT 0)
Hi all....Thank you so very much for your input.
UPDATE:
Urologist/Surgeon just called. Guess the made the decision for us.
He said he always leans toward surgery but in this case, he said its invaded the SV...(although the RO said no). He said he would be cutting through cancer to take it out.
So, that's that. I will email/call the RO now and let him know that we'll start the Casodex tomorrow....

Here we go.
Posted 1/14/2014 12:02 AM (GMT 0)
Having a plan is half the battle...keep us posted and hang in there....things will calm down soon.
Posted 1/14/2014 1:55 AM (GMT 0)
I had similar stats, decision made for me also.

Both my Uro's consults, they still wanted to operate first,(not surprised) then on to radiation. No thanks

IMRT, Seeds and ADT.

good luck bien viaje
Posted 1/14/2014 8:16 AM (GMT 0)
Ashley,

I think this is the right decision. I think now it's a question of learning more about your radiation options so that you and your husband can have an open and educated discussion with the radiologist about the right plan for the radiation.

Regards,
An
Posted 1/14/2014 10:19 AM (GMT 0)
My advice is to take an aggressive path. Surgery with regional lymph nodes removal, followed by radiation+HT.It depends uppon the age of your husband.If he is over 70 you can omit surgery, but keep in mind that surgery is the only treatment which can give you the exact pathology of the cancer: STAGE( sv & LN involvement),real GLEASON score.
I had no problem with any of those treatments.ED is the only issue to deal with.
Whatever you decide, good luck with yoi journey.
MY OPINION REFLECTS ONLY MY EXPERIENCE!
Posted 1/14/2014 9:51 PM (GMT 0)
Having a plan seems to ease some of the anxiety.
You always have to make decisions based on what makes you both comfortable.
Glad to hear you got responses from uro quickly.
As for radiation... I think I heard in the media St . John's got a new machine this time last year. Can't remember which one though.
All the best.
Posted 1/15/2014 1:46 AM (GMT 0)
I was diagnosed with Gleason 8 in January 2009. My scan and MRI were negative. My Uro surgeon suggested surgery. I was afraid of radiation because i had a sigmoidoscopy in 2008 and was concerned that radiation may damage my colon. I had EPE but mu surgeon cut enough tissues that I ended up with negative margins. So far after almost 5 years I'm still in the zero club. I wish your husband the best.
Posted 1/15/2014 2:38 AM (GMT 0)
Hi Ed,

You have great results and congratulations. I hope you have zeros forever.

I think the difference between your case and Ashely's husbands is the your biopsy was positive for 2/12 cores. Her husbands biopsy showed positive on 8/12 cores. This indicates higher volume. If there is more local spread the radiation is more likely to get it than surgery.

Regards,
An
Posted 1/15/2014 3:32 AM (GMT 0)
Hi there,
My husband had a RALP procedure in December in Toronto. Our experience here in Toronto has been world class.
If you are seeking a second opinion, and out of province is an option for you, Dr. Finelli at Princess Margaret and Dr. Goldenberg at UBC are two of the best surgeons in the country.
Good luck to you!
Posted 1/15/2014 4:00 PM (GMT 0)
Surgery here with pT3a but with gleason 7. Good luck!
Posted 1/15/2014 6:57 PM (GMT 0)
An, I agree with you about radiation being the right answer in Ashley's husband's case. I probably would have done radiation if it wasn't for colon surgery the prior year and my fear of radiation damage. By the way, I was in Sydney Australia for 2 weeks in early December and enjoyed the warm early summer weather.
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