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Thread: Active Surveillance vs Radiation

  1. #21
    Experienced User
    Join Date
    Feb 2017
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    93
    Interesting information about JH and genomic testing.

    Carter is one of the best prostate surgeons in the country, though I think he pretty much does only the "open" variety. In any case, I'm guessing that the relatively low volume (10% of only one core) of pattern 4 combined with your husband's age combined with his other medical issues was the basis of the "overkill" statement with respect to surgery. Hard to disagree with that assessment based on the facts you presented. The PSA number and rise is concerning, but the AS program will track that closely.

    I don't know enough about HD Brachy to say much about it, though one sees high praise for it on message boards. Still, I'd agree with the view that AS is an appropriate option for your husband. At one of the two consults I had at JH, I was told that the presence of any pattern 4 is generally a disqualifier for their AS program. But I imagine that's a rule of thumb there, not something set in concrete. Apparently there are enough extenuating circumstances to make an exception in your husband's case.

    Best of luck!
    YOB: 1954
    PSA 4.4 -- March 2016
    PSA 5.9 -- January 2017
    Cystoscopy to assess unexplained episode of severe overnight bleeding from urethra in December 2016; results normal; incident unexplained -- February 2017
    PSA 7.7 and PHI 59 -- March 2017
    3T MRI of prostate -- April 2017; prostate found to be enlarged (79cc) with two potentially cancerous lesions, one PIRADS-3 and one PIRADS-4 -- the latter in the anterior apex of organ
    Fusion biopsy -- August 2017; 14 cores taken, with two measured at Gleason 4+3, corresponding to the MRI PIRADS-4 target location
    PSA 7.0 -- November 2017
    RALP at Johns Hopkins, Dr. Allaf (highly recommend) -- February 2018
    Pathology report upgrades G4+3 tumor to 4+5. One additional cancerous nodule found, G3+4; organ-confined; margins clear, SV clear, LN clear
    Continence: One pad for two months, then dry
    ED: Resolved at one month with aid of Cialis
    PSA <0.1 -- May 2018
    PSA <0.1 -- Aug 2018
    PSA <0.1 -- Dec 2018

  2. #22
    Top User
    Join Date
    Aug 2016
    Posts
    1,256
    AS requires active survellience which means ongoing PSA testing, MRIs and biopsies.

    If you have symptoms they may continue to worsen particularly if you have an enlarging prostate. Drug therapy to ease them may affect your PSA monitoring.

    The anxiety of living with cancer will remain and have the biggest impact, imo.

    I am certain ASadvocate has committed a lot of time and resources in managing his AS as evidenced by his time here and his signature.

    It's not a cake walk.

    For another view point, I had a successful experience and my prostate is gone and every six months going by without recurrence kicks the can further down the road for me. I was lucky. My biopsy came close to matching my pathology except I had a lot of 3+4 instead of a lot of 3+3. You will also hear from men whose biopsy and MRI does not represent the cancer they have/had.

    I believe the poster is a candidate for AS and have said so. Choose AS if it is the best treatment for your cancer. Do not choose AS to avoid side effects.

    At 63 I was already developing incontinence and a diminished libido. The RP improved the incontinence to practically none and it took two years to get my erection back which I use once a week, but without the libido. Glad to have it, but would give it up in a heart beat to have the outcome I have, and importantly, my partner agrees.
    Last edited by Another; 02-11-2019 at 06:24 PM.

  3. #23
    I'll give a little insight from my 3+4 PCa. As you can see from my signature, I had surgery first with the full path report verifying the 2nd opinion on the biopsy as 3+4. But the surgical pathology showed a much greater % of 4. I did have a positive margin, but the gleason at the margin was 3+3, which meant all was pretty good.

    One year after surgery my PSA was no longer undetectable. By 18 months post surgery it was time for Salvage Radiation which I am currently undergoing.

    My main point for you is that if you choose AS, the emphasis is on the ACTVE part (which ASadvocate would highly second). That secondary gleason 4 in the biopsy - you don't really know the full extent of that and if you don't keep an eye on it, it can get away from you.
    There is no right or wrong decision for treatment. Make the decision you are comfortable with and can live with and not second guess if all does not go optimally.

    6/2016 PSA 5.1, negative DRE
    6/2016 Urologist PSA 6.0, %free = <10% chance cancer, negative DRE
    12/2016 PSA 7.7, %free = 50% chance cancer, negative DRE
    2/2017 biopsy Bostwick 5/12 3+3, perineural invasion. Hopkins 5/12, 4 3+3, 1 3+4 (5% 4), perineural invasion
    5/17/2017 Open RP by Dr Alan Partin - Hopkins (5500+ prostate cancer surgeries, open & robotic)
    5/2017 Pathology 3+4, T2x, +margin (6mm, 3+3), organ contained except unevaluable at +margin, moderate tumor extent
    seminal vesicles, lymph nodes all neg
    Age: 62 @ surgery
    8/2017 PSA < .1
    11/2017 PSA <.1
    5/2018 uPSA .06, standard .1
    8/2018 uPSA .07, standard .1
    11/2018 uPSA .10, standard .1
    12/29/2018 6 month Lupron shot
    1/22/2019 start SRT, 39 treatments, 5 days per week

  4. #24
    With regard to genomic testing, I added this study to the Subforum today:

    Defining Prostate Cancer at Favorable Intermediate Risk: the Potential Utility Of Magnetic Resonance Imaging And Genomic Tests [2019]

    (The authors forgot to define AP in the abstract. I believe it is Adverse Pathology.)

    Abstract

    PURPOSE:
    To determine whether prostate multi parametric MRI (mpMRI) and genomic biomarkers might help further defining patients with favorable intermediate risk patients (FIR) prostate cancer which could safely considered suitable for active surveillance (AS).

    PATIENTS & METHODS:
    From our institutional database, we identified 509 patients who underwent radical prostatectomy with a preoperative MRI and a postoperative Decipher test (GenomeDx Biosciences, Vancouver, BC). According to NCCN risk stratification, 125 had FIR and 171 had Unfavorable Intermediate Risk (UIR) disease.Univariable and multivariable binary logistic regression analyses was used to test the utility of different variables in predicting AP, defined as Gleason Grade Group >2, pT3b or pN1.

    RESULTS:
    On univariable analysis, FIR, mpMRI and Decipher significantly predicted AP; on multivariable analysis, FIR and Decipher maintained their independent predictive value whereas mpMRI did not meet statistical significance (p=0.059). The 19 FIR patients with high genomic risk had an AP rate slightly higher than UIR patients (42.1% vs. 39.8%, respectively, p=0.56), whereas those with low genomic risk had an AP rate slightly lower than VLR-LR patients (7.5% vs. 10.2%, respectively, p=0.84). The 31 FIR patients with high mpMRI and genomic risk had an AP rate slightly lower than UIR patients (25.8% vs. 39.8%, respectively, p=0.14), whereas those at low mpMRI and genomic risk had an AP rate slightly lower than VLR-LR patients (8.5% vs. 10.2%, respectively, p=0.89).

    CONCLUSIONS:
    MpMRI and Decipher allowed to better define the risk of AP in FIR patients being diagnosed with PCa.
    69 yr at Dx, BPH x 20 yr, 9 (!) negative biopsies, PCA3 -
    2013 TURP (90→30 g) then PSA 2x/yr, DRE yearly
    6-06-17 DRE nodule R, last PSA rise, on finasteride: 3.6→4.3
    6-28-17 Biopsy #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 5% RLM
    Bone scan, CTs, X-rays: negative
    8-7-17 Open RP, neg. frozen sections, Duke Regional, my Uro, 8-20 RPs/mo. x 25 yr.
    SM EPE LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0, bilat. adenocarcinoma G9 (4+5) 5% of prostate (4.5 x 5 x 4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%; 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 weeks) PSA <0.1; Pomi-T (2 cap/day)
    LabCorp uPSA (Roche ECLIA):
    11-28-17 (3 mo. ) 0.010
    02-26-18 (6 mo. ) 0.009
    05-30-18 (9 mo. ) 0.007
    08-27-18 (1 year) 0.018
    09-26-18 (13 mo) 0.013 (checking rise)
    11-26-18 (15 mo) 0.012

  5. #25
    Top User garyi's Avatar
    Join Date
    Apr 2017
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    1,026
    Thanks for the most enlightening study, Jared.

    Hopefully helps clarify the mistaken notion that genomic testing is unreliable.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19
    We'll see....what is not known dwarfs what is thought to be fact

  6. #26
    Quote Originally Posted by garyi View Post
    Thanks for the most enlightening study, Jared.

    Hopefully helps clarify the mistaken notion that genomic testing is unreliable.
    Keep in mind, this is just one study; however, all papers I've come across have favorable conclusions about a role for genomics--I haven't seen any downplaying it's role.

  7. #27
    Top User garyi's Avatar
    Join Date
    Apr 2017
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    1,026
    Quote Originally Posted by DjinTonic View Post
    .....I haven't seen any downplaying it's role.
    Copy that, Jared. The wife of a new member was questioning it, IIRC, the other day.
    72...LUTS for the past 7 years
    TURP 2/16,
    G3+4 discovered
    3T MRI 5/16
    MRI fusion guided biopsy 6/16
    14 cores; four G 3+3, one G3+4,
    CIPRO antibiotic = C. Diff infection 7/16
    Cured with Vanco for 14 days
    Second 3T MRI 1/17
    Worsened bulging of posterior capsule
    Oncotype DX GPS 3/17, LFP risk 63%, Likelihood of Low
    Grade Disease 81%, Likelihood of Organ Confined 80%
    RALP 7/13/17 Dr. Gonzaglo @ Univ of Miami
    G3+4 Confirmed, Organ confined
    pT2c pNO pMn/a Grade 2
    PSA 0.32 to .54 over 3 months
    DCFPyl PET & ercMRI Scans - 11/17
    A one inch tumor remains in prostate bed = failed surgery
    All met scans clear
    SRT, 2ADT, IMGT 70.2 Gys @1.8 per, completed 5/18
    PSA <.006 9/18, .054 11/18, .070 12/18, .067 2/19
    We'll see....what is not known dwarfs what is thought to be fact

 

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