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Newbie starting out debating rp or ro in hawaii

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Posted 4/4/2022 4:09 AM (GMT 0)
psa level 3.7 to 5.7 one year. Biopsy done 3/18/22. Right Prostate benign left medial base acinar adenocarcinoma Gleason score 3+4 7 grade group 2 involving 10% of tissue acute inflamation. lft lateral base acinar adeno. gleason score 3+3 6 grade group 2 involving 10% of tissue acute inflamation. lft medial mid acinar adeno. gleason score 4+4 8 involving 20% of tissue acute and chronic inflammation. lft lateral mid acinar adeno. gleason score 3+4 7 grade group 2 involving 50% of tissue acute and chronic inflammation. lft prostate apex peripheral zone X 3 acinar adeno. gleason score4+3 7 grade group 3 involving 10% of tissue.
When I spoke to the Urologist he told me that the cancer was contained in the prostrate he did a mri fusion biopsy. When I asked him what were the odds of my surgery having negative margins he said 70%. I asked him why it was so low he told me that it was based on a table he used to determine surgical outcomes. Is this more likely because the last biopsy in the left apex peripheral zone was to close to organs and he could not get all of it or I would lose continence.
I am thinking if the odds are low maybe radiation with adt and brachytherapy maybe a better option.
Posted 4/4/2022 12:45 PM (GMT 0)
Glenn, Sorry you’re joining us. I hope your visits bring information that helps you make an informed treatment choice. Your urologist is most likely referring to the Partin tables or some version of it. I hope you’ll investigate them since they help define your statistical risks regarding if your PCa is contained. I’m sure you’ll hear from guys suggesting most every treatment option and the choices initially can seem a bit confusing and a little overwhelmed. The one thing I’m sure of is that an informed choice will be your best option.

You can pick up a lot of information from u-tube as well. A good starting point are videos from Dr. Mark Scholz. Dr. Scholz is well respected and has written a number of books worth reading.

Good luck and keep asking questions and learning. Terry
Posted 4/4/2022 3:21 PM (GMT 0)
Hi Glenn and sorry that you've become part of our world. Between your Gleason 8 core and your 4+3, your diagnosis shades on the more aggressive side--so the first thing I suggest that you do is have a second opinion your biopsy slides to see if you can get confirmation on those readings. The general agreement here is to have them sent to Johns Hopkins where they have an excellent second opinion service--it's actually a pretty easy process and the cost is generally picked up by insurance. Your uro should be able to facilitate that.

As I hope you know, even the higher risk diagnoses of prostate cancer are generally successfully treated. The best way to make a treatment decision is to talk to more than one expert. Uros are surgeons and will advise from that perspective. Radiation oncologists don't always practice the same types of radiation--you had mentioned brachytherapy as a possibility and you would certainly want to speak to an RO that specifically is equipped to do that. If your diagnosis is downgraded to a G7 (unlikely, but possible), brachy could likely be used as a mono therapy. At a G8, the combo treatment is likely better. (I had the combo treatment as a G9.)

I hope we can be helpful as you assess your options. Wishing you the best as you go through the weeks and months ahead...
Posted 4/4/2022 3:29 PM (GMT 0)
Welcome. Radiation is as or more effective than surgery alone. Plus, you have many options. Brachytherapy, both permanent seeds and High Dose Rate, and external beam, traditional low fraction and SBRT, or some combination are all good options. All are effective to control local and locally advanced cancer and with usually less significant negative treatment side effects than surgery.

The only way to find out is to get several assessments from different board certified radiation oncologists. No one doc does it all. Seek out external beam specialists, permanent seed brachytherapy specialist, and a HadR brachytherapy specialist.

Given your high risk dx, a combination of HDR brachytherapy couple with external beam radiation has shown to be the most effective combination. Personally, I would also have the pelvic lymph nodes radiated as this is usually the first site of spread. This would likely be accompanied by 9-12 months of ADT. Take the G8 and several other G4 scores seriously. This is the stuff that can get out of hand. And remember, the urologist or current scans can not detect any micro-met spreads. There is no assurance that you don’t have any cells that have escaped the surgical field. In your risk category at least 35% of surgeries fail and must be followed by radiation. The nomogram used by your urologist shows you that. You can easily run the nomograms yourself online and free at both Memorial Sloan Kettering and Johns Hopkins. Easy to find with Google.
Posted 4/4/2022 6:01 PM (GMT 0)
Glennyoshio - The above is good info. I might suggest a free document to read from PCF as you try to gain more knowledge about treatment options. You already seem to know quite a bit.

https://www.pcf.org/guide/prostate-cancer-patient-guide/

Your age and estimated prostate size from the MRI as well as if the MRI noted any EPE (extraprostatic extension) would be helpful pieces of information for your puzzle.

"Is this more likely because the last biopsy in the left apex peripheral zone was to close to organs and he could not get all of it or I would lose continence"

The proximity of the prostate to the bladder and rectum are very close to the prostate. The surgeon is limited in areas of how much margin he/she can maintain without damaging adjacent items.

Incontinence is not really a function of margins but more related to your plumbing layout and the skill of the surgeon which is why you want someone who is doing surgeries every week and has at least 500-1000 under their belt.

As far as erectile function goes, the nerves that control erections are essentially part of the prostate and have to be carefully separated from the prostate during removal. If the cancer is at the nerve location, the surgeon may not be able to save one or both of the nerves. A similar issue exists with most treatments given the close proximity of the prostate to important things so all treatments have potential side effects. There is not a "no risk" option unfortunately with prostate treatments but some are better than others and for you to decide after much study.
Posted 4/5/2022 12:47 AM (GMT 0)
Glenn, welcome to our reluctant brotherhood.

I'm a surgery guy, and as far as side effects, i had a reasonably good outcome, although i did need salvage raditaion 3 years post op.
However with that said, seems like you've got a fair amount of cancer in there with 5 positive cores. Combine that with your Gleason 8 and G7(4+3), and i would think your best bet for a one and done cure would be triple play, the 2 types of radiation + ADT that you mentioned.
An MRI can tell the Dr what the chances are of spread outside the prostate. But it is not definitive in that regard. There could be microscopic escapte that the MRI wouldn't pick up.

As was said, see a surgeon about surgery but see a radiation oncologist to get info on radiation.
Best of luck
Posted 4/7/2022 3:29 AM (GMT 0)
Mahalo for the replies and well wishes. I forgot to mention my age I am 68 years old and feel much younger, was in good health till the end of last year when I had thyroid problems and then concurrently had to have my gall bladder removed. I am wavering between rp and rt because the first book by Dr Walsh seemed to favor removing the cancer mass then the second book I read by Marckini seemed to be very much against rp. I have waiting for another consult from another radiological oncologist. The first one was well informed but has only been doing procedures solo for a year. He informed me that do to the size of my prostate 69cc I would need adt before I could do brachytherapy and then do external beam radiation.

Post Edited (Glennyoshio) : 4/6/2022 9:32:24 PM (GMT-6)

Posted 4/7/2022 3:58 AM (GMT 0)
One thing to ask your team about…..psma pet. Newly approved. Excellent tool to see if any of your lymph nodes are affected.

One of the primary uses of this tech is exactly your situation .

- Newly diagnosed.
- Checking to make sure all the hot spots are indeed in the prostate.

https://www.pcf.org/blog/5-things-to-know-about-psma-pet/

Your first swing is your best chance to eliminate it and the psma scan gives you and your team more information to maximize your treatment’s effectiveness. Take no prisoners!

Assuming it really is prostate confined, its kind of nice having choices. Some pluses for surgery not often mentioned:
- you get a definitive sample of your cancer that might be useful later (genetic testing of the original tumor)
- it spares the area of radiation. So for example if you needed pelvic radiation for some other reason sometime in the future you would not have to worry about overlapping treatment fields.

Good luck! ( pomaika'i)
Posted 4/7/2022 9:41 AM (GMT 0)
Glenny, you have already in your studies run into the debate, and it can be summed this way: Surgeons generally recommend surgery, Radiation Oncologists generally recommend radiation. All of the study, and discussion, and questions and answers really are simply information for YOU. And then, you make the decision based on your own metrics.

IMO, from your biopsy results, you are what is known as low-intermediate risk, so while is likely that you are organ-confined, it's possible that you aren't. The apical involvement adds a risk factor for surgery by increasing some of the potential side effects.

Your first RO is proposing what is known at the triple play: ADT+external radiation+brachy. It's a good, solid treatment that will likely have a good outcome. There are several guys in here who went that route. I'd also suggest you look for a site that offers SBRT--it's a radiation therapy that involves 5 treatment sessions only over a 2 week period. A number of guys here have done that, and I don't think anyone has been unhappy with the choice.

Best of luck to you.
Posted 4/7/2022 1:40 PM (GMT 0)
What ever treatment you chose, get off the rock to get it. Medicine in Hawaii is not the best.
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