Active Surveillance might be best choice

Met with Dr. Tollefson at Mayo in Rochester and I am so glad I went. He basically said the 2 choices for me would be either AS or RP. Couple of things I thought were interesting and may help others in my predicament...

Since I had a low grade cancer (G6) in only 1 core, and the cancer was in <5% of that core, this is the absolute minimum for a diagnosis. You can't have less cancer I guess. Caviat being that there is no guarantee that the biopsy did not miss other, more aggressive cancers. However, with my PSA at only 2.85, he feels there is a pretty low risk of that being the case.

40% of men who choose active surveillance, eventually have additional treatment. So, 60% do not. I would bet that those 60% that don't are much older than me.

My local Doc said RRP would not be good choice for me because of a previous abdominal surgery (had a kidney removed). Dr. Tollefson thought RRP would not be a problem at all, at least he said there would be a less than 5% chance that they would need to convert to open during the procedure.

Dr. Tollefson strongly advised against any form of radiation now for someone of my age with such a low grade cancer. Just not worth the SEs at this juncture. Might be a better option in the future.

So, I am thinking AS is the route for me at this point. Seems like RP is over-treatment considering all the factors. I can wait and watch my PSA levels, and even if it goes up, and even if the cancer becomes more aggressive, in all likelihood it would still be very treatable.

IMHO that is an intelligent and well thought out approach. You seem to have the right mentality and disposition for AS.

The key is to give it the due diligence when it is required AND the rest of the time just keep on enjoying the hell out of life.

Sonny

Geetar, AS certainly does sound like a reasonable choice in your case. However, I second Davidg's reminder to get a second opinion on your biopsy slides and I also would suggest that your due diligence is not complete w/o seeing an experienced brachytherapist.

Jim

Thanks all. All comments and suggestions are welcome and considered.

Todd... just checked out your blog, very nice. Read your post about finding a support group. I couldn't agree more. I feel for you, you've had a tough road.

I envy you living in the Northwest. I love that part of the country. I am in Seattle about every 4-6 and I absolutely love it out there.

I see you play guitar, as you can tell by my handle, so do I.

Peace my friend.

So, I am thinking AS is the route for me at this point. Seems like RP is over-treatment considering all the factors.

surgery would be the last option for me with your amount of cancer. your doctor was pretty glib about radiation vs surgery. in fact his reasoning has a barnyard waft to it. with such a small amount of cancer I just don't agree that your two best options are AS or surgery. good luck to you!

ed

Correct, he said RT would be an option down the line if I were older, or if there were more cancer.

If I understand correctly, another reason he felt RT was not the best choice at this time is because if it fails, I have fewer options in the future. Of course AS, by definition, pretty much keeps all options on the table. Surgery leaves lots of RT options available should there be a recurrence, but RT would leave the fewest options on the table if needed. Also, the risk of ED occuring after a few years from RT doesn't sound appealing to me.

The other factors for me are that I am very active. I run 5 miles most days, I golf (a lot), I travel a lot on business, I have a great relationship with my wife. I am just not feeling threatened enough yet to risk the SEs of any of the treatment options. Plus, I'm going to use this to my advantage while I'm healthy to remind my wife that she needs to have lots of sex with me while I'm still intact!

I did send my medical records down there but they did not ask for the slides.

Well... I'm going to have one more consult with my uro, just to talk it over with him. I think unless he violently objects then I'm pretty comfortable. Even if I can put this off 6 months I will be happier. With spring and summer coming up, I do not want to be laid up. If my PSA shoots up radically in 6 months, I can reconsider.

I agree with Allen. The younger you are, the more years of side effects you can avoid using AS. In any case, if the cancer does progress, you can treat at that time. All AS studies show that men on AS who treat later are no worse off than those who treat immediately.

If you need more assurance, I would suggest using a 3T mp-MRI to check whether larger tumors have been missed by the original biopsy.

Finally, if Mayo did not re-evaluate your biopsy slides, I would second davidg's advice to get a second opinion.

By the way, most of the 30% to 40% of those who get off AS because of cancer progression, do so in the first couple of years. This is primarily because the significant cancer was originally there but was missed by the first biopsy. True Gleason 6 rarely progresses.

Excellent call on the AS.

GeetarMan said...
Correct, he said RT would be an option down the line if I were older, or if there were more cancer.

If I understand correctly, another reason he felt RT was not the best choice at this time is because if it fails, I have fewer options in the future. Of course AS, by definition, pretty much keeps all options on the table. Surgery leaves lots of RT options available should there be a recurrence, but RT would leave the fewest options on the table if needed. Also, the risk of ED occuring after a few years from RT doesn't sound appealing to me.

The other factors for me are that I am very active. I run 5 miles most days, I golf (a lot), I travel a lot on business, I have a great relationship with my wife. I am just not feeling threatened enough yet to risk the SEs of any of the treatment options. Plus, I'm going to use this to my advantage while I'm healthy to remind my wife that she needs to have lots of sex with me while I'm still intact!

I did send my medical records down there but they did not ask for the slides.

You sound more & more like myself -- I run about 7 miles every single day. Did this up to the day I left for my surgery at Mayo. The better shape you're in, the quicker you tend to recover from surgery.

It is true that you can have salvage radiation if the surgery fails. It's also true that, in most cases, it is difficult to do salvage surgery if the radiation should fail. So there ARE more options when going with surgery.

However, they also say that today's up to date radiation equipment does not fail very often, so that might be something for you to consider if treatment is deemed necessary somewhere down the road.

But you do seem to be an ideal candidate for AS. As Dr Tollefson said, with such a low PSA, it is not likely that it is any worse than estimated by your biopsy report.

So I join the others in wishing you a lifetime of successful AS! :)

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Pathology showed Gleason 3 + 3, pT2c, N0, MX, R1
adenocarcinoma of the prostate.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain painlessly removed morning after surgery.
Catheter painlessly out in 7 days. No incontinence, occasional minor dripping. 100% continent after 3 weeks.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1. PSA tests now annual.
Brief, firm erections on occasion, still hoping for more improvement.

Post Edited (HighlanderCFH) : 3/7/2014 9:50:59 PM (GMT-7)

GeetarMan if the surgeon actually said "cut it out and if that fails we can radiate later" without explaining his reasoning, and providing some stats on success if the cancer has not escaped the prostate with ANY treatment, I'd get another surgeon's opinion.

Geetarman,
I think you are a great candidate for AS. I can tell you from experience that PSA day can be a little anxious.
You should also consider a diet modification. I cut out most red meat, and diary milk ( I use almond milk now), and I think that helped keep my psa down for awhile. My psa actually fluctuated quite a bit for the 3.5 years I was on AS, from 2.3 - 3.8.

My only caution to you is that your psa has shown a consistent rise, so do monitor your velocity closely.

Be well...

Geetar, your AS decision seems really sound as does your thinking. I'm glad to see you are getting a second slide reading and the MRI. One point of emphasis on the second slide reading -- hopefully it is from one of the acknowledged PCa pathology experts, e.g. Bostwick, Epstein or Oppenheimer. Reading these slides is art as well as science and you want to make sure you have the best.

Jim