PSA 150 - Are we looking at PC w Mets or is there a chance it’s something else?

We need all the data for a sensible discussion of possible therapies. But I do see a bit of baloney already from the surgeon regarding brachytherapy.

As others have mentioned, Gleason 9 cases can be attacked with a 'triple play'. This means a combination of ADT (hormone therapy) and two kinds of radiation. Typically, IMRT supplemented with either brachytherapy with seeds, high-dose brachytherapy, or stereotactic body radiation therapy (SBRT; with CyberKnife or another instrument).

The consult with the Rad Oncologist should be quite informative; I hope your husband will take notes as well. Four ears are so much better...

That's not true on brachy. Talk to a RO, ADT, Brachy, EBRT is the most affective combo I know of.

There is no reason to do surgery and the RT. RT alone will do the debulking.

LadyJaneK said...
Can we trust the scans?

The trustworthyness of the MRI is only as good as the equipment, the image quality, and the expertise of the practitioner who analyzes the images. The differences in tissue appearance, based on which conclusions are drawn, are subtle at best. Prostate MRI analysis is a relatively new undertaking, with many rookies.

I am Gleason 9. I flew 2500 miles to seek out a practitioner who I concluded was one of the few legitimate experts. I don't know what options you have in Canada. Unfortunately, it falls to you to assess the expertise of your practitioners.

You have already indicated that you know the limitations of the pelvic/abdominal CT scan and bone scan.

Unfortunately for all of us, there is no test available anywhere in the world that is able to detect the earliest bundles of spreading prostate cancer, which are microscopically small.

There are experimental scans with better detection capabilities that can sometimes be obtained with sufficient research/persistence/payment, but as said above, there is no scan for which a finding of "clear" guarantees you are actually clear.

That is why some practitioners make use of Gleason score and PSA score to guide treatment decisions. By studying results of treatment over long periods of time, they have observed that certain combinations of Gleason score and PSA score have highly elevated risk of local, regional, and distant metastasis at the time of diagnosis, even when the scans return findings of "clear".

For this reason, some recommend against surgery when Gleason scores and PSA scores reach certain thresholds, even when cancer outside the prostate is not proven. It is assumed.

At the current state of technology, choices of treatment are, at best, educated guesses.

Lady Jane, we keep coming back to the same question: have you and your husband met with one or more radiation oncologists, without a surgeon in the room? Yes, there are men out there with encapsulated G9 who had surgery and nothing else. They are not the typical G9. At least here in the US, G9 with high PSA is assumed to be metastatic until proven otherwise--and there is no proof possible at this point--the mets might be there but so small to be undetectable.

It’s possible the ADT worked very quickly to reduce cancer load. Be optimistic but stay very aggressive on treatment. I agree you should meet with an RO before making a decision. But with g9 and a PSA of 150, if you did have surgery I’d think i’d Want Adjuvant RT to follow regardless. Maybe all the morereason to consider RT as primary treatment if he’s gonna need it anyway

LadyJane,

I just ran what I know through Memorial Sloan Kettering and found the following based on age 56, 150 PSA, 12/14 cores positive and G9. The probability of organ confined disease is 1%. The probability of extra capsular extension is 99%. The probability of lymph node involvement is 98%. Using surgery as the initial primary treatmen the probability of recurrence in 5 years is 95%.

While these are not predictive in a specific situation, they should be considered as a data points to help with the treatment These indicate that you should expect to need radiation and ADT following surgery. These probabilities basically tell you not to expect surgery to be curative and to expect you will also need follow up radiation. The problem then is that radiation following surgery presents greater probability of more significant treatment side effects than radiation as a primary treatment. Plus the expected adverse surgical side effects.

This is why so many here are stressing that you see a radiation oncologist for their professional assessment regarding well proven effective radiation therapy as a primary initial treatment. Your surgeon can not give you a specialized professional assessment regarding radiation therapy as it is not his professional field by training, practice or certification. Go to the specific source.

And while you are hoping surgery will be curative, remember that hope is not a plan. The deck of cards your husband has been dealt is very much stacked against surgery being curative. If it is he will be a one-percenter. .

You need to listen to all the guys on this board that know their you know what. Your husband is pretty young at 56, just like me. The fact that he's a welder I would assume that he is in pretty good shape. Having your prostate removed is no easy feat, make sure you read up on it as he will be out of work for a while. He knows that, correct? Make sure you talk to an RO asap, you need as many specialist involved at this point so you can make the correct decision.
Good luck to you and your husband.

Hello All,

First off, thank-you all for your comments & the MSK & Urology Times Links.

We also ran my husbands numbers through the MSK nomogram & got those same results. We were in the car for 3hrs for a pre-op PT appt in the city so my husband read all of your responses.

The article published Aug 16,2018 (RP as primary treatment for high risk PCa) and the most recent one
Feb 28/19 (RP vs RT) are of particular interest. My husband doesn't fit the cohort exactly, his PSA is much higher & we really cant know if his Lymph nodes are negative, but it does explain the pro-surgery mentality @the Prostate Center in cases like his.

Although we are leaning towards surgery & it is currently being booked, we have taken your advice and advocated for the referral to see an RO; but we were up against a blockade @the Prostate Center since Monday. Finally today they agreed to the referral. I guess most go w the advice of the surgeon and don't challenge. We are not trying to be difficult, or go against the grain, we just want to talk to an RO!

We are hopeful the scans are correct but we are very aware that if we go the surgical route he will likely need adjunct RT and ADT following surgery, & there's a slim chance of a cure. We have to be realistic.

The PT certainly gave us lots to think about too. He's had pelvic floor physio before so he knew what the appt would involve, & had his coworkers in stitches the next day describing it to them!! She explained what he will be up against after surgery w muscle recovery, & gave him his exercises to do. He will likely be off work for nearly 3 months if all goes smoothly & longer w RT. He is a welder so the surgeon already said 3 months for sure.

We are starting to breathe easier, & laughing more again. Not an easy road but we're finding our way through.

Thanks again for the support so far, the updates and the info you've all shared.
This is a special place ~LjK

Great LadyJane,
Meeting with an RO will give your husband addition information to help him make the best possible decision for his treatment. He is lucky to have you as an advocate.

Good luck with whatever he chooses!

Maybe you have also read the article of Kishan, 2018, comparing the treatments for G9-10 Gleason patients (very easy to google). This one is written by radiologists and claims that HDBR, plus external radiation plus ADT is the best option according to several end point criteria, though not showing advantage for long term overall survival. It is a tough decission; not easy to choose for a particular case. It is good you are going to have several different professional opinions before deciding. I guess this is the best advice that we can unanimously give here.

Good advice Fauntleroy.

Why we are considering surgery...

Following G9 biopsy results, PSA 150, we met w the surgeon for his MRI results & even w negative CT & Bone scans, we were totally prepared to hear our only or better option would be the RT/ADT route. This is not what happened. The MRI results were -ve too, so surgery was put forward as our better option w negative scans & for men <60yrs old; & is being recommended by the entire surgical & nursing team @the Prostate Center in our province. We’ve had to advocate for a referral to the RO to see if this is his/her opinion also & to clear up something the nurse practitioner told us, “that he would NOT be a candidate for brachytherapy.” This concerned me right away b/c this seems to be standard treatment in cases like his.

They are not presenting the RT & RP routes equally, only the RP route w vigor & have made him feel like he doesn’t have a choice & I feel they haven’t presesnted info fairly or pros & cons of each so he can make an informed decision. Nor has anyone said “we will support you w whatever decision you make. “

Because of his age, and the negative scans they cannot understand why we want this appt. w the RO now. Usually they book the RO after pathology reports come back following surgery. When I’ve pointed out so you are telling me he will likely need salvage RT & ADT after, they all agree.
Last wk I finally said we are not necessarily saying no to surgery but we’d like the opinion of the RO before we take that step & I finally got the referral. But then I got to hear how “they don’t do salvage surgery after RT” & “they don’t know how quickly they can book that appt w the RO and “it will delay surgery.” “The sooner we get him in there for surgery, the better.”

I’ve challenged all of them by pointing out but if he was in his 70’s you would not be advocating surgery. They’ve all agreed “no we would not.” But because he’s under 60 they feel surgery as primary treatment is his best chance for OAS & the “possibility” of a cure. No matter how slim that might be.

My husband needs to feel confident in his treatment plan & in the surgeon & treatment team if he chooses this route & I don’t want to take that away, so I’ve been slowly presenting info supporting both routes w/o overwhelming him, & there is some supportive literature he could do really well w surgery & I don’t think we should dismiss it, just hear the other side.

As many of you have said we need that RO appointment so he can make an informed decision. ~LjK.

These surgeons are not being straight with you guys re: your husband's age and the "urgency" for him to get wheeled into surgery. I was in 57 when I had brachytherapy, and plenty of other men who have had radiation as their primary treatment were in their 50s too.

The surgeons are also not correct that surgery is a better option for men under 60. There is no evidence to back up their claim.

It is a red flag that they are pushing you like this. It gives me a bad vibe too.

I saw several surgeons, several radiation oncologists, before deciding on what course to take. The surgeons, except one, pushed surgery. One of them, a robotic surgeon, when asked about erections post-surgery told me I didn't need an erection to achieve orgasm. He also said I'd be continent post-surgery. I didn't realize continence to a surgeon means a different thing that it does to a layman. The radiation oncologists did not push radiation but said all of the treatment options would likely "cure" me.

My thinking in deciding, and I was a G7 (4+3), was why have surgery when I might need radiation afterward? Why have the side effects from both treatments? If the cancer had not escaped the capsule then radiation would arrest it as well as, with less side effects, surgery.