Second biopsy report in

Hello Oceanfisher. When I had my PCa I was living in NoVA and, while there is excellent treatment available in the Greater DC area, I went thru several urologists before finding my choice which was Dr. Walter O'Brien who is the Urology Group of Virginia. While the name is similar I don't think this is the same urology group you are visiting. If you want another opinion I can strongly suggest Dr. O'Brien. While he was/is a surgeon, he was wide open to making sure I reviewed applicable radiation treatments and actually ending up assisting on my LDR Brachytherapy.

One thing you should do right away is find out who your urologist used to read your prostate biopsy pathology. A lot of NoVA doctors use Bostwick Labs and, if so, you are probably good to go since they are expert in PCa pathology. However, if that's not the case, you should make sure your slides get sent to Bostwick or to Johns Hopkins for a second opinion. Reading PCa pathology is a real art and you want to make sure you use an artist -- especially since you are still on the borderline of continuing AS.

I'm biased towards radiation over surgery and to me the 10 weeks of radiation sounds a bit like overkill. But I'm not a doctor. If you provide us with some more of your stats like your PSA history, % cancer in your cores, do you have a palpable bump and location of the cores it would help us to give you better advice.

Finally, when I was treated in 2008, Cyberknife (SBRT) was just ramping up in the DC area. I understand it is now well established especially at Georgetown. I would strongly suggest you consider that radiation option as well as LDR Brachy and HDR Brachy before you pull the trigger on anything. You will need to visit experts in EACH of those options to get well educated on them -- do not rely solely on your urologist for radiation advice and he/she is likely not much of an expert in anything other than surgery.

Good luck to you.

Jim

Nothing to add to Halbert and Tudpocks well informed comments. Just want to say good luck on your decision making process.

of58 - All of the above is most important. Two thoughts from my peanut gallery:

I had RALP and ART. The surgery is much more physically demanding than RT and would seem to be tougher on those with a bad back. Everything in that area has been disrupted so it takes some time to heal up. Surgery has its benefits, especially if you have had/have prostate related urinary issues, and you get a final accounting of the prostate cancer. With abdominal surgery comes a significant recovery period that can challenge many patients for quite some time.

Radiation is more mysterious and not as easy to quantify but works well also. There is little physical disruption so long as you can lie on a table for a short time so it would seem to be a lot easier on those with back issues. There are different treatment protocols with SBRT typically being 5 sessions at high dosage over a couple of weeks and standard IMRT around 44 daily treatments at low dosage. There are also IMRT treatments being done over 26-28 treatments at a somewhat higher dosage rate which might be applicable. The brachy treatments get done fairly quickly but have some unique considerations from radiation beam treatments. This where talking with the various RO's that offer all these methods can help you determine which will work best with your back issues and provide the best odds of success with your specific set of conditions and possible side effects.

Sorry for your upgrade, although I agree with MG above...it didn't necessarily get worse, they may have just poked in slightly different parts of your prostate. Regarding your back issues, if you select radiation you will be immobile on your back for up to 30 minutes depending on the type of treatment. (Or longer with brachytherapy.) If that's difficult for you, SBRT might be easier given it's only five treatments. And presumably, your back issues can be managed around in terms of making sure you're supported in whatever way is the most comfortable for you.

Agree with above comments. Personal thoughts.

My 3+4 came from Kaiser Permanente and University of Washington pathology labs. However, it was downgraded by Epstein's lab to 3+3. Well worth the $300.

http://pathology.jhu.edu/department/services/secondopinion.cfm

The Gleason score by itself would stage you as Favorable Intermediate with active surveillance, surgery and radiation as options. Without knowing the complete findings that's as far as I can comment.

https://www.nccn.org/patients/guidelines/cancers.aspx

Page 'PROS-6' https://www.nccn.org/professionals/physician_gls/pdf/prostate_blocks.pdf

MG: I did some looking at studies and....for men with G6 or G7 (G3+4) post surgery pathology, and with clear margins, clear SVI, and clear LNI, 50% or fewer will need post surgery radiation. For men with worse pathology (G4+3 or higher, ECE, SVI, and/or LNI, the numbers get higher.

So, yes, many men who have surgery will need radiation later. However, as Mumbo points out, many men never will need it. It's all about the individual case characteristics. It's just like pointing out that many men who have surgery wind up incontinent or impotent. True. Many men who have PC and never have surgery wind up incontinent and impotent as well. Never mind the men who go on ADT for years--impotence there is a guarantee for as long as they are on hormones and for some time afterwards.

mumbo -- maybe he means a lot of men on this board who have surgery also have radiation. i'd say it's got to be at least half.

dmo -- you've gotten some great advice and you're moving in the right direction. if your doctor gets offended that's on him. just worry about yourself. good luck to you!

mumbo -- i think you do a good job of it. here's one I have a problem with, and from the OP.

"I am tending toward radiation rather than surgery. I know surgery has immediate side effects whereas radiation has more long term side effects."

that's like saying do you want your SEs now or later.

F8 said...
mumbo -- maybe he means a lot of men on this board who have surgery also have radiation. i'd say it's got to be at least half.

But this forum is far from representative of the general PC population. I’d say that the guys that hang around here are the guys that needed additional treatment. Most of the guys that have surgery and are one and done, tend to leave, after a period of time has passed. Not all but many, maybe even more than not; so I don’t think that’s a fair representation.

F8 - True, there are all sorts of statements that are not carefully thought out and re-read for clarity of thought, that is part of the problem of the electronic age where you can post pretty quickly and not look back. I many times type comments to a post and then erase them since I am not comfortable when I re-read what I typed. Sometimes I realize I am not adding anything so I stop typing and move on.

OceanFisher - Did not mean to go off subject here. Most will recommend that you take charge of your own situation and don't worry about hurting a doctor's feelings when asking questions or for referrals. When you consider surgery, prepare a list of questions and ask the urologist how many surgeries he has done and what his results have been regarding treatment success and side effects, same with the RO when you get to that point. Ask for a recommendation for second surgical opinion and for a radiation oncologist recommendation. Any urologist worth a dam knows this is a big deal to you and knows other doctors they trust to recommend. You can ask if would be worthwhile to go to the local university, J Hopkins, or Georgetown for a second opinion or treatment. You will get lots of suggestions here once you provide more information about your results. My doctors did best when I was asking them questions, otherwise they just give you the standard speech about their treatment expertise. I think they actually like it more when you quiz them with good questions and concerns.

The 2nd opinion at JH was easy, I just asked the urologist if they could arrange it and hospital pathology called me directly a few days later and I gave them the link to the JH pathology site with the shipping instructions for the slides. The urologist is not the pathologist so his feelings are not hurt at all and has probably done it before. The larger urology groups may have their own in-house pathologist for biopsies so they can easily arrange the shipment.

Based on what you have described so far, there is no need for a medical oncologist quite yet. You are considering primary treatments of surgery and radiation so the urologist/surgeon and radiation oncologist are your first stops. Radiation may necessitate multiple RO visits since not all RO's offer all treatment types and it appears that a number of treatment schemes may be viable for you based on what you have shared so far.

Prostate cancer does not get better or go away so you are heading for treatment someday based on the Gleason 7 pathology. You can hope that the second expert opinion lowers the score back to G6 but use this time to visit other doctors and get treatment opinions. Get copies of your pathology and any other test results for your records. It takes time to do all of this and to digest the information you obtain. Good luck with your journey.

Ocean, a few answers:

1. Your doc should not be offended by you asking for a second expert opinion on your biopsy slides. If he/she is, then shame on him/her and you should probably move on to another doctor without such an easily bruised ego. BTW, there is no reason to wait for your appointment in a "few weeks". Get the ball rolling NOW...you will need this expert opinion when you seek options for your treatment.

2. No need to see a Medical Oncologist now. You have early stage cancer that can and should be treated by a surgeon or a radiation oncologist.

3. You also don't need to wait a few weeks to get your current pathology. Ask you doctor's office for it now then you can share it with us as you wish. It's your pathology not theirs.

4. Active surveillance is not necessarily off the table with your 3 + 4...some programs allow that depending on the number of cores, % of each core and location of the cores. You should discuss that with a doctor who has significant experience with AS.

As you can see from my responses and those of the others you need to take control of your situation. There are many options for successfully treating your cancer and, unfortunately, there is no one Master Guide who will tell you what to do. Read the info for new patients at the top of our forum and get yourself as educated as possible on our disease. Most importantly get yourself a plan to meet with doctors in various specialties so you can make the decisions you need to make.

Jim