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  • How dire is this path report. Gleason 5+4

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    Old 06-07-2021, 06:20 AM   #1
    john_ct1
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    How dire is this path report. Gleason 5+4

    57 yo, family history, PSA 5.7, Neg DRE, Gleason 9, Grade 5, T1c, Stage 1; perineural invasion not identified.

    Urologist recommending RARP then adjuvant RT and ADT. Bone and CT scans forthcoming. Second opinion scheduled. Urologist suggests low chance PCa has escaped the prostate.

    What are the odds of this aggressive therapy being curative? Needless to say I'm freaking out!

    Thanks All,

    -John

    ----------------------------------------------------------------------

    PSA Level: 5.7 ng/mL

    Final Diagnosis Diagnosis
    Diagnosis Summary
    Specimen Diagnosis GS/Grade Group PTI
    A Adenocarcinoma 9(5+4)/Grade
    Group 5
    100%
    B Adenocarcinoma 9(5+4)/Grade
    Group 5
    D Adenocarcinoma 9(5+4)/Grade
    Group 5
    E Adenocarcinoma 9(5+4)/Grade
    Group 5
    85%
    C Adenocarcinoma 9(4+5)/Grade
    Group 5
    100%
    F Adenocarcinoma 9(4+5)/Grade
    Group 5
    70%
    G Adenocarcinoma 9(4+5)/Grade
    Group 5
    13%
    H Adenocarcinoma 9(4+5)/Grade
    Group 5
    35%
    (Based Upon Gross and Microscopic Examination)
    Prostate Gland, Transrectal Ultrasound Guided Needle Biopsies:
    A. Right Posterior Medial, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(5+4); 4 of 6
    cores involved;
    Tumor measures 4.1 cm in length; 100% tissue
    area involved by tumor; Perineural invasion not
    identified.
    B. Right Posterior Lateral, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(5+4); 3 of 6
    cores involved;
    Tumor measures 0 cm in length; Perineural
    invasion not identified.
    D. Right Anterior Medial, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(5+4); 2 of 2
    cores involved;
    Tumor measures 0 cm in length; Perineural
    invasion not identified.
    E. Right Anterior Lateral, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(5+4); 2 of 2
    cores involved;
    Tumor measures 3.15 cm in length; 85% tissue
    area involved by tumor; Perineural invasion not
    identified.
    C. Right Base, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(4+5); 2 of 2
    cores involved;
    Tumor measures 3 cm in length; 100% tissue area
    involved by tumor; Perineural invasion not
    identified.
    F. Left Posterior Medial, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(4+5); 2 of 2
    cores involved;
    Tumor measures 3.01 cm in length; 70% tissue
    area involved by tumor; Perineural invasion not
    identified.
    G. Left Posterior Lateral, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(4+5); 1 of 3
    cores involved;
    Tumor measures 0.3 cm in length; 13% tissue area
    involved by tumor; Perineural invasion not
    identified.
    H. Left Base, Transperineal Biopsy
    Adenocarcinoma; Gleason Score 9(4+5); 1 of 1

    core involved;
    Tumor measures 1.4 cm in length; 35% tissue area
    involved by tumor; Perineural invasion not
    identified.
    I. Left Anterior Medial, Transperineal Biopsy
    Benign prostate tissue
    J. Left Anterior Lateral, Transperineal Biopsy
    Benign prostate tissue
    Partin Table
    9(5+4)
    T1c
    PSA Value(ng/mL) : 5.7
    Gleason Score :
    Clinical Stage :
    Pathologic Stage Percentage Score
    Organ confined 55
    Capsular Penetration 32
    Seminal vesicle (+) 10
    Lymph node (+) 3
    This Partin Table was generated from clinically provided information. Stage T1c is assumed unless otherwise indicated.
    This data is extracted from the 2001 AUA abstract #952: Contemporary

     
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    Old 06-07-2021, 07:11 AM   #2
    guitarhillbilly
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    Re: How dire is this path report. Gleason 5+4

    I know it is difficult to be patient after a diagnosis like you have received.
    Your UR and Care team needs test results from several tests including a MRI [if you have not already had one] , a NBS or Bone Scan as well as a pelvic CT Scan before a treatment plan can proceed. They also may do more testing than what I mentioned.
    Just remember dealing with Prostate Cancer is a marathon and not a 100 yard dash. I wish you the very best results possible in whatever treatment you and your MD's choose.
    Use this time to do as much research and educate yourself on this disease and available treatments.
    __________________
    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 06-07-2021, 07:11 AM   #3
    DjinTonic
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    Re: How dire is this path report. Gleason 5+4

    Hi John and Welcome to the Forum,

    I'm another G9 guy. You are probably imaging the worst-case scenario, so I'll give you a rosier one.

    I had a G10 biopsy that found one 5+5 core that was 50% cancer and another 4+5 core that was 3%. My definitive G score after surgery was G9 (4+5). You have a decent change of a downgrade to 4+5, simply because it's more common than 5+4. You had some 4+5 cores, and in these cases a biopsy simply can't tell you which pattern is >50% prostate-wide, as was the case with my biopsy cores.

    Even though RT and ADT are advised for G9-10 men with even one adverse finding at RP -- extraprostatic extension, seminal vesicle invasion, lymph node invasion, or positive margin(s) -- this adjuvant therapy is not needed if your PCa is prostate-confined (i.e. no adverse features) and your post-op PSA drops to an undetectable level. Perhaps some 25% of high-Gleason men have prostate-confined PCa as determined by surgery.

    That was my case. Now 4 years post-RP, I have needed no radiation or ADT. Of course that may change in the future if my PSA goes up. In a nutshell, having prostate-confined PCa has a good prognosis even with high G scores.

    In addition, a Decipher test on my RP tissue came back low risk for metastases within 5 years.

    However, G9-10 men need to understand that RT (± ADT) may be needed as part of their primary treatment after RP. This is unlike the decision for men choosing RT as their primary treatment. Currently that path usually involves EBRT+brachytherapy boost+2 years ADT upfront.

    Recent studies have given the edge to RP over RT for overall survival in high-risk/high Gleason men. In addition, adding a brachy boost to EBRT increases radiation toxicities over EBRT or brachy alone.

    Hope that helps,

    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.)...0.020 (3 yr. 7 mo.)

     
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    Old 06-07-2021, 08:07 AM   #4
    Prostatefree
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    Re: How dire is this path report. Gleason 5+4

    The concern besides the high risk Gleason score is the sheer volume of the cancer.

    I suggest you use a highly regarded cancer center of excellence with a strong prostate cancer resume for a coordinated approach to your treatment. Any urologist who suggests there is a chance of confinement at this time based solely on this report may be too amiable for this journey. While it may be confined, I suggest it is highly unlikely and any urologist offering unsolicited the idea of it may not be the one, imo.

    Prostate cancer has been with us for a long time and is very treatable in its many ways and forms. There is enough hope there for a professional to avoid misrepresenting the risk, for whatever reason.

    First things first. Now that you know what you're dealing with make sure you have the team you will need in place to manage it for the long haul. And if a change in the treatment team is to be made, now is the time to consider it, imo.

    In my view, cancer cures are widely misunderstood/misrepresented. I prefer to view myself, at this time, as a cancer survivor. I have too much respect for cancer to ever declare myself cured.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    1-15-21 PSA less than 0.02; zero club 4.5 yrs

     
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    Old 06-07-2021, 09:11 AM   #5
    guitarhillbilly
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    Re: How dire is this path report. Gleason 5+4

    Prostatefree:
    "In my view, cancer cures are widely misunderstood/misrepresented. I prefer to view myself, at this time, as a cancer survivor. I have too much respect for cancer to ever declare myself cured."


    You are very correct and this is excellent advice.
    __________________
    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 06-07-2021, 09:12 AM   #6
    Insanus
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    Re: How dire is this path report. Gleason 5+4

    Trauma is good description of your mental state right now.

    The standard of care is a bone and CT scan before any consideration of treatment. Negative results on those scans tend to settle the mind a bit. Have those been done or scheduled.?

    I second the advice of others to get a cancer center of excellence onboard now. If you were fortunate enough to walk away from this 100% cured, this is your best shot at it.

     
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    Old 06-07-2021, 09:19 AM   #7
    john_ct1
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    Re: How dire is this path report. Gleason 5+4

    Quote:
    Originally Posted by Insanus View Post
    Trauma is good description of your mental state right now.

    The standard of care is a bone and CT scan before any consideration of treatment. Negative results on those scans tend to settle the mind a bit. Have those been done or scheduled.?
    Waiting on insurance pre-authorization.

     
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    Old 06-07-2021, 09:21 AM   #8
    Insanus
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    Re: How dire is this path report. Gleason 5+4

    I added a bit before you posted. Normally discussions of treatment aren’t done until after the scans.

     
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    Old 06-07-2021, 11:57 AM   #9
    IADT3since2000
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    Re: How dire is this path report. Gleason 5+4

    Hi John, and I’ll add my welcome to the Board!


    Your diagnosis reminds me of someone: me! I was much more fortunate on the Gleason, mine was Gleason 4+3=7, confirmed by an expert (something you should do if the biopsy was not interpreted by a center of excellence), but my prostate on DRE was “rock hard” – an exact quote from more than one doctor, with all cores positive, most 100%, perineural invasion, and a first-ever, baseline PSA of 113.6! (See more in my signature below.) I now have good evidence suggesting that I have been cured by radiation plus ADT , but none of us can be sure we have been “cured” until we pass on due to something else, I guess the bottom line here is that you do have a shot at a cure, with the critical fact, yet to be established, being whether the cancer is confined or not, and even with some potential for a cure, depending on future evidence (mainly scans), if any distant spread is not yet widespread. And even if you are not cured, you have a good shot at turning this into a chronic disease that you can survive and still have joy in your life.


    Getting very real here, odds are high with a Gleason 9 tumor, as indicated by the Partin Tables, that there is already some metastasis. Typically, while the technetium 99 (Tc99) bone scan (the routine one for higher risk patients that has been used for decades) and a CT scan are so useless for lower risk patients that they are no longer used by most doctors, they are used, kind of to provide triage evidence, for high-risk patients. Neither is all that reliable, as it takes about 10% of a bone area to be occupied by cancer before a spot turns up on the scan, leaving ample opportunity for a tumor that is even slightly smaller to go unnoticed, and it takes a rather sizeable tumor about the size of a pea to show up as an enlarged lympth node on a CT sca, again allowing ample opportunity for a smaller metastasis to exist under the radar. That said, if either scan is positive, that can shortstop the process and be useful in decision making. If both scans are negative, that is often evidence needed by many insurers to approve far more accurate and reliable scans for the bones and /or soft tissues. These days, those advanced scans are often done, even if the earlier less sensitive scans were positive, as the advanced scans will give a much better picture of whether and where the cancer has metastasized. If the advanced scans are negative, that will open up more therapy options, particularly surgery if the cancer seems otherwise contained, especially if backed up by genetic and other biomarker evidence.


    As others have suggested here, with such a challenging case it is of the utmost importance to go to a top doctor/team if your circumstances allow that. One doctor for whom I have the utmost respect urged men to mortgage their homes if necessary to get that highest quality care if they had challenging cases. Fortunately, good insurance is a wonderful financial shield for many of us, and I hope that is true for you. Even so, sometimes it is worthwhile to pay extra, out-of-pocket, if insurance won’t cover any doctor/facility that will provide that top-quality care. I have done that to get several strategic consultations beyond my very good local care, and I am so glad I did get that strategic advice. After all, your life is so much more important than a new car, and most of us would pay a lot for a great set of wheels. Major academic centers and other well-known institutions are often centers of excellence, and there are also about a dozen expert stand-alone practices dedicated to prostate cancer in the US, plus others outside the US, of course.

    One of the reasons this forum helps people is that you can find a range of opinion, and there is a lot of respect here for research based evidence, and it is evidence that allows us to rise above our own individual experiences. I’m going to differ with DjinTonic here, though I do respect his experience and viewpoint. To me, unless it is medically not feasible, it appears that radiation, plus ADT and perhaps other medical support has clearly superior results over surgery for treating men at high risk such as you and me. (On the other hand, his success with surgery shows that surgery has a fair claim to being a worthy option for high-risk men, and some surgeons with excellent reputations strongly believe that.)


    Here’s the problem with surgery. For someone in your circumstances, the program starting with surgery will very often need radiation plus ADT, etc. to complement the surgery, and it will usually be needed fairly soon, typically within two years, maybe three, and not uncommonly as soon as the patient has healed sufficiently from surgery to avoid almost surefire extra burdensome side effects that happen when radiation is given prior to full healing. There are two major potentially serious consequences that patients need to consider. The lesser (though often very substantial) consequence is that there is an adverse synergy of side effects when the patient’s body has to deal with the side effects of both surgery AND radiation plus ADT, etc., even after the body has healed from the surgery itself. In other words, if you have to deal with the risk of side effects of just one treatment or the other, you lower your overall risk, and these days modern radiation and associated care is at least as good as surgery in knocking out prostate cancer in the prostate (for the vast majority of patients, with some known exceptions), so it’s not a question of getting an extra, special medical benefit that can only be provided by surgery. (There is some added staging data obtained, but these days that is of arguably limited or minimal added value due to advances in imagery from scans, genetic testing, etc.)

    The second and much more potentially serious consequence of the surgery-first approach is that there will certainly be a very substantial delay in treating areas outside the prostate where small metastases would likely be lurking, with a prospect of at least micro metastases being especially high when the cancer is very aggressive, as indicated by Gleason 9 pathology - sites that would have a strong potential of being treated in an effective, timely way by radiation (with ADT) up front, skipping surgery.The delay happens, as mentioned above, because the body needs to heal from surgery before radiation can be commenced without a substantial risk of aggravating side effects from the surgery, and that will take many months. I haven’t checked the exact average timetable, but I’m thinking that a year or more would be typical.

    It is now known that more often than not, early metastases will be in the range of pelvic radiation that would be given in a case like yours in addition to radiation to the prostate. However, if you are unlucky and use surgery first, by the time radiation is given, metastases may have spread beyond the range of pelvic radiation. I suspect this is a primary reason why backup “salvage” radiation after surgery, or even “adjuvant” radiation as shortly as practical after surgery, don’t seem as effective as up-front radiation that skips surgery. (Keep in mind that I'm a layman with no enrolled medical education or authority, but that also means I believe I have more objectivity than many doctors who naturally tend to favor their specialty. I actually initially chose surgery shortly after my diagnosis until I was rejected for surgery by Johns Hopkins, renowned in the prostate cancer surgery world, because my case was too high-risk.) There is still a possibility of effective treatment if metastases beyond the pelvis have not yet reached the point of explosive spread, but it is easy to see that the risks are higher. All this said, some men, like DjinTonic, do succeed despite the risk.


    An outstanding resource for men in your circumstances is the 2018 book “The Key to Prostate Cancer” by renowned medical oncologist Mark Scholz, MD, and 29 others, all contributing chapters. The book is divided into sections depending on a patient’s circumstances (per a brief quiz), and your section would be the color-coded chapters for “azure” (aka high-risk) prostate cancer. I cannot recommend this book too highly – it is superb. While surgery is a worthy option for many lower-risk men, being competitive in success with radiation, the book has a skeptical view of surgery for high-risk men, to put it mildly. Many surgeons would agree, though, as mentioned earlier, others do not.

    A side note to DjinTonic: In your post #3 you stated: “Recent studies have given the edge to RP over RT for overall survival in high-risk/high Gleason men. “ I am not aware of such studies that have been well done (I am aware of poor studies so asserting.), and on the other hand am aware of a number of numerous well-done studies that indicate a superiority for radiation plus ADT. What studies are you thinking of? You also wrote: “In addition, adding a brachy boost to EBRT increases radiation toxicities over EBRT or brachy alone.” Yes, that is also my impression, but for many men the increased toxicities are minimal or quite tolerable, though not always. That said, high-risk prostate cancer is no cake walk, and we all know that in a war there are going to be casualties, true of surgery as well as radiation, arguably considerably more so side-effects wise with surgery. I have a list of studies supporting a superiority of radiation that I think I can find, but an overview of the research is available online at https://prostatecancerfree.org/compare-prostate-cancer-treatments-high-risk/ . The backup study, updated to 2021, for this graphic information is available at https://prostatecancerfree.org/********-prostate-cancer-treatment-comparisons/ (substitute "d o w n l o a d" - without the quotation marks or spaces between the letters, for the asterisks).

    One odd note: with the extensive cancer found at biopsy, that negative DRE is strange. Was the DRE done by a primary care doctor rather than your urologist?

    Good luck with this. You have a really challenging case, but enormous progress has been made over the years in prostate cancer, and that progress is continuing at a rapid pace. It is almost a sure bet that you will enjoy some of the fruits of progress that has not even reached the clinic yet.

    Keep your spirits up!

    ….Jim

    - - - - - - - - - - - - - - - - - - - - - - - -
    21 years as a survivor. Doing well. 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 12/2/2020). (Current T 93 12/2/2020.) 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. What I experienced is not a guarantee for all but shows what is possible.

     
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    Old 06-07-2021, 12:26 PM   #10
    john_ct1
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    Re: How dire is this path report. Gleason 5+4

    Thanks Jim for the thorough feedback! Yes, I have Scholz's book and have been watching his videos. My primary care doc and the Urologist both reported a negative DRE. I'm scheduled for a 2nd opinion next week with the top Urologist a Penn Medicine in Philadelphia. Finger's crossed.

     
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    Old 06-07-2021, 12:40 PM   #11
    DjinTonic
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    Re: How dire is this path report. Gleason 5+4

    Radical prostatectomy versus external beam radiation therapy for high-grade, clinically localized prostate cancer: Emulation of a target clinical trial (2021, Full Text)

    https://www.sciencedirect.com/science/article/pii/S1078143921001277?casa_token=QeJqvl0i2d8 AAAAA:tJOeWvuWzKPEcQ7ZElXqBs1O_qsCpW20Kj fsQWzYrGY92kPkgI2yKUb5t1ijTuAAIggUOYKW

    "Highlights

    • We conducted observational analyses to emulate a hypothetical target clinical trial of RP versus EBRT+ADT for high-grade prostate cancer

    • RP was associated with improved OS compared to EBRT+ADT (HR 0.54;95% CI 0.48-0.62; P<0.001), with 5- and 10-year OS of 93% vs 87%, and 76% vs 60%, respectively

    • RP was associated with improved OS across all categories of Gleason score, PSA, cT stage, age, and Charlson comorbidity index examined"

    One of the major flaws in most studies of more recent RT regimes is that they continue to use BCR stats instead of Overall- and PCa-survival stats. See the comments about EBRT+brachy boost results in the above paper. Until I see OS stats for EBRT+brachy boost, I see no reason to assume they are any better than EBRT alone.

    One should keep in mind that men for whom all indications point toward their PCa being prostate-confined have a much better chance of that being true post-surgery than is true for all G9-10 men undergoing RP. That means a greater chance of single-play primary treatment.

    If one wants to use BCR for very short-term results, then Gleason score is not very relevant for prostate-confined disease, since The 5-year biochemical recurrence-free survival rates in patients with no risk factors after RP was 92.9% in a 2018 study.

    https://onlinelibrary.wiley.com/doi/abs/10.1111/iju.13514

    Jim stated above

    "The second and much more potentially serious consequence of the surgery-first approach is that there will certainly be a very substantial delay in treating areas outside the prostate where small metastases would likely be lurking, with a prospect of at least micro metastases being especially high when the cancer is very aggressive, as indicated by Gleason 9 pathology - sites that would have a strong potential of being treated in an effective, timely way by radiation (with ADT) up front, skipping surgery." [Emphasis mine]

    It is not true that all G8-10 PCa is aggressive. That's is outdated thinking. my Decipher score, e.g., was low-risk for mets, and, infact:

    46% of pT2 men have low-risk Decipher scores and
    39% of pT3a men have low-risk Decipher scores


    Also, SOC does not treat the possibility of one's harboring micromets (only) with ADT; otherwise men in with RP results would be advised to have adjuvant ADT -- no major guideline mentions (let alone advised) this.

    Men going the RT route for high-grade/high risk are advised to get 2 years of ADT only in part because of the increase in radiosensitivity in the cancer cells. The other part is they will not receive confirmation as to whether their PCa is prostate-confined and no pelvic node will be removed and examined for PCa. The ADT is also and necessarily prophylactic. Post RP, I can monitor my low PSA to indicate any met growth; this is not true for primary RT, given the post-RT dynamics of PSA decline.

    If the OP's workup points to prostate-confined PCa, then, coupled with his low PSA, I don't see why RP should be ruled out. He is in his 50's and I'm seeing a number of newly diagnosed younger men on Forums (even with lower Gleason scores) be advised toward RP over RT by radiologists.

    Djin
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    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.)...0.020 (3 yr. 7 mo.)

     
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    Old 06-07-2021, 02:01 PM   #12
    Michael F
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    Re: How dire is this path report. Gleason 5+4

    Hi john_ct1! Let's break down your status into individual segments.

    First and foremost, you need to be treated by URO MDs who are Prostate Cancer (PCa) Specialists at a top tier institution. You are accomplishing this by going to U Penn. Congrats! Good job!

    The Bad News is: you have PCa that requires treatment. The Good News is: you have recently discovered that you have PCa vs a few years from now.

    The Big Question is: How to treat this? You will arrive at the answer by getting the very best opinions from the URO Team at Penn. There have been major advancements in the past 10 years in Detection, Assessment and Treatment technologies and you will be a benficiary!

    Now is the time to learn as much about PCa as possible and become both an educated patient and educated consumer = exactly as you are currently doing. Start a notebook with questions. At your MD consultations, bring an advocate with you and have them take notes and write down the answers.

    IMO, take the word "dire" out of your PCa vocabulary. There is a strong likelihood that your PCa may be fully contained within the prostate gland. A topic of discussion with your URO MDs is: "Am I a candidate for a new type of PET Scan (68GaPSMA-11 or 18F-DCFPyL) to determine if my PCa is 100% confined to the prostate gland?" (These are very expensive and not likely covered by most health insurance plans.)

    Early detection offers the best possibilities for complete Cure. In the event that Complete Cure is not achieved following treatment, PCa can then be managed and controlled for many many years into the future.

    Take things 1 step at a time:

    Step 1 = Biopsy =
    Step 2 = URO MD consultations
    Step 3 = Treatment Decision
    Step 4 = Treatment

    Ultimatley, you need to select the treatment that best addresses your specific pathology and best suits your psyche.

    The path is long. You are not alone. You will get through it.

    Stay Strong. Keep asking questions and keep us updated!

    MF
    __________________
    PSA: Oct '09 = 1.91, Oct '11 = 2.79, Dec '11 = 2.98 (PSA, Free =13%)
    Jan '12: Biopsy: 1/12 = G7 (3+4) & 5/12 = G6
    March '12: Robotic RP: Left: PM + EPE => Surgeon went back and excised additional adjacent tissues on Left side down to (-) Margins
    Pathology: Gleason (3+4) pT3a pNO pMX pRO c tertiary pattern 5 / Prostate Size = 32 grams / Tumor = Bilateral: 20% / PNI: present
    uPSA Range: 0.017 - 0.039 at 105 Months Post Op: Mean = 0.023 (n = 26)
    LabCorp: Ultrasensitive PSA: Roche ECLIA
    Continence = Very Good (≥ 99%) ED = present

     
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    Old 06-07-2021, 02:17 PM   #13
    john_ct1
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    Re: How dire is this path report. Gleason 5+4

    Thanks for the encouragement Michael. Fortunately I've been doing annual PSA tests for the past 17 years (started at 40), hopefully I've caught this early enough. I'll be happy if the guy at PENN (Dr. Guzzo - head of urology) can treat me. Right now it's a very difficult psychologically battle for me, especially as a chronic catastrophizer.

    -John

     
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    Old 06-07-2021, 06:03 PM   #14
    HighlanderCFH
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    Re: How dire is this path report. Gleason 5+4

    Has anyone yet recommended the book, "Guide to Surviving Prostate Cancer" by Dr Pat Walsh? The 4th edition is a couple years old now, but well worth the read.

    Simply put, the Gleason 9 diagnosis is bad in terms of it being almost the most aggressive form of the disease. However.....

    Equally simply put, the T1 biopsy report is GREAT! To continue putting it simply, if the cancer is still totally confined to your prostate, indeed you CAN be very hopeful -- and expectful -- of a cure.

    With the highly aggressive nature of your case, you don't want to wait too long for treatment. And that treatment should be at one of the absolute icons in the medical world, such as Mayo Clinic, Cleveland Clinic, Johns Hopkins, etc.

    So, in short, you have a very good opportunity to cure this disease, so please keep moving right along toward the treatment that will provide that cure.

    Good luck!
    Chuck

     
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    Old 06-07-2021, 06:28 PM   #15
    IADT3since2000
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    Location: Annandale, VA, USA
    Posts: 2,867
    IADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB UserIADT3since2000 HB User
    Re: How dire is this path report. Gleason 5+4

    Hi again John,

    Some worthy centers of excellence have been recommended, but you also have some great options nearby in Philadelphia. You are fortunate to have a urologist, Dr. Guzzo, who certainly appears to be on the top of his game based on his position and impressive body of research, and for radiation you have Fox Chase, which has been in the forefront of radiation treatment nationally for years (together with a number of other centers of excellence).

    Jim

     
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