New DX, G8, treatment decision time

Age 63, physical (Scripps) 11/2017 PSA 4.1, referred to urologist. DRE Jan 2018 found nodule, biopsy recommended. I switched to UCSD for mpMRI before biopsy; MRI scored PIRAD 5 (begin mental preparing for PCa being found by biopsy).

Biopsy (UCSD) late February 2018. DX via phone night before departure for one week trip to UK.

12 core + 2 targets from mpMRI. 8/12 cores PCa (7 4+3, 1 4+4), both target cores PCa (4+4 and 4+3). MRI does give good view to spread of PCa, urologist and read of MRI says PCa not in seminal vessels or lymph nodes, i.e. prostate contained.

Office visit upon return (after bone scan which was negative) with urologist to discuss biopsy and his recommendations -- no surprise recommends RP, but agrees I should talk to RO and then make a decision in the next month or two.

Visit RO this Monday. RO said I'm a good candidate for IMRT (the hypofractionated 25 treatment mode) + BT (LDR) with 12 months ADP, but because I said there was some urinary issues / symptoms (likely due to PCa nodule), I need to have uroflow and post void residual testing to see if BT should not be offered (risk of blockage, not incontinence).

RO says he will talk to urologist.

RO calls me Tuesday morning, says he talked to urologist and I should just call urologist office to get tests scheduled. I call office, explain, appt person takes info and says I'll get a call back within one day. Long story, but urologist won't order test because he thinks it's not needed and provides no useful information. I explained that based on what RO and I discussed, and what I've read at Prostate Cancer News posts, BT is a valuable boost that studies show offer lower occurrence of cancer vs no BT or RP, and as such having these tests to see if there are contraindications to BT is important to my decision process.

But this discussion went nowhere. He said he would just proscribe Flomax and I should see what this does to urinary symptoms (basically a slower flow and some retention; bone scan was showing a non empty bladder even though I tried to fully eliminate).

I am not very happy with the inability to convince the urologist to just order the darn test. Tempted just to call the Scripps urologist to see if I can have the uroflow and retention test done there. I'll probably call RO first, but I'm not happy and I'm only at the beginning of this journey.

Any thoughts on how to approach this?

From everything I've read, both radiation and RP offer similar statistics in being above ground in 15 years, but it seems to me that IMRT + ADT + BT might offer a lower risk of the cancer reoccurring -- but to get that lower risk I would need BT added to the mix.

Like CaliJR, I'm another Triple Play guy. That said, my only SE after many years is that I don't pee as well as I used to, so I think you're right to be concerned about flow. In my case, I'm taking 1-2 Rapaflo a week (works better for me than Flomax) I'm fine.

Good luck and hope we can help!

I had a uroflow and post void residual test - took 10 minutes maybe. I just peed into a trough that measured flow rate, and then the uro checked residual with an ultrasound probe from the front. Nothing to it. It sounds like the uro thinks it is to help decide if you need flomax, which is not really the issue. The ADT is started at least 2 months before radiation begins, and that will shrink your prostate - you can always run it longer on the front end to shrink it more. If the RO says he wants it before deciding if the boost is safe, you'll have to get it somewhere else.

Much better day today. Called RO office, left message with Dr's case nurse explaining my frustration and concern. Received a call from RO that of course went straight to voice mail without ringing cell phone. He gave me a number to call back, which I did, and he we had an excellent chat.

RO and I had a nice 10+ minute call. He said he and urologist had both face to face discussions about my case as well as exchanged several long internal messages. Bottom line is urologist wants to treat urinary symptoms first while holding off cancer with ADT then run the flow test.

There are studies that show positive results with ADT before both surgery or radiation -- so I'm not really running a risk with this approach.

Plan is Flomax + ADT for 2 to 3 months, then do urine flow and retention tests. If these look good, then I will go triple play (ADT + IMRT + BT), if BT looks to be contraindicated I can then decide whether to continue with only ADT and IMRT or do RP (and then I'm not sure if that's it, i.e. go to "watch" or ?).

RO is setting up appt with medical oncologist to discuss which ADT drug(s) is best for me.

I am aware of the UCLA trial, but now that I am back to thinking the UCSD urologist and RO are back working together on my team for me (and I did have very good individual interactions with both), I'm more inclined to keep going with UCSD.

Sounds good. Now that I remember..(not easy for me these days)..I was on ADT and flowmax for 3 months when they ordered the uroflow test. Sounds like you are on the exact path I was on in the early going. Nice to hear that things are going better with your Drs.

Mark