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-   -   How dire is this path report. Gleason 5+4 (https://www.healthboards.com/boards/cancer-prostate/1052272-how-dire-path-report-gleason-5-4-a.html)

john_ct1 06-21-2021 05:58 AM

Re: How dire is this path report. Gleason 5+4
 
Thanks Jim and Djin for the feedback. The science is sure not easy to decipher. I just hope I can be kept alive long enough, and with a decent QoL, for new breakthrough treatments to come along. Not necessarily a "cure" but something to keep this in remission with decent QoL.

-John

DjinTonic 06-21-2021 06:30 AM

Re: How dire is this path report. Gleason 5+4
 
John, stay positive! Have you had any imaging or other testing done since your initial MRI?

If you can create a signature it will be of immense help to all. You won't have to keep repeating information and those replying will be able to focus on the information relevant for your status, instead of trying to cover all eventualities. Have a look at other Forum brothers' signatures for example of what to include.

Thanks,

Djin

john_ct1 06-21-2021 06:47 AM

Re: How dire is this path report. Gleason 5+4
 
Good idea about the Signature. I'll work on that.
I've only had a Bone and CT Scan, no MRI. Is an MRI required prior to the RP. The urologist never mentioned it.

DjinTonic 06-21-2021 07:08 AM

Re: How dire is this path report. Gleason 5+4
 
[QUOTE=john_ct1;5511592]Good idea about the Signature. I'll work on that.
I've only had a Bone and CT Scan, no MRI. Is an MRI required prior to the RP. The urologist never mentioned it.[/QUOTE]


Not, not if a CT was done. Did the CT show any indications that cancer had spread out of the prostate?

If you have chosen surgery, it pays to be optimistic. I was lucky and you could be too. As I mentioned, if there are no adverse findings in the post-op path report that the cancer has spread out from the prostate, and your PSA is undetectable, your treatment will stop there and you'll be in the same waiting mode we are [i]all[/i] in are after any PCa treatment. We say we are recurrence-free, rather than cured, unless otherwise found. As the years go by, the chances of recurrence eventually go to almost zero.

If there is local spread, or you your post-op PSA isn't undectable, RT will complete your treatment before starting the waiting game.

Djin

john_ct1 06-21-2021 07:14 AM

Re: How dire is this path report. Gleason 5+4
 
Yes, the CT found 1 pelvic lymph node that's diseased. 3cm x 2cm, quite large. No bone mat noted via a standard bone scan. Yes, I'm assuming RT and ADT after surgery.

DjinTonic 06-21-2021 07:39 AM

Re: How dire is this path report. Gleason 5+4
 
[QUOTE=john_ct1;5511595]Yes, the CT found 1 pelvic lymph node that's diseased. 3cm x 2cm, quite large. No bone mat noted via a standard bone scan. Yes, I'm assuming RT and ADT after surgery.[/QUOTE]

Sorry, now I remember. (This is why a signature helps so much.) Was enlargement of any other nodes noted? Unfortunately, the standard bone scan can only detect mets down to a certain size and, of course, is of no help with soft tissue. That's where the new generation of scans comes in.

Even when the PCa has spread to pelvic nodes or out of the prostate locally like in seminal vesicle invasion, it is still possible that surgery removes all of one's cancer. Just be mentally prepared that you may need radiation or, possibly, RT + ADT after healing from the RP. On the other hand, if there is no adverse finding of contiguous spread, only one node is found to be positive among all those removed, and there is no persistent PSA, you'll have the best possible outcome.

Discussion of post-RP therapy needs to wait for the surgery findings. Here, too, stay optimistic.

Your PSA is relatively low, which is good. Do you have a surgery date, John?



Djin

john_ct1 06-21-2021 07:55 AM

Re: How dire is this path report. Gleason 5+4
 
Djin,
Only that 1 node was nodes as suspicious. The surgeon basically said what you've stated. He'll remove a whole bunch of lymph node along with the usual bits. He'll monitor the PSA after surgery and go from there. I guess the post-op pathology report will have a lot to say about treatment(s) required after surgery.

Interestingly my original Urologist started me on Firmagon last Wednesday (I guess he assumed I was going for RT as the primary treatment...although he know I was going for an expert 2nd opinion). The surgeon on Friday said no harm. In my mind I see the Firmagon as possibly putting the brakes on the cancer until surgery in 2 weeks.

Thanks,

-John

DjinTonic 06-21-2021 08:46 AM

Re: How dire is this path report. Gleason 5+4
 
Yes, no harm done by neoadjuvant ADT (given prior to treatment, as is usually the case when RT is the primary treatment).

Something to put on the back burner is whether a Decipher test on your RP tissue may prove useful. The Decipher score itself is for the risk of mets within 5 years, but, assuming the large node is confirmed as positive, you know already know your PCa can metastasize. However, there is an option GRID report that you can request with the Decipher results. It has 0-100 scores for a panel of RNA markers and scores for the theoretical response of your PCa to one chemo drug (docetaxel), one immunotherapy drug (dasatinib), and the response to post-op RT (a score for how long you will likely remain castration-sensitive). Unlike the Decipher score itself, the GRID report has [i]not[/i] been clinically validated and is marked For research purposes and the reports states the results shouldn't be used for clinical decisions. However, if you and your doc are on the fence about, say, saying on ADT or, instead, seeing how your PSA does without it, the GRID report might be of help. Just a thought.

Djin

john_ct1 06-21-2021 10:31 AM

Re: How dire is this path report. Gleason 5+4
 
Just spoke with my local urologist and he doesn't agree with the 2nd opinion urologist's (Top guy @ UPENN) recommendation to do a RP. He said it won't buy me much but make side effects when later combined with adjuvant RT significantly worse. My local urologist was trained by the 2nd opinion uro so my local uro said he would call him to discuss my case. If long term outcomes are similar between RP+RT+ADT and RT+ADT then I'd obviously rather skip the surgery and it's trauma.

Prostatefree 06-21-2021 11:02 AM

Re: How dire is this path report. Gleason 5+4
 
That was my thinking, but in the other direction. If I can gain a cure with surgery and skip the trauma of radiation and ADT, I will.

DjinTonic 06-21-2021 12:36 PM

Re: How dire is this path report. Gleason 5+4
 
[QUOTE=john_ct1;5511600]Just spoke with my local urologist and he doesn't agree with the 2nd opinion urologist's (Top guy @ UPENN) recommendation to do a RP. He said it won't buy me much but make side effects when later combined with adjuvant RT significantly worse. My local urologist was trained by the 2nd opinion uro so my local uro said he would call him to discuss my case. If long term outcomes are similar between RP+RT+ADT and RT+ADT then I'd obviously rather skip the surgery and it's trauma.[/QUOTE]

See what the result of their pow-wow is. One difference between treatment routes is with RT for high-Gleason men, the treatment is EBRT plus brachy boost plus 2 year minimum of ADT upfront. With surgery, it's RP upfront, with RT and/or ADT decided afterward, along with the duration of ADT, if any. A decision for RT is perfectly valid and perfectly understandable. I am not saying I think the RP route is better. Two different men with identical statuses can make different choices. Of course the choice is yours, and even if both of these docs arrive at one recommendation, your are not bound by it.

Keep us posted, please.

Djin

Insanus 06-21-2021 01:56 PM

Re: How dire is this path report. Gleason 5+4
 
John,

With your current staging, there is no way I would opt for RT treatment without Brachytherapy.

Prostatefree 06-22-2021 05:55 AM

Re: How dire is this path report. Gleason 5+4
 
[QUOTE=john_ct1;5511600]Just spoke with my local urologist and he doesn't agree with the 2nd opinion urologist's (Top guy @ UPENN) recommendation to do a RP. He said it won't buy me much but make side effects when later combined with adjuvant RT significantly worse. My local urologist was trained by the 2nd opinion uro so my local uro said he would call him to discuss my case. If long term outcomes are similar between RP+RT+ADT and RT+ADT then I'd obviously rather skip the surgery and it's trauma.[/QUOTE]

Somebody help me with this please. Is this strategy acknowledging the treatment outcomes on the cure spectrum are similar, but does not include side effect outcomes?

I can't see how two years on ADT is in anyway similar to the long or short term side effects of surgery or radiation alone.

I understand not wanting to climb the treatment ladder of surgery, radiation, and ADT if the long term outcomes will be the same. Dismissing surgery because of [I]added[/I] [I]trauma[/I] is misleading. A choice here not to have surgery is acknowledging [I]now[/I] it has an unacceptably small possibility of a cure. Do we know enough to make that call now?

Even then, the value of the pathology of the organ itself and the suspicious lymph nodes may have a role to play in charting a path forward with the radiation and ADT.

I will suggest you follow up with the 2nd opinion doctor after your doctor's call. Do not rely solely on your urologist's interpretation of his call. No judgement of your urologist. He is human and confirmation bias is powerful.

john_ct1 06-22-2021 06:25 AM

Re: How dire is this path report. Gleason 5+4
 
[QUOTE=Prostatefree;5511617]Somebody help me with this please. Is this strategy acknowledging the treatment outcomes on the cure spectrum are similar, but does not include side effect outcomes?

I can't see how two years on ADT is in anyway similar to the long or short term side effects of surgery or radiation alone.

I understand not wanting to climb the treatment ladder of surgery, radiation, and ADT if the long term outcomes will be the same. Dismissing surgery because of [I]added[/I] trauma is misleading. A choice here not to have surgery is acknowledging [I]now[/I] it has an unacceptably small possibility of a cure. Do we know enough to make that call now?

Even then, the value of the pathology of the organ itself and the suspicious lymph nodes may have a role to play in charting a path forward with the radiation and ADT.

I will suggest you follow up with the 2nd opinion doctor after your doctor's call. Something always gets lost in the translation.[/QUOTE]

Yes it's clear as mud. There's so many variables involved. How is the layman patient supposed to make an optimal informed choice when the professionals can't come to a treatment consensus? For me the formula has to also include quality of life over quantity of life. Seems like a leap of faith / gut feeling has to play a part as well. A concern with the 2nd opinion Doc is how briefly he spent time reviewing my records and asking me questions. Seemed like he almost reflexively recommend surgery but stressed that it's my call. The local doc gave me a thoughtful argument against surgery with stats to back it up.

Prostatefree 06-22-2021 06:54 AM

Re: How dire is this path report. Gleason 5+4
 
My first reaction to your profile was RT. The possibility of starting with surgery and a cure caught my ear. You have effectively discredited your second opinion as unprofessional. Will you get another?


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