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Old 10-04-2010, 08:11 AM   #1
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Carcinoma Gleason score 4+3 meaning!

hi all ,

What is the meaning of a prostate biopsy report of Gleason score of 4+3?
I understand it is intermediate stage, but is it curable and how long can a patient survive and what could be the treatment. This is the score of my father,77yrs old. Does it mean the spread of cancer has started?

What could be the possible treatments? Can he get cured?
Point to be noted that he is leading a normal life without any symptoms
Thank you. Please write ASAP.

 
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Old 10-04-2010, 09:43 AM   #2
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Re: Carcinoma Gleason score 4+3 meaning!

The Gleason score is just one of several pieces of information needed to answer the many questions you have. By itself, it merely tells how aggressive the cancer appears to be. A 4+3 score says that the majority of the cancer is aggressive, possibly bordering on "high risk." That said, high risk has a different meaning for a 77-year-old man versus a 55-year-old. With current technology, and assuming the cancer is still localized, the patient could easily live ten years and more -- and may be more likely to die of other causes than prostate cancer.

To answer your questions, you would also need to know the percentage of cancer in the biopsy cores, the PSA level, the PSA doubling rate, the results of a rectal exam and ultrasound, and possibly other test results that may better tell if the cancer has spread beyond the prostate.

You may want to consult one of the many books about prostate cancer to learn about diagnosis, staging and treatment options. Perhaps A Primer on Prostate Cancer would be a good place to start.

Tom

 
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Old 10-04-2010, 02:09 PM   #3
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Re: Carcinoma Gleason score 4+3 meaning!

Hi Brendon and welcome to the board!

I'm reading this after Tom already replied with some important information. I'll add to that, interspersed in an excerpt of your post, in green below.


Quote:
Originally Posted by brendonwoodford View Post
hi all ,

What is the meaning of a prostate biopsy report of Gleason score of 4+3?
I understand it is intermediate stage, but is it curable and how long can a patient survive and what could be the treatment. This is the score of my father,77yrs old.
Yes, it could still be curable, based on the limited information you now have, but trying for a cure might not be the best strategy. That really depends on both the total clinical picture and on your father's preferences.

At his age, the strong consensus of experts is that surgery is not a sound choice. The main reason is that side effects, complications and their risks are much amplified in a man in his 70s or older. However, that's very much okay as surgery is not usually the best choice with intermediate risk prostate cancer.

In fact, at the other end of the scale from surgery, active surveillance is still a choice, assuming other facts, such as mentioned by Tom, are favorable, or that there are other serious health conditions, in a man of your father's age. That would especially be so if your father is willing to pursue lifestyle tactics - diet/nutrition/supplements, aerobic and strength exercise (could be fairly low-key and adjusted to his age and capability), and stress reduction, possibly also aided by mild medication.

A more usual choice would be some form of radiation - radioactive seeds, some form of external beam radiation, or a combination, as radiation often is very effective in curing prostate cancer and is often reasonably tolerable from a side effect standpoint.

Cryo surgery - freezing the prostate - is also an option. Often it is not pursued by younger men who still have a vigorous sex life, but older folks often do not mind the high risk of impotence from cryo surgery. Focal cryosurgery - meaning freezing just part of the prostate - often preserves potency, but it may not be a good choice for a Gleason score 7 cancer.

Hormonal blockade therapy, my own choice, is also very much worth consideration, especially by an older man. For most of us it is more than capable of knocking the cancer way back on its heels, though it is rarely curative. Many of us need just one course of hormonal blockade of about a year to a year and a half, and then we continue with low-key maintenance medication, achieving excellent control of the cancer and usually recovering fully from side effects. Some of us, like me, need cycles of intermittent therapy. Either way, when we go off the heavier duty drugs, side effects for the vast majority of us go away.

Survival time - Here's some good news: prostate cancer is by far the slowest growing of the major cancers. It's very important that new patients and their supporters realize this key fact. To get specific about intermediate-risk cancer, virtually 100% of patients have not died due to prostate cancer by the ten year point. That's documented on page 39 of the new book "Invasion of the Prostate Snatchers--No More Unnecessary Biopsies, Radical Treatment Or Loss of Sexual Potency," by Ralph H. Blum and Mark Scholz, MD (August 2010) based on a study by Hermann Brenner in the Journal of Clinical Oncology in 2005. In fact, even guys with "high-risk prostate cancer" (me) have a 95% shot of survival at the ten year point. Keep in mind that those statistics are based on results from patients treated at least a few years ago; that means that patients treated today will likely do even better. Contrast that with any other major cancer and you see how different prostate cancer is! However, it can take some work, and a bit of luck, to be in these fortunate groups.


Quote:
Does it mean the spread of cancer has started?
As Tom noted, you need to tell us more. But the tentative answer is that it may have spread, but not necessarily. My GS 4+3=7 cancer, with a baseline PSA of 113.6, stage 3 with all biopsy cores positive, most 100%, had not spread in a way that was detectable by CT, bone and ProstaScint scans.

Quote:
What could be the possible treatments? Can he get cured?
Point to be noted that he is leading a normal life without any symptoms
Thank you. Please write ASAP.
In view of your father's age, my personal hunch is that he would do better if he can achieve some success controlling the cancer with one of the low key strategies. Active surveillance might do the trick, especially if it turns out that he gets improvement in PSA results as a result of lifestyle tactics, such as normalizing his vitamin D level and consuming quality pomegranate juice or extract pills, along with other lifestyle tactics.

A mild form of hormonal therapy might also work. The mildest would be the generic and relatively inexpensive drug finasteride, which is prescribed as 5 mg or 10 mg (me) daily, closely followed, if needed, by the somewhat more expensive brand name sister drug Avodart. Often doctors like to see their prostate cancer patients on a statin drug as well, as research shows that being on a statin is associated with a much lower death rate from prostate cancer, especially if the patient has been on the statin for at least three years. I recently passed that point with the dirt-cheap statin drug simvastatin (generic version of Zocor).

If that level of attack does not work, the next level is to add what is known as an "antiandrogen" drug. The drug of choice is bicalutamide, which is the recently available and much cheaper version of Casodex, which was quite expensive (~ $12-$15 per pill). Dr. Scholz, author of Invasion, has said that he sees 80% of the benefit of hormonal blockade for only 20% of the side effects with that level of approach. I'm on full triple blockade, which adds the "LHRH-agonist" member to the assault on the cancer, often as a shot of Lupron in the butt or Zoladex in the stomach muscles every few months. That's the heavy-hitter part of the strategy; it's excellent for knocking down the cancer, but it often comes with some side effects that take work and attention to counter.

In addition to the Primer, which Tom and I recommend, and Invasion, which is also a great book mentioned above, I feel strongly that a third book is also very helpful and encouraging to men on hormonal blockade or with higher-risk prostate cancer. It is "Beating Prostate Cancer: Hormonal Therapy & Diet," by Dr. Charles "Snuffy" Myers, MD. It's an easy read and delivers a whopping dose of optimism. (Dr. Myers happens to be a survivor of a challenging case himself. He's now at the eleven to twelve year point and doing great.)

I hope this helps, but please keep your questions (and facts of your father's case) coming.

Take care,

Jim

 
Old 10-04-2010, 08:05 PM   #4
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Re: Carcinoma Gleason score 4+3 meaning!

Thank you all for answering and giving me some hope.
My father's recent PSA level has been 56.9 and the details of the biopsy report is given below :-

Speciment: Prostrate(TRUS GUIDED)biopsy.

Macroscopic Description:
1.Right:5 grey white linear bits each measuring 1.1cm to 1.5 cm. A-Entire tissue processed.
2.Left: Received 4 grey white linear bits each measuring 1.1 to 1.4cm.-Entire tissue processed.

Microscopic description:
Right lobe : All the cores show normal prostatic acini seperated by a fibromuscular stroma.There is no evidence of a malignancy.

Left lobe: All the cores are infiltrated by neoplastic microacini seen predominantly in a fused acinar pattern with few acini being discrete. They are lined by a single row of cuboidal cells with a vesicular nucleus having a central nucleolus and are minimally pleomorphic.

Diagnosis/comments:
Right lobe biopsy negative for malignancy.
All cores of the left lobe biopsy show involvement by adenocarcinoma, Gleason's score- 4+3.


He is diabetic, Hypertensive for 12 years now and a creatinine level of 17 for last 2 yrs.
You mentioned radiation therapy, Is it safe? I have seen patients suffering and becoming weak post radiation.

What is the meaning of 10years point survival? Does it mean that despite a cancer a patient would survive for 10years?


Thank to all again.

 
Old 10-04-2010, 08:54 PM   #5
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Re: Carcinoma Gleason score 4+3 meaning!

Hi Brendon,

I'll insert some comments in green. Do you know your father's "stage"? Were any scans done, and do you know the results? (Bone and CT scans, which until the last couple of years were done routinely, even on men clearly at low-risk, are often of no value and new guidelines are that they should not be done routinely, but your father's PSA and biopsy results are a sound basis for doing the scans.)


Quote:
Originally Posted by brendonwoodford View Post
Thank you all for answering and giving me some hope.
You're welcome. It's really important for patients, family and friends to understand how different prostate cancer is from other cancers. It's often not a cake walk, but there is reason for hope.


Quote:
My father's recent PSA level has been 56.9 and the details of the biopsy report is given below :-
That PSA is consistent with other features of a high-risk case, but I think you would be amazed how successful certain treatments are against such cases.

Quote:
Speciment: Prostrate(TRUS GUIDED)biopsy.

Macroscopic Description:
1.Right:5 grey white linear bits each measuring 1.1cm to 1.5 cm. A-Entire tissue processed.
2.Left: Received 4 grey white linear bits each measuring 1.1 to 1.4cm.-Entire tissue processed.

Microscopic description:
Right lobe : All the cores show normal prostatic acini seperated by a fibromuscular stroma.There is no evidence of a malignancy.

Left lobe: All the cores are infiltrated by neoplastic microacini seen predominantly in a fused acinar pattern with few acini being discrete. They are lined by a single row of cuboidal cells with a vesicular nucleus having a central nucleolus and are minimally pleomorphic.

Diagnosis/comments:
Right lobe biopsy negative for malignancy.
All cores of the left lobe biopsy show involvement by adenocarcinoma, Gleason's score- 4+3.
The key here is the Gleason score of 4+3=7, indicating cancer of intermediate aggressiveness. (Mine was a 4+3=7 too.) It's too bad it was not a Gleason 6 or lower, but it's good that a nine core biopsy indicated it was not a Gleason 8 or higher cancer, which is substantially more aggressive compared to a total of 7.

Try to find out if a pathologist who is expert in prostate cancer did the review. Many times the pathologist is a generalist - one who examines all kinds of samples from all kinds of patients, including children and adults, men and women, for all kinds of diseases. Frequently their scoring is not ideal, and the Gleason score is a key indicator. If the pathologist was a generalist, it would be wise to get a second opinion from an expert.


Quote:
He is diabetic, Hypertensive for 12 years now and a creatinine level of 17 for last 2 yrs.
In essence, he is facing threats to his life and well being that are likely more challenging than the prostate cancer. Hormonal therapy (my therapy) is often highly effective for advanced cancer, but the heavy duty drug component (the "LHRH-agonists" such as Lupron, Zoladex, Viadur, Trelstar, etc.) can aggravate insulin issues and cardio problems that already exist, unless well countered. However, milder forms of hormonal therapy have a good chance of being tolerable, even with the problems you mention. Surgery should already have been off the table, but these issues move it even further from the table.

Quote:
You mentioned radiation therapy, Is it safe? I have seen patients suffering and becoming weak post radiation.
Yes, with an expert doctor/radiation team and a good facility, modern radiation for prostate cancer has low rates of problems, though it is not completely safe, and many patients will experience some degree of side effect burden long term. Radiation for prostate cancer has improved greatly over the past decade. Some fatigue is common for external beam radiation, but it goes away.

Quote:
What is the meaning of 10years point survival? Does it mean that despite a cancer a patient would survive for 10years?

Thank to all again.
Yes, it means he is still surviving cancer after ten years since he was diagnosed. That's not a hope, it's a well documented fact! (There are a few men with high-risk cancer that have extraordinarily rare types that can kill a man fairly quickly, but usually these types do not produce much PSA - nothing like the quantity your dad's cancer is producing.) I can refer you to some of those research papers if you would like. We can access brief but informative descriptions of key points in an amazing tax-payer-supported tool known as PubMed (www.pubmed.gov). We can refer to it on this board because it is Government sponsored.

Take care,

Jim

 
Old 10-04-2010, 10:03 PM   #6
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Re: Carcinoma Gleason score 4+3 meaning!

Thanks Jim for your valued information.

This is the first time in my life that I am reading and getting to know about cancer. Otherwise my information was limited to cancer being more likely to occur to those who consume some form of tobacco or Alcohol.
Initially I panicked a little but now I have decided to know it fully and decide on the best way forward.
Today I am going to the Urologist for showing him the biopsy reports and he would most certainly suggest the possible course of action.
My question is what are the things I need to ask and confirm from the doctor and ensure that he delivers the right treatment forward.

May God bless all

Brendon

 
Old 10-05-2010, 06:59 AM   #7
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Re: Carcinoma Gleason score 4+3 meaning!

Hi Brendon,

You are welcome. In your previous post you wrote:


Quote:
Originally Posted by brendonwoodford View Post
... Otherwise my information was limited to cancer being more likely to occur to those who consume some form of tobacco or Alcohol.
Both are significant influences in causing some cancers, but prostate cancer is not one of them. Genetics plays a strong role for a few of us, but it appears to play only a subtle role for many others. It is believed that oxidative damage to the DNA of our cells over many years is a likely culprit. Other influences, such as a shortage of vitamin D, excess meat in the diet, and other nutritional practices also appear to play a role.

Quote:
Initially I panicked a little but now I have decided to know it fully and decide on the best way forward.
I'm convinced that becoming an empowered, knowledgeable patient improves our outcomes.

Quote:
Today I am going to the Urologist for showing him the biopsy reports and he would most certainly suggest the possible course of action.
My question is what are the things I need to ask and confirm from the doctor and ensure that he delivers the right treatment forward.
In the US, urologists are very strongly biased toward surgery and against other effective approaches, such as radiation, without good reason. A minority are more objective and give an even handed presentation of options. Most of us need second opinions (and third, fourth, etc.) with doctors from other specialties - doctors who were not recommended by the initial consultation doctor - to get objective opinions. I'm not clear whether that is so in India, but it might be.

A key question to ask a urologist is how many prostatectomies he does a year. He needs to do a high volume to be proficient in this very complex and difficult operation. You can also ask whether he tracks the outcomes of his patients regarding both cancer control or cure rates and side effects, especially incontinence and impotence. Because your case has some higher-risk factors, ask how his higher risk patients like you are doing, hopefully getting numbers for those he has treated and how many have had their cancer recur, along with the average time of follow-up. The well-known surgeon Dr. Patrick Walsh pioneered some advances in surgery for prostate cancer, especially advances in reducing blood loss and sparing nerves for potency, if possible. I believe a competent surgeon in India should be using such techniques, and you could ask him about that. It would also be wise to get references from patients he treated about a year or two ago; contact them and learn how they are doing and what they thought of the care and advice they got after the operation.




Quote:
May God bless all

Brendon
May he bless us all indeed!

Jim

 
Old 10-08-2010, 08:28 PM   #8
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Re: Carcinoma Gleason score 4+3 meaning!

hi Jim and rest of the other forum visitors.
Hope you are doing well.

As per the advice of the Urologist we got the Bone scan and the CT scan of Pelvis done yesterday. The reports seem normal. I'm giving the details of the reports below:-

CT PELVIS WITH IV CONTRAST

TECHNIQUE:Multislice CT of pelvis was performed on Light Speed VCT 64
using 70ml of non-ionic contrast IV.Detector collimation 0.625mm,
3/5mm multiplanar reformations.

Clinical details: Recently biopsy proven carcinoma of prostate.
To rule out lymphadenopathy.

Findings: (IV contrast was not given in view of deranged renal parameters.)
Urinary bladder is normal.
Prostate is 4.2*3*5.6cms. Mild enlargement with normal density is noted.
Rectum and perirectal fat planes are normal.
No ascites/lymphadenopathy.


Impression:
Mild enlargement of Prostate.
No pelvic lymphadenopathy.




RADIONUCLIDE BONE SCAN

Tracer: Tc 99m MDP

Technique: About 20mCi Tc 99m MDP was injected IV Bone image were
acquired after 3hours using dual detector Gamma Camera.

FINDINGS: Bone scan shows increased tracer uptake in the following
regions:

Shoulder
Elbow
Wrist
Sacroiliac joints
knees(R>L)
Left ankle
Metatarsophalyngeal joints of right foot.

Kidneys show normal tracer distribution.

Impression: Degenerative arthritic changes.

Do they mean that the malignancy is localized? The doctor has previously suggested all the three options surgery, radio-therapy, hormone-therapy. And also said that if the cancer has spread to the other parts of the body then he would prefer only hormone therapy.

(I will visit the doctor on Monday next with all the reports.)

What is your view on that?

Thank you all.
God is almighty.
Brendon.

 
Old 10-09-2010, 04:32 PM   #9
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Re: Carcinoma Gleason score 4+3 meaning!

Hi Brendon,

Those are favorable reports - just what you hope to see. I'll insert some comments in green in an excerpt from your post, which immediately precedes this one.


Quote:
...

As per the advice of the Urologist we got the Bone scan and the CT scan of Pelvis done yesterday. The reports seem normal. I'm giving the details of the reports below:-

CT PELVIS WITH IV CONTRAST

...Impression:
Mild enlargement of Prostate.
No pelvic lymphadenopathy.
That last phrase is the punch line - no cancer in the nodes that is detectable by a pelvic CT scan. It's really encouraging when we are on the negative side of CT scans. Even though it takes a pretty well established tumor to trigger such a scan, having a negative scan puts us in a considerably better prognostic category, and it means that the risk of local therapy is a reasonable bet instead of something that should not be done.

Quote:
RADIONUCLIDE BONE SCAN

...

FINDINGS: Bone scan shows increased tracer uptake in the following
regions:

Shoulder
Elbow
Wrist
Sacroiliac joints
knees(R>L)
Left ankle
Metatarsophalyngeal joints of right foot.

Kidneys show normal tracer distribution.

Impression: Degenerative arthritic changes.

Do they mean that the malignancy is localized?
In a word, yes. From what is detectable with a bone scan, a technique that has fairly good sensitivity, they found no cancer. Such a scan is virtually a guarantee that any cancer that might exist occupies only 10% of any site of metastasis, or less, as I understand it. Old bone injuries and arthritic areas will take up extra tracer just like cancer will, but radiological pathologists are good at determining which is which. For instance, often symmetrical black spots on the scan in certain likely locations indicate arthritis or injuries rather than cancer.


Quote:
The doctor has previously suggested all the three options surgery, radio-therapy, hormone-therapy. And also said that if the cancer has spread to the other parts of the body then he would prefer only hormone therapy.
That makes sense and is in line with current practice. However, even when there is spread to just a few spots ("oligometastasis"), a local therapy such as surgery or radiation plus radiation to those few spots has had impressive success. Fortunately, you did better than that so you do not have to consider that technique. When the doctor outlined the three options, he probably did not want to overload you with detail; a combination of radiation plus hormonal therapy is also quite effective, as are combinations of radiation (seeds plus external beam) with hormonal therapy.

Quote:
(I will visit the doctor on Monday next with all the reports.)

What is your view on that?
My first thought: envy. Second thought: those scan results open up your options. However, there are other techniques that can further pin down whether or not a strictly local therapy - just the prostate - will work. One effective option is an endorectal MRI with spectroscopy, an excellent way of determining whether the cancer has spread just beyond the prostate capsule. There is also an outstanding scan for detecting spread to lymph nodes throughout the body, known as Combidex. However, it has been available only in the Netherlands, and even at that site there has been a recent interruption in availability of the infusion agent.

Many doctors will go straight to therapy without performing additional staging to refine the clinical picture, which usually requires travel to an institution that has the specialized expertise and facilities. Frankly, I would want the additional work, but it involves expense, time and effort, and many patients and doctors are comfortable proceeding without it. If you want to go the extra miles, the Primer and "Invasion of the Prostate Snatchers" provide the information you need to be an informed patient decision maker.


Quote:
Thank you all.
God is almighty.
Brendon.
I hope this helps, but I believe that remembering prayer is also important.

Take care,

Jim

 
Old 10-09-2010, 09:29 PM   #10
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Re: Carcinoma Gleason score 4+3 meaning!

Hello Brendon-
I thought I might jump in on this discussion since my husband's case is similar to your fathers. The main difference would be ages. My husband was 57 when he was dx'd with PCa (4+3) and he is also diabetic. This is why I thought I might join the dialogue because not many people on the board bring up the fact of diabetes and PCa. Is your father insulin dependent? My husband is a type 1 with an insulin pump. He did elect to have surgery and found he did have extra capsular extension. All his test before hand did not show this possiblity but at the time we were more comfortable with surgery than radiation. We were worried about the possiblity of radiation induced cancer down the road since he was pretty young at diagnosis. We were looking for a cure and at that time did not really look much further than surgery or radiation.

That being said a year later he did have a recurrence of PCa and had to have radiation after all. Unfortunately a year later that failed too. And now he is on hormone therapy just with Eligard. He just had his 2nd shot last week so he has not been on it for long. His PSA was .02 so we are very pleased that it is working well.

This brings me to a little discussion now on HT and diabetes. They warn that HT will make you insulin resistant and it has. My husband uses about 1/3 more insulin that before and is having a harder time controlling the swings between Highs and Lows. They have now put him on one of those blood glucose sensors to help him control his blood levels. We're not really sold yet on them but working closely with his endocrinologist to get it right. His Endo says for him to do what his urologist says he needs to do and then they will follow up and do what they need to do to control the diabetes.

I hope my experience will help you a little to be more informed and hope all goes well with your dad. If I can help in anything else please just ask.

Mart

 
Old 10-12-2010, 10:08 PM   #11
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Re: Carcinoma Gleason score 4+3 meaning!

Thanks Mart & Thanks Jim,
I went to urologist day before yesterday and after looking at the bone scan and the pelvic CT scan he said it was good that the spread has not started but he was in doubt about the PSA level (56.9) as person without metastasis usually has much lower PSA.
He suggested a repeat of the PSA and we followed suit.The latest reading is 52
He said if the PSA level came out to be below 20 then he would prefer surgery and if more then he would go ahead with hormone therapy.Today we are supposed to visit him once more for his suggestions.

What are the side effects of hormone therapy and are they tolerable? how is the quality of life affected by this? Now he is leading a normal life and his other parameters like diabetes and hypertension and the creatinine well under control.
If there is side-effect how to counter it? and other than the treatment what do you suggest the patient to do to increase his well being (you suggested diet, exercise, and prayer before please elaborate).
Is it important to lower the PSA level.If it remains upward of 50 what happens?
HT is administered over a period of time and then withdrawn.What is the time period that a patient is kept on?

To answer Mart's question "whether my dad is insulin dependent ?" the answer is "no". He has been on a single tablet of Diamicron in the morning for over 5yrs now and his diabetes is well under control.
Mart, I have question for you as you are very closely watching a person in his fight against PC. How difficult is it for the patient's family members to help the patient take the right decisions? And what should they do to cope with the pressure that this disease wrecks on the entire family.



It has been turbulent last one month and you people, Jim and the rest forum members have been source of good information for me and you have been part of my struggle against a formidable road-bump in my life.Thanks a zillions times.
May God always be with us to see us through this journey.I pray that He gives strength, courage and conviction to us all. Keep the faith.

Brendon

Last edited by brendo; 10-12-2010 at 11:24 PM.

 
Old 10-13-2010, 09:07 PM   #12
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Re: Carcinoma Gleason score 4+3 meaning!

Brendon-

Right now you are in shock and this is all hard to choke down. It will get easier though I know it seems hard to accept that now. Especially when your father feels fit and shows no signs of cancer making it harder to accept. Luckily for us all this is a slow moving cancer and you will learn to think of it more as a chronic condition like diabetes that has to be maintained. Your journey has just begun and hopefully you might get a cure from your treatment yet. His PSA numbers are worrisome but you have many many good years ahead. We have found the treatment of this disease harder to deal with then the disease itself but at 3 years out it is still early for us too.

My husband has alot to deal with having diabetes and now cancer. It has affected our lives in so many ways. We try to stay active but the thought process to simply go out is formidable. He is incontinent after his surgery also. So he has to test his blood, make sure a bathroom is close by, have a snack available, diapers, cell phone in case of emergency etc. We have to plan well but we do. It's not going to stop us and we just work around it all the best we can. He gets chills from the radiation and hot flashes from HT. Never a dull moment. But thank heavens he's still here with his family!

And he's stubborn so I suggest things but don't push it. He has to chart his own course. You will all settle into a workable schedule and for the most part forget about PCa until the dreaded PSA test. Everytime that comes up then we start to think cancer thoughts again. After the dr's appt back to our routine and forget about it the best we can.

In previous posts Jim has outlined HT and discussed in detail some effective counter measures. Try to read thru some of the old posts and I think you will find answers to your questions.

Hope you find the answers you are looking for.
Martha

 
Old 10-20-2010, 07:37 PM   #13
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Re: Carcinoma Gleason score 4+3 meaning!

hi all,

hope all is well. Thanks Mart for your comments.

I visited urologists with all the reports and he suggested either to go with hormone injection or get one surgery done called orchiectomy ie. removal of the testicle surgically to prevent the androgen production there.

The injection he suggested once in three months is called Lupride Depot(which I believe is a LHRH agoinst) and must be continued for the rest of the life. And also one Casodex (bicalutamide) tablet for initial three weeks starting one week prior to the injection.

He also said that the surgery is a very simple one and would be a one time solution rather than repeating the same injection every three month.

My father is ready for both the options. So I am also tilting a little towards the surgery as it provides one time solution.

Do pour in your suggestions .
Thanks all .
Brendon

 
Old 10-21-2010, 09:33 PM   #14
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Re: Carcinoma Gleason score 4+3 meaning!

Hi Brendon,

I'm responding to your post #11 of a few days ago. Here's what you posted, in part:


Quote:
Thanks Mart & Thanks Jim,
I went to urologist day before yesterday and after looking at the bone scan and the pelvic CT scan he said it was good that the spread has not started but he was in doubt about the PSA level (56.9) as person without metastasis usually has much lower PSA.
His analysis appears sound to me.

Quote:
He suggested a repeat of the PSA and we followed suit.The latest reading is 52
There is some day to day variation in PSA, and that might account for the decrease. However, it's good news that the PSA is not increasing at a rapid clip and may be increasing only slowly if at all.

Quote:
He said if the PSA level came out to be below 20 then he would prefer surgery and if more then he would go ahead with hormone therapy.Today we are supposed to visit him once more for his suggestions.
I don't know of any top surgeons who would be comfortable with surgery on a man aged 77, especially one with diabetes. The usual cutoff is around 69 or 70, though the use of modern techniques is notching that upward slightly for men in good shape with a long life expectancy. The reason for the cut-off is that older men typically have a much harder time with the side effects, and that is in the balance together with the fact that the period of possible benefit from the surgery is not as long.


Quote:
What are the side effects of hormone therapy and are they tolerable?
I and some other board participants have posted about this a number of times. You might want to check my post of 9/18/2010 in the thread "Thinking of triple hormone therapy". I also started a thread about this on 3/6/10 titled "Hormonal Therapy Side Effects: Likelihood, seriousness and countermeasures." The books mentioned earlier (the Primer, Invasion and Beating) contain excellent information, much of it not overlapping.

In a few words, the most bothersome likely side effect is hot flashes and sweats, but often these are less bothersome for older patients. I'm now nearly 11 years into this, and during the last 19 month cycle of full blockade, ending in April, the flashes and sweats were barely a minor nuisance for me, often barely noticeable. Loss of interest in sex affects 90% of us to some degree (often nearly total loss while on the LHRH agonist drug), but that often does not matter much to men in their upper 70s and older. A likelihood of losing some bone density is one of the more serious potential side effects, but there are excellent countermeasures. Exercise (aerobic and strength) are very important in holding down several of the side effects, and age 77 is not too old to exercise.

For some men, one or more of the side effects will make hormonal therapy intolerable. However, countermeasures can often make it quite tolerable.



Quote:
how is the quality of life affected by this? Now he is leading a normal life and his other parameters like diabetes and hypertension and the creatinine well under control.

If there is side-effect how to counter it? and other than the treatment what do you suggest the patient to do to increase his well being (you suggested diet, exercise, and prayer before please elaborate).
Mart has posted about diabetes, and I think I may have also earlier on the thread. It deserves extra attention while on the LHRH agonist drug. I'm convinced that exercise and other lifestyle tactics, especially nutrition and diet, are very important in achieving success here. I just had my annual physical a few weeks ago, and my fasting glucose level was perfectly normal, indicating no diabetes despite being on intermittent hormonal blockade for nearly 11 years.

Hormonal therapy can contribute to hypertension. Once again, exercise, nutrition and diet can play a major role in countering this. My blood pressure tends to be on the low side and is absolutely not a problem.

Casodex (generically available as bicalutamide, much less expensive) can cause liver damage in a few men, but is easily monitored with a liver function test, which catches any problem before harm is done.

Is creatinine a kidney function test, or liver? It's late, and I forget. My impression is that kidney function is little affected, if at all, by hormonal therapy.

A statin drug may be helpful in preventing or controlling high or increased bad lipids, especially bad (LDL) cholesterol, which hormonal blockade can boost in some men. Diet and exercise also help.

The books (the Primer, Beating and Invasion) provide a wealth of detail. Please take a look at the previous related posts or a book or two first, and, if you have questions, I'll get into specifics.



Quote:
Is it important to lower the PSA level.
Yes. In men with challenging cases of prostate cancer, especially if the PSA is high, PSA is typically an excellent indicator of the extent and aggressiveness of the cancer and how it is responding to treatment.


Quote:
If it remains upward of 50 what happens?
That is an extremely unlikely scenario, but it would suggest either that administration of the hormonal therapy had been flawed, or that the patient, despite not having been on hormonal therapy before, had cancer cells that were already at the outset more or less independent of the testosterone level - highly unlikely. The PSA level is likely to plumet. I'm convinced, based on advice from experts, that the PSA really needs to drop to less than (<) 0.05, and even better to <0.01. If it does not, then other tactics need to be put to use. "Beating ..." by Dr. Myers is especially informative about that.


Quote:
HT is administered over a period of time and then withdrawn.What is the time period that a patient is kept on?
"Invasion ..." is good about that, as I recall. These days a lot of doctors are keeping patients on therapy for 9 months, which to me is a minimum. The experts I have followed prefer to keep patients on until the PSA reaches <0.05 or <0.01, unless the patient is having extraordinary difficulty in tolerating the therapy. Some patients, often with extensive metastases, do not get their PSA low enough to make withdrawal reasonable, so they stay on the therapy continuously.

Quote:
...
Mart, I have question for you as you are very closely watching a person in his fight against PC. How difficult is it for the patient's family members to help the patient take the right decisions? And what should they do to cope with the pressure that this disease wrecks on the entire family.
I'll answer too. Of course a great deal depends on the patient, and also on the family. Dr. Myers' book "Beating ..." gives a huge dose of optimism to those involved in fighting the disease. I feel it should be required reading for all involved with advanced prostate cancer. Understanding the disease can go a long way toward lowering the pressure. Ultimately though, I feel the patient should make the key decisions.


Quote:
It has been turbulent last one month and you people, Jim and the rest forum members have been source of good information for me and you have been part of my struggle against a formidable road-bump in my life.Thanks a zillions times.
May God always be with us to see us through this journey.I pray that He gives strength, courage and conviction to us all. Keep the faith.

Brendon
You're welcome.

Hang in there.

Jim

 
Old 10-22-2010, 12:34 PM   #15
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Re: Carcinoma Gleason score 4+3 meaning!

Hi again Brendon,

I'm now responding to your post #13 after responding to your post #11 yesterday. I'll put my thoughts in green and use excerpts from your post.


Quote:
hi all,

hope all is well. Thanks Mart for your comments.

I visited urologists with all the reports and he suggested either to go with hormone injection or get one surgery done called orchiectomy ie. removal of the testicle surgically to prevent the androgen production there.

The injection he suggested once in three months is called Lupride Depot(which I believe is a LHRH agoinst)
Yes, that's right, though the last word is "agonist".

Quote:
and must be continued for the rest of the life.
Some doctors still believe that, but I believe they are in a minority. The experts in hormonal therapy whom I follow closely are convinced that going on and off hormonal blockade, an approach known as intermittent therapy, is best if the patient's PSA drops far enough to make going off therapy a good choice. My impression is that most patients, except some patients who are metastatic, are able to go off therapy. Despite the challenging characteristics of my case, I have been able to go off therapy three times for extended periods, during which I have recovered from all noticeable side effects and have enjoyed a great quality of life, as it was before I was diagnosed. It appears that your father's doctor has not yet learned about the merits of intermittent hormonal therapy, especially with combined (two drug) or triple drug blockade.

Quote:
And also one Casodex (bicalutamide) tablet for initial three weeks starting one week prior to the injection.
I'm glad to read that your father's doctor is doing that. It prevents what is known as "flare". I can give details if you want, but in rare instances, uncontrolled flare can cripple a patient who has bone mets in the spine, especially if they are extensive. Flare can also temporarily boost cancer growth before the full effect of the medication kicks in and sharply reduces the cancer and associated PSA. I hope your dad stays on the bicalutamide in addition to either the surgery or the LHRH-agonist. That dual approach, combined blockade, is superior to single blockade for many patients, especially those with challenging cases. I am thoroughly convinced that adding a third drug, in the class known as 5-alpha reductase inhibitors, is also very beneficial for most patients; these drugs do not add much expense or contribute much if anything to additional side effects. Many doctors who are not expert in hormonal therapy still do not understand the role and effectiveness of the 5-ARI drugs. In the US, there are two choices; one is available as a generic, finasteride, and the other as a brand name, Avodart (scientific name: dutasteride).

Quote:
He also said that the surgery is a very simple one and would be a one time solution rather than repeating the same injection every three month.

My father is ready for both the options. So I am also tilting a little towards the surgery as it provides one time solution.

Do pour in your suggestions .
Thanks all .
Brendon
Surgery is certainly a worthy choice. It is faster acting and slightly more thorough in cutting testosterone production than the drugs are. However, it means that a man will need to supplement with testosterone if he wants to go on intermittent therapy. If an LHRH agonist is used instead of surgery, when the patient is ready to go off therapy, he just lets the shot expire without getting another one. The vacation from the LHRH agonist is not important just for interest in sex, which may no longer be important to an older man. Taking the vacation also helps with all the other functions to which testosterone contributes, including building bone density, mental sharpness, building muscle, and energy, for example.

These LHRH agonist shots have been very expensive up until now, though insurance coverage in the US is good, leaving me with about $200 to pay for each injection. However, Zoladex, one of the main LHRH agonist choices, is about to go generic. That should sharply reduce the cost.

I hope this helps.

Take care,

Jim

 
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