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  • new guy confused

    Hi I had a biopsy they found 3=4 =7 in one of 15 cores with <1% 4 my PS!I has been around 5 my urologist wants to do to remove the prostate he said not to watch it because I could have more cancer that was not picked up in the biopsy ..So I went to a Radiologist for a second opinion. He said I was barely a stage 2 and we could watch and wait or we could do beam radiation with out any follow up hormone therapy . Because I got 2 different opinion I went to see a urology oncologist he wants to put me on a hormone casudex to stop cancer growth. I am really confused be cause I can not get an agreement between 3 doctors any thoughts on this

  • #2
    You haven’t included your age, which is important. My comments assume you properly listed what each doc suggested. The reason you can’t get an agreement is they are all correct. With prostate cancer you have make treatment choices.

    1. A biopsy is like sticking 15 needles in a strawberry and hoping to hit all the seeds and none of the seeds are the same. Men have biopsies that are negative and have cancer. Some of those could be an aggressive form. The safest course of action is to treat the cancer with radiation or surgery. Most men having external beam radiation with a small amount of 3+4 do not do hormone suppressing drugs, but ADT adds about 12% to the cure rates and maybe the RO wants 3-4 months due to your age.

    2. Some men today with small amounts of 3+4 opt for a period of active surveillance (watch it closely). Active surveillance requires more biopsies.

    3. The last doctor says if you want to active surveillance, he suggests adding Casodex, which does not turn off your testosterone. Casodex blocks the cancer from using T. You keep your testosterone. Generally Casodex is well tolerated.

    i would opt for radiation because you do have some grade 4.


    Last edited by Duck2; 04-25-2022, 09:08 PM.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &lt;5%, Right side negative.

    3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
    T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
    7 Nodes, SV, SM, PNI, and BNI were negative.
    LVI and Cribriform pattern present.
    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (25 days)
    4/25/19 <.03. (2 months)
    5/25/19 <.02 (3 months)
    9/10/2019. <.02 (7 months)
    11/27/2019. <.02. T < 3 (9 months)
    5/19/2020. <.02 (15 months)
    11/2/2020. <.02 (21 months)
    5/11/2021. <.02 T <3 (27 months)
    8/25/2021. <.02 T <3 (30 months)
    12/6/2021. <.02 T <3 (33 months)


    3 Part Modality Treatment Completed

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
    ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
    ADT - 5/19- 5/21 Eligard and Casodex.

    Comment


    • #3
      my age is 71

      Comment


      • #4
        I suggest discussion (1) a mpMRI (if you haven't had one) possibly followed by (2) another biopsy if targets are identified or a saturation biopsy and (3) a genomics test (e.g., Decipher, OncotypeDx, Prolaris) on your biopsied tissue to estimate your cancer's 5-year risk of metastasis and the risk of it already having grown out of the prostate capsule (the risk of adverse findings if RP is chosen). The genomics test should wait if you choose to have another biopsy, in which case it would not be needed if more high-grade lesions are found or. if nothing is found, you could use tissue from the biopsy already done.


        Djin
        Last edited by DjinTonic; 04-26-2022, 06:09 AM.
        69 yr at diagnosis, BPH x 20 yr, 9 (!) negative biopsies, PCA3-
        7-05-13 TURP for BPH (90→30 g) path negative for PCa, then 6-mo. checks
        6-06-17 Nodule on right + PSA rise on finasteride: 3.6→4.3
        6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
        Nodule was negative for PCa
        Bone scan, CTs, X-rays: neg.
        8-7-17 Open RP, negative frozen sections, Duke Regional Hosp.
        SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
        pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma
        5% of prostate (4.5 x 5 x 4 cm, 64 g) involved
        Dry; ED OK with sildenafil
        11-10-17 Decipher score: 0.37, Low Risk:
        5-yr met risk: 2.4%, 10-yr PCa-specific mortality: 3.3%
        9-16-17 (5 wk) PSA <0.1
        LabCorp uPSA:
        11-28-17 (3 m ) 0.010
        02-26-18 (6 m ) 0.009
        05-30-18 (9 m ) 0.007 (nadir)
        08-27-18 (1 yr.) 0.018 (huh?)
        09-26-18 (13 m) 0.013 (retest)
        11-26-18 (15 m) 0.012
        02-25-19 (18 m) 0.015
        05-22-19 (21 m) 0.015
        08-28-19 (2 yr. ) 0.016
        12-18-19 (28 m) 0.015
        06-30-20 (34 m) <0.014
        12-30-20 (40 m) 0.037 (?)
        03-31-21 (43 m) 0.020
        07-13-21(46 m) 0.018
        01-25-22(52 m) 0.023

        Comment


        • #5
          Of course you are confused. Biopsies are notoriously inaccurate, and each of the doctors you saw recommended the specific type of treatment in which they specialize. To make matters worse, there is no single right answer, and you only get one chance to get it right the first time.

          I too am 71. When I was 63 my first biopsy was totally negative. It was performed by a urologist whom I had been seeing for over ten years. I had no reason to doubt him when he told me that my prostate was normal. Two years later a different urologist ordered an MRI that identified a large tumor just beneath my bladder. The MRI targeted biopsy found high grade (4+4) prostate cancer. I chose surgery because I was told it had a 50% chance of getting it all, and that I might require follow up radiation if it did not. Furthermore I learned (only by asking) that if I had radiation first, that surgically removing my prostate afterwards would be difficult.

          Among the other variables in your biopsy is the location of the 3+4 and the percent in each sample. After telling another urologist about my biopsy findings, that it was located in the "base" (which is where most of the nerves are located) he said "you can never find it when it's up there".

          The advantage of radical prostatectomy is that your entire prostate will be sliced up and analyzed by a pathologist. Mine turned out to be 25% cancerous. Typically prostate tumors are scattered around in various parts of your prostate, so trying to hit one with a biopsy needle is a very inexact science. Statistics show that something like a third of all biopsy grades and staging are altered after surgery and the full pathology analysis, usually for the worse.

          As your PSA is relatively low for your age, and it appears that the amount of grade 4 cancer seems to be low, you have time to pursue additional testing as suggested by Djin. But don't delay. The cancer can be growing in you faster than was indicated in your biopsy. Good luck to you!
          Late 2012: PSA 4, age 62 all DRE's 'normal'
          Early 2014: PSA 9.5, TRUS biopsy (false) negative
          2015: PSA's 12 & 20, lots of Cipro ... Mar '16: PSA 25, changed Urologist

          Jun'16: MRI fusion biopsy, RT base, 2ea 15-40-100% G8(4+4)
          Aug'16:DVRP, "broad cut" 11 LN-, neg margins, gland 53g, 25% involved
          multifocal EPE, PNI, BNI, bilateral SVI, pT3b N0
          Dec 2016: Mrs: Dx stage 4 NHL/DLBCL, Primary Bone Lymphoma
          spinal RT boost+6X R-CHOP21+6X IT MTX via LP.
          Remission ended 2020, Follicular NHL. Currently active surveilance.

          Mar 2020: older adult son, T-cell acute lymphoblastic leukemia (TALL)
          Hyper-CVAD + pegaspargase, RBC transfusions in NYC amid COVID-19

          Bone marrow transplant Oct 2020, currently in Remission
          Jan'17: began Lupron ADT, uPSA's ~.03
          May'17: AMS800 implanted, revised 6/17
          Aug'17: 39 tx (70 Gy) RapidArc IGIMRT
          Jan 2018-Jan 2022: PSA's <0.008, T=50
          Apr'18: Dx radiation colitis, Oct'18: Tx sclerosing mesenteritis
          June 2020: younger adult son, small bowel resection
          adenocarcinoma of lower ileum (SBA) w/+lymph node, stage T3a-N1
          Adjuvant chemo: 12x FOLFOX, currently in Remission

          "Everyone you meet is fighting a battle you cannot see"

          Comment


          • #6
            they tried to get a genomics but the biopsy sample was to small. I also had a MRI They found a lesion that is why the biopsy was done. The lesion turned out to be nothing the cancer core was found in one of the other 15 cores they took. I also had a bone and they determined the cancer had not gotten out of the prostate

            Comment


            • #7
              If you decide to go on Casodex please note that a common side effect is gynecomastia (man boobs). There are two drug options to minimize this. One drug has essentially no side effects but costs over $800 per month. The other drug is cheap but causes blood clots. I don't remember the drug names but can look them up if you want. The last option is to have radiation to the breast buds to prevent or minimize the gynecomastia. However, the trick is to complete the radiation BEFORE starting Casodex. If found out about the BEFORE clause after it was too late and now I have man boobs so learn from this. If you don't go the Casodex route then you can ignore all this.
              2018-10 PSA 11.84
              2019-01 Da Vinci Prostatectomy
              2019-03 PSA 0.133
              2019-05 PSA 0.143
              2019-07 PSA 0.183
              2019-08 PSA 0.197
              2019-08 Start ADT
              2019-09 Start SRT
              2019-12 End ADT and SRT
              2020-01 PSA <0.006
              2020-04 PSA 0.040
              2020-07 PSA 0.096
              2020-08 PSA 0.104
              2020-09 PSA 0.113
              2020-10 PSA 0.122
              2020-10 Started bicalutamide 50mg daily
              2021-01 PSA <0.014
              2021-04 PSA <0.014
              2021-11 PSA 0.018
              2022-02 PSA 0.018

              Comment


              • #8
                You are drinking from a fire hose, we all know that feeling...

                Get the additional scans and tests listed above
                Use this time to decide on a treatment plan - radiation, surgery, etc. - choose a center of excellence and a surgeon who has done hundreds if not thousands of surgeries.

                I had numbers similar to yours, and a couple of Drs recommended Active Surveillance. I thought hard, and decided that the thought of cancer in my body, probably growing, was not for me.

                So i decided on surgery. Sure enough, the cancer was more widespread than what the biopsy found. It was caught "early" and I was in remission for many years.... And it ended up coming back

                It is a personal decision on whether to consider AS, and what your "trigger" is for having treatment. In my case, just having PCa in my body passed that threshold.

                If you do decide on AS, get tested very regularly, and have a treatment plan ready when/if you decide on that journey.


                BD: 1959 PSA 4.9 11/2012 (no symptoms)
                Biopsy 12/2012 Negative
                PSA 5.9 05/2013 (still no symptoms)
                Biopsy 6/2013 3+4 (thank goodness for PSA tests)
                1 core positive (upper left), 1 suspicious (lower left) out of 12
                DRE: bump right side T1c; PCA-III = 20 (normala)

                Da Vinci 7/18/2013:
                Total prostatectomy with seminal vesicles (S13-6085, 1-29, 7/18/13, 29 H&E and 1 paraffin block)
                Invasive carcinoma involves left lobe of prostate only, extends from left apex to posterior mid region of left lobe Gleason 7/10 (4+3); G4 tumor comprises 75% of invasive carcinoma present
                Estimated total volume of carcinoma in entire prostate gland: 10%
                TNM: T2b NX MX (Stage IIA)

                PSA History:
                8/13 11/13 2/14 8/14 2/15 8/15 3/16, 8/16, 3/17,9/17,4/18, 9/18 PSA "undetectable" (PSA <.1)

                March '19 = 0.1
                April '19 = 0.10 <-- switched to uPSA tests
                June '19 = 0.10
                Sept '19 = 0.10
                Dec '19 = 0.09
                Jan '20 = 0.13
                May '20 = 0.2 <- standard test by mistake
                Jun '20 = 0.11 <- back to uPSA test
                Aug '20 = 0.16
                Jan '21 = 0.23
                Feb '21 =0.20
                Mar '21 - started ADT/HT, radiation scheduled
                Jun '21 Eight Weeks Radiation @MSKCC
                Jul '21 <.05 (T-Level 0)
                Feb '22 <.05 (T-Level back to normal)

                Comment


                • #9
                  Originally posted by dayglo View Post
                  So i decided on surgery. Sure enough, the cancer was more widespread than what the biopsy found. It was caught "early" and I was in remission for many years.... And it ended up coming back...
                  Your case highlights just how serious and unpredictable this disease can be, including the likelihood of upgrading following full surgical pathology, and the importance of staying on top of PSA's after primary treatment and the possibility of requiring salvage radiation after surgery. As you are still < one year post SRT let's hope that your PSA remain essentially undetectable.

                  I feel sad for the guys who are ardent advocates of primary radiation based upon a favorable biopsy, only to have a recurrence down the road and have few options remaining.


                  Casualty of 2012 USPSTF recommendations

                  Comment


                  • #10
                    Originally posted by rick View Post
                    my age is 71
                    You don’t need aggressive treatment. Get an MRI to confirm what’s going on, then radiation treatment and go on with life.
                    YOB 1957

                    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &lt;5%, Right side negative.

                    3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
                    T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
                    7 Nodes, SV, SM, PNI, and BNI were negative.
                    LVI and Cribriform pattern present.
                    Decipher .86 High Risk.

                    Post Surgery PSA
                    3/25/19 .03. (25 days)
                    4/25/19 <.03. (2 months)
                    5/25/19 <.02 (3 months)
                    9/10/2019. <.02 (7 months)
                    11/27/2019. <.02. T < 3 (9 months)
                    5/19/2020. <.02 (15 months)
                    11/2/2020. <.02 (21 months)
                    5/11/2021. <.02 T <3 (27 months)
                    8/25/2021. <.02 T <3 (30 months)
                    12/6/2021. <.02 T <3 (33 months)


                    3 Part Modality Treatment Completed

                    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
                    ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
                    ADT - 5/19- 5/21 Eligard and Casodex.

                    Comment


                    • #11
                      Originally posted by PCFnet.org View Post

                      Your case highlights just how serious and unpredictable this disease can be, including the likelihood of upgrading following full surgical pathology, and the importance of staying on top of PSA's after primary treatment and the possibility of requiring salvage radiation after surgery. As you are still < one year post SRT let's hope that your PSA remain essentially undetectable.

                      I feel sad for the guys who are ardent advocates of primary radiation based upon a favorable biopsy, only to have a recurrence down the road and have few options remaining.
                      What do you mean by “fewer options”?

                      “If you have radiation first, you can’t have surgery later” is, in my opinion, a misleading talking point used by urologists to steer men into surgery.

                      It is true that it is difficult to remove a prostate after radiation; but, remember that radiation is a whole gland treatment. So, if there is a recurrence, it’s because the cancer had already left the prostate, and surgery would not be curative. Targeted radiation such as SBRT or protons, or cryotherapy, HIFU, or TULSA-PRO would be the salvage treatment.

                      Comment


                      • #12
                        ASA your statement assumes that radiation has a 100% effective treatment rate in the gland. As I pointed out in the Kwon video, his experience at Mayo was 55% of recurrence post radiation is in the gland. Yes, there may be other treatments as a follow up, but fistulas from radiation can limit those treatments significantly - even for us guys that did surgery with ART or SRT.

                        As a surviver who has had both state of the art surgery and state of the art radiation, the radiation I received worries me and the surgery doesn’t. To totally discount secondary cancer risk from any RT isn’t prudent in my view. If I would have been statistically more confident, there would have been no way I would have got RT. I don’t even like the radiation from the sun at this point in life.
                        YOB 1957

                        DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &lt;5%, Right side negative.

                        3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
                        T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
                        7 Nodes, SV, SM, PNI, and BNI were negative.
                        LVI and Cribriform pattern present.
                        Decipher .86 High Risk.

                        Post Surgery PSA
                        3/25/19 .03. (25 days)
                        4/25/19 <.03. (2 months)
                        5/25/19 <.02 (3 months)
                        9/10/2019. <.02 (7 months)
                        11/27/2019. <.02. T < 3 (9 months)
                        5/19/2020. <.02 (15 months)
                        11/2/2020. <.02 (21 months)
                        5/11/2021. <.02 T <3 (27 months)
                        8/25/2021. <.02 T <3 (30 months)
                        12/6/2021. <.02 T <3 (33 months)


                        3 Part Modality Treatment Completed

                        2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
                        ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
                        ADT - 5/19- 5/21 Eligard and Casodex.

                        Comment


                        • #13
                          Originally posted by Duck2 View Post
                          ASA your statement assumes that radiation has a 100% effective treatment rate in the gland. As I pointed out in the Kwon video, his experience at Mayo was 55% of recurrence post radiation is in the gland. Yes, there may be other treatments as a follow up, but fistulas from radiation can limit those treatments significantly - even for us guys that did surgery with ART or SRT.

                          As a survivor who has had both state of the art surgery and state of the art radiation, the radiation I received worries me and the surgery doesn’t. To totally discount secondary cancer risk from any RT isn’t prudent in my view. If I would have been statistically more confident, there would have been no way I would have got RT. I don’t even like the radiation from the sun at this point in life.
                          As a surgery and radiation survivor, I agree.

                          Radiation is far from perfect, and rare is the radiologist who will discuss, at length, either the side effects of being radiated, or the negative impact of ADT.

                          Good luck, do some in-depth research, and take the advise of those of us who have been through it with a grain of salt.

                          Comment


                          • #14
                            Originally posted by Duck2 View Post
                            ASA your statement assumes that radiation has a 100% effective treatment rate in the gland. As I pointed out in the Kwon video, his experience at Mayo was 55% of recurrence post radiation is in the gland. Yes, there may be other treatments as a follow up, but fistulas from radiation can limit those treatments significantly - even for us guys that did surgery with ART or SRT.

                            As a surviver who has had both state of the art surgery and state of the art radiation, the radiation I received worries me and the surgery doesn’t. To totally discount secondary cancer risk from any RT isn’t prudent in my view. If I would have been statistically more confident, there would have been no way I would have got RT. I don’t even like the radiation from the sun at this point in life.
                            Duck, can you provide a link to the video of Dr. Kwon? This is the first time I’ve heard any stats about the location of prostate cancer after radiation. I am curious to see if he can provide any details on that patient treatment population.

                            Comment


                            • #15
                              Same information and video I provided you Jan 31. Info at 5 minutes. https://youtu.be/Q2joD360_pI

                              He simply states in men who had radiation as the primary treatment and recur, 55% of the cases is cancer radiation failed to kill in the prostate glade.
                              Last edited by Duck2; 05-03-2022, 07:47 PM.
                              YOB 1957

                              DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM &lt;5%, Right side negative.

                              3/6/19. Post surgery Pathology Report - Grade Group 4 Intraductal Carcinoma
                              T3aNO, <1 mm non focal EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.
                              7 Nodes, SV, SM, PNI, and BNI were negative.
                              LVI and Cribriform pattern present.
                              Decipher .86 High Risk.

                              Post Surgery PSA
                              3/25/19 .03. (25 days)
                              4/25/19 <.03. (2 months)
                              5/25/19 <.02 (3 months)
                              9/10/2019. <.02 (7 months)
                              11/27/2019. <.02. T < 3 (9 months)
                              5/19/2020. <.02 (15 months)
                              11/2/2020. <.02 (21 months)
                              5/11/2021. <.02 T <3 (27 months)
                              8/25/2021. <.02 T <3 (30 months)
                              12/6/2021. <.02 T <3 (33 months)


                              3 Part Modality Treatment Completed

                              2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic, Dr. Kaouk, surgery #41 in US.
                              ART - 7/25/-9/25 2019 (78 Gy, yes, I glow in the dark).
                              ADT - 5/19- 5/21 Eligard and Casodex.

                              Comment

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