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  • Recently Diagnosed w/PC - Questions

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    Old 01-09-2019, 08:06 PM   #1
    NU2This99
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    Recently Diagnosed w/PC - Questions

    In Dec 2018 I had a biopsy and was diagnosed with Prostate Cancer - Low Risk. There were 14 cores taken and 5 were positive. I don't have the pathology report but will ask the surgeon for it.


    My initial thoughts (and the doctor's/surgeon's quasi suggestion) was to have surgery to remove the prostate (his comment was "surgery is booked up thru Mar"). The options given at the time were:

    1. Active Surveillance

    2. Surgery, Radical Prostatectomy (Robotic or Open)

    3. Radiation

    4. Other: Cryosurgery, high intensity focused ultrasound (HIFU), focal therapy


    The plan at this time are to eat more plant-based foods, get a PSA in Apr, and get a 2nd biopsy in May.


    Questions:

    a) Where do I go to get a 2nd opinion?


    b) What additional information is in the pathology report (i.e. other that 5 of 14 cores tested positive)?


    c) Anyone had experience with the Cyberknife procedure?

     
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    Old 01-15-2019, 01:34 PM   #2
    IADT3since2000
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    Re: Recently Diagnosed w/PC - Questions

    Hi NU2This99 and welcome to the Board!

    I like your screen name – pretty much true for all of us when we get diagnosed.

    The fact that your doctor described your case as “low-risk” – which has a very specific technical meaning, is a very good sign for your long-term survival and well-being but a bit of a challenging circumstance for your own decision making as you have quite a few good options, with one likely best option – active surveillance.

    It is not surprising that your urologist is nudging you toward surgery. After all, he or she is a surgeon: that’s what he or she trained for, believes in, and makes much of his or her income from. Guidelines from his medical association push surgeons toward informing getting “informed consent” from their patients prior to surgery, so some outlining of options is typical, but did you receive any subtle guidance? These days, assuming your case is truly “low risk,” active surveillance is THE go to approach - not surgery, though that is an option too, especially for patients who would be so worried about not “getting the cancer out, in a jar, and out of my life forever” that active surveillance is not an option. Unfortunately, surgery for most patients is going to leave some lifetime side effect burden, and some of the time it is not going to get all the cancer for low-risk patients; that said, it is a chance well worth taking and well worth the side effects if your case characteristics indicate that you do need some treatment rather than active surveillance.

    I’ll leave these initial thoughts with a few key points. Radiation, in these modern times, is at least as effective as surgery in dealing with the cancer and typically has a lighter burden profile of side effects. Cryosurgery may work but is not as effective as radiation or surgery. HIFU has had a distinctly less favorable record of beating prostate cancer in research conducted around the world (with the notable exception of one unusually successful center in Japan), and comes with the risk of substantial scar tissue that creates problems. Focal therapy, with a longer and more extensive track record in the UK and Europe, may be appropriate depending on the size, location and aggressiveness of the cancer as ideally confirmed by multiparametric MRI (mpMRI) imaging; personally, I would not want to be treated for focal therapy without data from an mpMRI scan.

    Regarding a), second opinion sources: I am not familiar with centers of expertise close to you, though there may be some. There are such centers in New York City and Pittsburgh. “Medical oncologists,” particularly those with a lot of prostate cancer patients, are a good source of more objective opinions as they do neither surgery nor radiation. A “radiation oncologist” would be a good source about the various radiation options; results are already impressive and enhancements keep coming. A “second” opinion often turns out to be several opinions and is common for prostate cancer patients.

    Regarding b), the pathology report: The most important aspect, among several important aspects involving the biopsy, is the score for aggressiveness of the cancer. In the past couple of years the pathologist community has been moving toward a new scoring system that uses a range of 1 (lowest risk) to 5 (highest risk). That system is essentially a simpler summary of the Gleason scores previously reported, which also were evolving prior to the new system. Let us know what is reported and one of us can say more on this. The fact that your doctor classed you as “low-risk” suggests that your score was a 1 (new system) or a Gleason score of 6. Another important aspect is the location and extent of cancer reported in each positive biopsy core. If the cancer is too spread out, then focal therapy, which is not often used in the US yet anyway, is ruled out. If cancer has been found too near the edges of the prostate capsule, or in the “apex”, that makes the odds for successful surgery less likely (but fine, no problem, for radiation). You had 5 of 14 cores that were positive, and that might make active surveillance a doubtful choice, depending on the total picture, and that might be why your surgeon was nudging you toward surgery; that could be a legitimate reason for either surgery or radiation. The extent of cancer in each core is also worth knowing.

    Regarding c), CyberKnife: this is a brand name for just one radiation technique, but research suggests it is a perfectly good one, and it is the technology most used in research that demonstrated equal or superior effectiveness in reducing external beam radiation therapy sessions from around 39 or 40 to 20, or even just 5 (usually with one day or so in between sessions), with somewhat higher doses and longer times-on-the-table per session (resulting in a substantially lower but equally “bioeffective” total dose); side effects during and shortly after the sessions appear to be somewhat stronger, but about the same long-term. Now, other brands of radiation equipment that use image guided IMRT can also be used with these shorter courses. Of course, the longer course is still available and has very good results/side effects. I had 39 sessions of IMRT with image guidance, with a specific technology known as TomoTherapy, but not CyberKnife; at the time it was too experimental for my taste, but substantial favorable research results have been published since then and it is very well accepted in the radiation oncology community.

    Please feel free to ask more questions.

    Good luck!

     
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    Old 01-19-2019, 08:53 AM   #3
    NU2This99
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    Re: Recently Diagnosed w/PC - Questions

    IADT3since2000, thanks for replying. Your comments are appreciated. I contacted the doctor’s office and obtained a copy of the pathology report and a Prolaris biopsy test result.

    The pathology report showed the following info for the five cores that tested positive:

    1. Prostate biopsy left base lateral
    • Adenocarcinoma, Gleason grade 6 (3 + 3), 5% of the biopsy
    • No evidence of perineural invasion

    2. Prostate biopsy left base mediaal
    • Adenocarcinoma, Gleason grade 6 (3 + 3), 10% of the biopsy
    • No evidence of perineural invasion

    3. Prostate biopsy left mid lateral
    • Adenocarcinoma, Gleason grade 6 (3 + 3), 1% of the biopsy
    • No evidence of perineural invasion

    4. Prostate biopsy left mid medial
    • Adenocarcinoma, Gleason grade 6 (3 + 3), 5% of the biopsy
    • No evidence of perineural invasion

    5. Prostate biopsy lesion 1A
    • Adenocarcinoma, Gleason grade 6 (3 + 3), 1% of the biopsy

    I’m thinking this is good news (i.e. no widespread cancer cells at this point and all are contained on the left side). Agree?


    The Prolaris Biopsy Test shows:

    • Prolaris Molecular Score of 4.2 – More aggressive than patients in the same risk category. The Active Surveillance Threshold is 3.2.

    • When considering Active Surveillance, this patient’s 10-year prostatic cancer Disease Specific Mortality (DSM) risk with conservative management is 4.7% DSM

    • When considering Primary Radiation Therapy or Radial Prostatectomy, this patient’s 10-year Metastasis (METS) risk with definitive management is 1.9% METS

    The Prolaris info has me concerned since my mother died of pancreatic cancer at age 59 (late stage diagnosis).

    Additional thoughts or comments?

     
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