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  • Treatment Options for an Insufferable Horndog

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    Old 09-26-2020, 12:03 PM   #1
    SmasherOfAjumma
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    Treatment Options for an Insufferable Horndog

    60 year-old insufferable horndog here. I was just diagnosed and am trying to decide on treatment. My urologist wants to cut it all out. He will attempt to preserve the nerves. That's probably the safest option. But here's the problem: I'm still very attracted to my (younger) wife (of 30 years), and the sex I get (once a week) is by far the highlight of my life. (She would have no problem giving up this chore.)

    So I'm doing a second opinion at a big urban teaching hospital, but that appointment is not until end of October. In the mean time I am sending slides off to Johns Hopkins for another 2nd opinion.

    Ultimately I will do the responsible thing and not risk the cancer spreading, but gosh it would be nice if I could keep banging the milf.
    __________________
    D.O.B. 1960
    Diagnosed prostrate cancer @ age 60.
    Father was diagnosed at age 70, treated with radiation, still healthy at 86.
    Last PSA: 3.1
    Gleason: 6
    Biopsy showed 5 positive out of 12.
    "Diagnosis Summary:Adenocarcinoma; Gleason Score 6(3+3); 1 of 1 core involved; Tumor measures 0.1 cm in length; 7% tissue area involved by tumor; Perineural invasion not identified."

     
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    Old 09-26-2020, 01:15 PM   #2
    IADT3since2000
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    Re: Treatment Options for an Insufferable Horndog

    Hi Smasher and welcome to the Board!

    At 60 you still have many good years ahead of you as an insufferable horndog, provided prostate cancer treatment does not interfere too much, and, at this point, based on what you have stated, being good to go is a real possibility.

    Good move sending your slides to Hopkins. That is really important as a fair proportion of slides are either under graded or over graded when not evaluated by an expert, and that Gleason score is so important in selecting the best treatment.

    Right off, I’m curious why you did not mention “active surveillance” (AS) as an option. Do you know what it is? Did your urologist bring it up as an option? Did the urologist indicate special circumstances that would make AS a doubtful option for you? In view of what you have presented – your fairly low PSA and Gleason of 6, AS looks like an option, and it is now the standard of care for appropriate, mostly low-risk cases. However, the third key leg at this initial point is the “stage,” which essentially is whether the doc can feel what might be a tumor, and how extensive it is, and you did not mention this. The fact that five cores were positive suggests the stage might make AS a doubtful proposition, but the other data suggests that the potential cancer might be very small and suitable for AS. Five positive cores of 12 that are positive does not rule out AS. AS is now a safe and effective management strategy if the case is appropriate, and it would definitely be “the safest option” if your case is appropriate.

    Another key piece of information you may now have is your PSA doubling time (PSADT). Do you know that, or can you share any dates and results of past PSA tests you have had? There's more ground to cover, but this is enough for a start.

    In 2020, what you have is “not your father’s prostate cancer.” AS was not an option back when he was treated, rather, investigational studies were just beginning to be reported. In the nearly two decades since, a mountain of encouraging studies have accumulated for AS. Also, back when your dad was treated, radiation was not so effective and often left men with burdensome long-term side effects; that has changed: radiation is now highly effective, if needed (not for low-risk cases best suited to AS) and safe, with burdensome long-term side effects now very infrequent for the vast majority of patients. Of course surgery is also an option if the case is not low-risk.

    Keep your spirits up!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 9/4/2020). (Current T 128 9/4/20.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education.

     
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    Old 09-26-2020, 01:40 PM   #3
    Insanus
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    Re: Treatment Options for an Insufferable Horndog

    First I will say up front I am not a proponent of active surveillance. You have evidence of a very curable cancer and the biopsy does not preclude the chance of higher grade cancer that went upsampled during biopsy. There are several men of this and other PCa forums who did AS to later discover they had high grade disease. The patient compliance with AS Program generally not good as many men drop out of the monitoring.

    With that said it seems to me you meet the criteria for AS, radiation, cryotherapy or surgery.

    Cleveland Clinic is maybe the top urology hospital in the US. They will tell you to allow 2 years post surgery for erections. They also have a rehab program to get you back in the saddle as quickly as possible. I sure other large institutions do as well.

    https://www.martinhealth.org/prostate-cancer-survivorship-1

     
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    SmasherOfAjumma (09-27-2020)
    Old 09-26-2020, 05:41 PM   #4
    Sw1218
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    Re: Treatment Options for an Insufferable Horndog

    Quote:
    Originally Posted by SmasherOfAjumma View Post
    60 year-old insufferable horndog here. I was just diagnosed and am trying to decide on treatment. My urologist wants to cut it all out. He will attempt to preserve the nerves. That's probably the safest option. But here's the problem: I'm still very attracted to my (younger) wife ...
    1. A uro is a surgeon. That's a like a car salesman who sells BMW's. Why would he sell you a Buick if he sells BMW's? Surgery is not always your best option. I would consider HDR brachytherapy. This type of procedure is not as rough on your body, plus it saves more lives and better preserves your sex life.

    2. There's a book called "The Key to Prostate Cancer: 30 Experts Explain 15 Stages of Prostate Cancer". This book was written by Dr. Mark Scholz. This book explains PCa and all of your different options that would save your life and keep your sex life going. I would like to encourage you to read it.
    __________________

    D.O.B. | 12/18/1973
    02.28.2019 | Dx 45
    Elev. PSA | 11.9
    GS | 4+3 = 7
    Treatment | HDR Brachytherapy & 6 mths of Casodex 50mg

     
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    SmasherOfAjumma (09-27-2020)
    Old 09-27-2020, 05:39 AM   #5
    SmasherOfAjumma
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    Re: Treatment Options for an Insufferable Horndog

    Thanks for the thoughtful response, I appreciate it. My urologist and his colleague the surgeon both mentioned active surveillance in passing, but they don't recommend it. My prostrate apparently still feels smooth, though its been enlarged for years, so no noticeable tumor. I am trying to get my PSA history, but right now I only have that last number. There was never a doubling.
    __________________
    D.O.B. 1960
    Diagnosed prostrate cancer @ age 60.
    Father was diagnosed at age 70, treated with radiation, still healthy at 86.
    Last PSA: 3.1
    Gleason: 6
    Biopsy showed 5 positive out of 12.
    "Diagnosis Summary:Adenocarcinoma; Gleason Score 6(3+3); 1 of 1 core involved; Tumor measures 0.1 cm in length; 7% tissue area involved by tumor; Perineural invasion not identified."

     
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    Old 09-27-2020, 05:45 AM   #6
    SmasherOfAjumma
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    Re: Treatment Options for an Insufferable Horndog

    Quote:
    Originally Posted by Insanus View Post
    Cleveland Clinic is maybe the top urology hospital in the US. They will tell you to allow 2 years post surgery for erections.
    Just great. Doctor already said I should give up alcohol afterwards to help with the healing. Coffee too. No sex, alcohol, or caffeine during that time. Guess I'll take up gluttony. Or smoking. Hmmm, I haven't done recreational drugs since the eighties... Maybe I'll give that a try again.
    __________________
    D.O.B. 1960
    Diagnosed prostrate cancer @ age 60.
    Father was diagnosed at age 70, treated with radiation, still healthy at 86.
    Last PSA: 3.1
    Gleason: 6
    Biopsy showed 5 positive out of 12.
    "Diagnosis Summary:Adenocarcinoma; Gleason Score 6(3+3); 1 of 1 core involved; Tumor measures 0.1 cm in length; 7% tissue area involved by tumor; Perineural invasion not identified."

     
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    Old 09-27-2020, 06:55 AM   #7
    guitarhillbilly
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    Re: Treatment Options for an Insufferable Horndog

    Please take your time and do a lot of research on various treatment methods and their possible complications short and long term.
    You stated that Sexual function is very important ["highlight of my life"] to you so I'll post some info that most men do not want to talk about.

    https://www.health.harvard.***/blog/preserving-penis-length-after-radical-prostatectomy-20090408165

    "Following radical prostatectomy, a significant number of patients notice a progressive shortening of the penis, a fact confirmed in recent studies. To better understand why, Italian researchers measured the length of the flaccid and stretched penis in 126 patients at five time points: just before surgery, when the catheter was removed 7 to 10 days later, and at 3, 6, and 12 months postoperatively. They reported that shortening peaked at the time the catheter was removed and continued, though to a lesser extent, for at least a year. (The average reduction in length after one year was just over a half inch when flaccid and nearly an inch when stretched.) Interestingly, men who had nerve-sparing surgery, as well as those who recovered some erectile function during the year of follow-up, lost less length than other study participants."
    __________________
    T2a / Gleason Score 8 / PSA at Diagnosis 6.9 /
    1-5 aggressive score : 4
    12 cores= 4 positive
    NBS = Negative
    Pelvic CT= Negative
    Pelvic MRI= Negative
    Age at Diagnosis= 60-65 age group
    Completed 42 IMRT Sessions
    Lupron scheduled for 2 years [Started DEC 2019]

     
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    Old 09-27-2020, 08:12 AM   #8
    DjinTonic
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    Re: Treatment Options for an Insufferable Horndog

    The penis itself is not changed during a prostatectomy. The perceived shortening is usually temporary (<12 months) and is probably caused by several factors: the urethra is shortened and pulled back; ligaments/nerves may be repositioned/traumatized; nerve/brain connections controlling erections are probably undergoing unconscious reprogramming. The majority of studies since the 2009 one above seems to be similar to the studies cited in this Urology article:

    Investigation of Changes in Penile Length After Radical Prostatectomy (2027)
    https://www.practiceupdate.com/content/investigation-of-changes-in-penile-length-after-radical-prostatectomy/56962

    "Take-Home Message

    Complaints of penile shortening following surgery are not always mentioned by patients. However, patients may be counseled preoperatively that temporary penile shortening may occur. Likewise, patients may be advised postoperatively that penile length should gradually return.

    The authors of this prospective study evaluated 102 men with MRI and stretched penile length pre- and post-prostatectomy. The MRI measurements were taken preoperatively and at 10 days and 12 months postoperatively. Measurement of stretched penile length occurred at 3, 6, 9, 12, 18, and 24 months. On average, men experienced penile shortening of 19.9 mm postoperatively, which gradually lengthened to the approximate preoperative length by 12 months. On univariate analysis, only prostate volume had a marked association with change in penile length. However, this did not meet significance on multivariable analysis. No other predictors were identified.
    ________________
    In the recent issue of BJU International, Kadono et al endeavor to explain penile shortening after RP using anatomical studies.5 Just over 100 patients undergoing RP at their institution were enrolled in the study and followed for 24 months with SPL measurements at 1, 3, 6, 9, 12, 18, and 24 months after RP. They observed that SPL is significantly shorter after RP, but normalizes to baseline by 12 months. In a novel approach, they used magnetic resonance imaging (MRI) at baseline, immediately postoperatively, and 1 year after RP to evaluate anatomical changes and correlate findings with penile length. Interestingly, the MRI studies demonstrate a shortened distance from the distal membranous urethra to pelvic outlet (DMU-PO) immediately postoperatively, which normalizes by 12 months, when SPL returns to baseline as well. Unfortunately, there are no MRI studies earlier in the postoperative period to determine if the DMU-PO distance actually normalizes earlier than 1 year and confirm if this anatomical measurement actually correlates with penile length at each time period. Importantly, only prostate size was a predictor of penile length shortening, which is consistent with an anatomic explanation."

    And stretched penile length (the parameter used in some studies) may not accurately reflect max. erected length. You can google other studies. I believe other studies found sexual satisfaction was not related to perceived penile length. I would estimate that I did lose perhaps 1/4" in my usual erection; I'm not as sure if the max erected length has changed, however.

    The choice between radiation and surgery for the primary treatment of PCa can sometimes be a difficult one. Personally, I think cancer control should be the goal, followed by your own evaluation of possible urinary and potency outcomes. I really don't see penile length discussed very much at all on the Forums by men who have had RPs -- the main related question is sexual function post-treatment.

    Djin
    __________________
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg. for PCa, then 6-mo. checks
    6-06-17 Nodule on R + 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 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) 5% of prostate (4.5x5x4 cm, 64 g)
    Dry; ED OK with sildenafil
    Decipher 0.37 (Low Risk), uPSA: 0.010 (3 mo.)...0.013 (2 yr. 10 mo.)

     
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    SmasherOfAjumma (09-27-2020)
    Old 09-27-2020, 02:02 PM   #9
    Terry G
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    Re: Treatment Options for an Insufferable Horndog

    Between now and the end of October you want to learn and do your homework and the fact you’re here shows a willingness to do both. If your urinary function is currently good (no significant BPH) radiation maybe a better option for treating the cancer than surgery. Radiation treatment comes in several forms. SBRT is growing in popularity since it has excellent cure rates, is relatively non invasive and for most guys has very few long term side effects. Any of the treatments will eliminate or greatly reduce the level of your ejaculate but for most men including myself orgasms are just as pleasurable. I always recommend finding the best treatment for you and that’s best accomplished be getting several opinions. Urologists are surgeons and most know little about RT. When the only tool in the toolbox is a hammer every problem looks like a nail. I also recommend seeking out the very best practitioner and team you can find to perform whatever treatment you find best for your situation.
    __________________
    Rising PSA:
    11/13 1.95; 9/15 3.28; 10/16 5.94
    TRUS 1/17
    Bx: Three of twelve cores adenocarcinoma Gleason 6 (3+3) all on left side, no pni.
    DOB 7/21/47; good health; age 69 @ Dx
    Treated 6/17 SBRT @ Cleveland Clinic by Dr. Tendulkar
    Reduced ejaculate only side effect; everything works
    To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.

    PSA’s post.SBRT 1.1, 1.1, .9, 1.8, 2.7, 1.0, 0.3, 0.6

     
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    Old 09-27-2020, 05:40 PM   #10
    Prostatefree
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    Re: Treatment Options for an Insufferable Horndog

    With surgery you're tossing the dice. Worked for me. Radiation, however, is a more predictable outcome.

     
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    Old 09-27-2020, 08:50 PM   #11
    ASAdvocate
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    Re: Treatment Options for an Insufferable Horndog

    First of all, I disagree in part with Insanus.

    In a strict active surveillance program, like the one I have been in since 2009 at Johns Hopkins, we have a PCa death rate of one-tenth of one percent at fifteen years. That said, I am increasing aware that many local uro’s and DIY patients are way too lax, and creating the bad situations Insanus mentioned. If you do AS, do it according to strict protocols.

    As far as treatments, the two advanced types of radiation, SBRT/Cyberknife and proton beam therapy are posting non-recurrence results that no other treatments can match, for your pathology.

    You owe it to yourself to speak with specialists who provide those treatments.

     
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    Old 09-28-2020, 06:15 AM   #12
    Insanus
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    Re: Treatment Options for an Insufferable Horndog

    30 to 40 percent of men who choose active surveillance will require prostate cancer surgery or radiation treatment. That’s a staggering number considering the percentage of older men in that group who are destined to die before treatment is needed.

    Yes, you may not die as the result of AS, but instead of one treatment you end up with several. If you are under age 65, get treated.

     
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    Old 09-28-2020, 12:39 PM   #13
    Southsider170
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    Re: Treatment Options for an Insufferable Horndog

    Quote:
    Originally Posted by Insanus View Post
    30 to 40 percent of men who choose active surveillance will require prostate cancer surgery or radiation treatment. That’s a staggering number considering the percentage of older men in that group who are destined to die before treatment is needed.

    Is that really accurate, the 30 to 40 percent will *require* treatment?

    I understand that a large percentage of men on AS eventually elect treatment. But for how many of them is their election of treatment at a later date just their personal choice not to continue with AS/deferral of treatment, even though they could and their circumstances really haven't gone south?

     
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    Old 09-28-2020, 02:02 PM   #14
    IADT3since2000
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    Re: Treatment Options for an Insufferable Horndog

    Hi again Smasher,

    You really need to learn the other side of the picture and supporting facts as a balance to the view provided by Insanus below:

    Quote:
    Originally Posted by Insanus View Post
    30 to 40 percent of men who choose active surveillance will require prostate cancer surgery or radiation treatment. That’s a staggering number considering the percentage of older men in that group who are destined to die before treatment is needed.

    Yes, you may not die as the result of AS, but instead of one treatment you end up with several. If you are under age 65, get treated.
    Actually, while I have not checked recent studies of the percentage of AS patients who will require treatment or choose it despite remaining qualified for continued AS, the 30 to 40% that Insanus quotes is quite an improvement over AS "failure/drop out" rates in the early days. In the summer of 2005 I had the pleasure of being a volunteer speaker escort for the leader of the Johns Hopkins AS ("expectant management" was their term back then) program, Dr. H. Ballentine Carter, MD, when he spoke at the national conference that year. One of his slides showed that virtually 50% of men were still in AS in their program back in 2005 (instead of 60% to 70% still on AS per Insanus's current estimate), with the other 50% back in 2005 having either progressed and gotten treatment or having chosen on their own to leave the AS program and get treatment. That's quite an improvement!

    The facts are that an increasing proportion of patients on AS stick with it and are delighted, and there is now a consensus that age of the patient does not matter. My guess is that that is because the ever-building mound of highly consistent research, especially from major centers,shows that well-done AS is both safe, effective, and preserves an excellent option for safe and effective treatment for those that later prove to need treatment. (See ASAdvocates point, someone, by the way, who is highly familiar with AS and related research).

    Key benefits from AS are (1) no side effects, except for very temporary biopsy side effects, for more than half of AS patients, these days, for the rest of life, with typically at least a couple years free of side effects during a period of life when most of us enjoy romance in our lives, and (2) time for technology to advance with ever more effective treatments that have an ever decreasing burden of side effects.

    You can check the medical papers from all over the world on AS by searching for - prostate cancer AND (active surveillance OR expectant management) - at www.pubmed.gov . If you are interested in any listed paper, just click on the blue hypertext to get a free abstract of the paper. I just did that, with the filter for "abstracts" activated, and got a list of 3,283 papers; obviously this has been a hot area for research. If you add the filter "clinical trial", you reduce the list to 174. Many of the papers have free links to complete papers.

    Treatment, these days, is a fine way to go for those who need it, but fortunately, many don't need treatment, and the know-how is there for how to separate the two groups.

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    Diagnosis Dec 1999 PSA 113.6 (first ever), age 56
    Gleason 4+3=7 (J. Epstein, JHU), all cores +, most 100%; "rock hard" prostate with ECE - stage 3, PNI, PSADT determined later 3-4 months; technetium bone scan and CT scan negative; prognosis 5 years.
    Later ProstaScint scan negative except for one suspicious small area in an unlikely location. ADT Lupron as first therapy, in Dec 1999, then + Casodex in March 2000, then + Proscar and Fosamax in Sep 2000. Rejected for surgery January 2000; offered radiation but told success odds were low; switched to ADT only vice radiation in May 2000, betting on holding the fort for improved technology; PSA gradual decline to <0.01 May 2002. Commenced intermittent ADT3 (IADT3) with first vacation from Lupron & Casodex. Negative advanced scans in 2011 (NaF18 PET/CT for bone) and 2012 (Feraheme USPIO for nodes and soft tissue). With improved technology, tried TomoTherapy RT, 39 sessions, in early 2013, plus ADT 3 in support for 18 months (fourth round of IADT3), ended April 2014. Continuing with Avodart as anti-recurrence shield. Current PSA remarkably low and stable at <0.01; apparently cured (Current PSA as of 9/4/2020). (Current T 128 9/4/20.) Supportive diet/nutrition, exercise, supportive medications during this journey, as well as switches in antiandrogen, 5-ARI, and bone drugs. Barely noticeable side effects from radiation; continuing low T, likely do to long use of ADT, but good energy and adequate strength. I have a lot of School of Hard Knocks knowledge, and have followed research, which has made me an empowered and savvy patient, but I have had no enrolled medical education.

     
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    Old 09-30-2020, 05:33 PM   #15
    SmasherOfAjumma
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    Re: Treatment Options for an Insufferable Horndog

    You've all given me a lot to consider. Thanks!
    __________________
    D.O.B. 1960
    Diagnosed prostrate cancer @ age 60.
    Father was diagnosed at age 70, treated with radiation, still healthy at 86.
    Last PSA: 3.1
    Gleason: 6
    Biopsy showed 5 positive out of 12.
    "Diagnosis Summary:Adenocarcinoma; Gleason Score 6(3+3); 1 of 1 core involved; Tumor measures 0.1 cm in length; 7% tissue area involved by tumor; Perineural invasion not identified."

     
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