More G6 cancer found while on Active Surveillance - Now What?

What advice are you receiving from your urologist?

Under the Johns Hopkins AS guidelines, which I am most familiar with, the amount of core involvement would not disqualify you. The three cores (counting only the last biopsy), two with small amounts, would not necessarily trigger treatment. However, the third factor, bilateral involvement, would be an exit flag. JH research now considers having PCa on both sides as a serious issue, necessitating treatment.

With only G3+3 found, and both genomics tests being optimistic, you could still make your own decision to keep delaying treatment, but now you would be taking a greater risk with less supporting data.

akai-

You're right that the guidelines for getting off AS are different from the guidelines for getting on it. Each institution has different protocols, but all of them agree that Gleason pattern 4 discovered on biopsy is an important indicator.

Klotz wants to see predominant Gleason pattern 4; that is, at least one core with GS 4+3. He used to also look for a PSA doubling time of less than 3 years, but with mpMRI monitoring, he feels that's no longer necessary. Most look askance now at PSA kinetics. ASCO this year endorsed a policy that included a recommendation to discuss coming off AS when Gleason score progressed to ≥7 or the GS6 cancer volume had grown to become significant. They didn't set a strict limit as to what constitutes significant cancer volume. Also they consider it reasonable to start AS with low volume GS 3+4, or high volume GS 3+3.

There are no universal rules. It's mostly a matter of how you feel about staying on it.

- Allen

Akai,

The biopsies are a shot in the dark. If you undergo another biopsy right now the probably is very good that the numbers will be entirely different. That is why some people undergo saturation biopsy to get a better grasp of what is actually going on in the prostate. How has your PSA been doing? Is it increasing rapidly? Luckily it is still GS6 and less than 50% of the cores.

Hi ASA, my urologist suggested Active Surveillance based on his biopsy (3 positive cores) without taking into account of my previous findings. I may not stay with this urologist, I think there is a lack of thoroughness in his practice.

Jack, I was a patient of Dr. Ukimura at USC, he returned to Japan last year to take a directorship at U of Kyoto.

LApilot, I started tracking my PSA since 2003, various labs, but mainly tested at USC after my Dx in August of 2012, my last two PSA rose quite rapidly from 3.8 to 4.74 (Feb 2016)and within a month from 4.74 to 5.4 in March of 2016, all at USC. However, tests at Quest was at 4.1 in February 2016 and 4.7 at USC last month.

DATE PSA

11/4/2003 1.5
7/8/2005 1.3
11/11/2005 1.3
7/9/2007 1.9
12/29/2008 1.8
11/3/2010 2.3
11/14/2012 2.1
3/9/2012 3.1
5/3/2012 3.35
5/25/2012 3.6
10/26/2012 2.5
4/30/2013 3.5
8/3/2013 3.9
11/6/2013 4.1
2/5/2014 4.9
5/14/2014 2.9*
2/24/2016 4.1



11/6/2012 3.16
2/7/2013 3.29
5/7/2013 3.23
8/14/2013 4.01
11/20/2013 3.85
2/10/2014 4.05
6/10/2014 3.52
10/10/2014 3.31
4/3/2015 3.93
9/21/2015 3.8
2/12/2016 4.74
3/11/2016 5.4
3/17/2016 4.7

I count 7 positives in 4 years. Out of 45 samples that 15% of the cores tested are G6.

Sounds like you're really on top of what's going on with your body. TA sums it up nicely I think. When doctors' opinions begin to differ...that is the point at which the patients' assessment of what to do begins to take on a bit more importance (for lack of a better word or way of putting it).

Hi Jack:
Good observation on your part.

I believe that my urologist had not reviewed my MRI report prior to the Bx. While there was one suspicious spot, there was also another concern regarding extrapostratic extension. My urologist never reviewed the MRI report with me.

On the day of the pathology review, he did not know what I was there for until he fired up the computer in the room, it was not a real review, he looked at the summary section of the path report on his computer screen which omitted to list a positive core!!! He did not realize that the summary was misstated my condition and wanted to wrap up the meeting by telling me to sign up for the AS program. I pointed out to him that the summary was wrong, there were three positive cores not two. Never was I given any written report. I happened to obtain the reports from the patient records and reviewed it prior to the meeting, that was how I discovered the mistake.

I also mentioned my concern that one of the cores involved at 50%, I also mentioned that I have three other positive cores from two prior Bx. The meeting would have ended in three minutes had I not started asking questions, and even that, the meeting ended quickly. Talk about disappointment! The sloppiness of the pathology report and overlooked of the mistake by my urologist? Please note that this was all happening at one of the highly regarded institution!

Every time I met with my urologist was like meeting him the first time. Wonder why he did not just glance at my file (electronic file) before the meeting just to be familiar with my case? My urologist is quite skillful at doing MRI fused biopsy. I may have to stay with him for a short while as we are going to send the tissue samples to Myraid for another Prolaris test (I brought up my concern on the 50% of one core from the suspicious area - my uro offered to send the samples to Myraid).

I was very lucky that Jim Bear so kindly guiding me and helping me navigating the whole system at this institute, I had to get all my reports (MRI, Pathology, CD of my MRI scans) by myself. There was no biopsy report generated?

Post Edited (akai) : 5/24/2016 8:05:56 AM (GMT-6)