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Thread: Undecided

  1. #1
    Regular User
    Join Date
    Apr 2019
    Posts
    14

    Question Undecided

    I have tried to educate myself for 3 months since my diagnosis. There is so much information and I feel like you folks could maybe help me along my journey. I am thinking on trying to be excepted into the Cleveland Clinic active surveillance program. Would you all have the treatment now or seek the surveillance protocol?
    1/2019 PSA 3.24, UP FROM 2.8 3 Months earlier. Had Biopsy 1/19 with 4 cores positive in both sides of prostate. 5%,5%,20% and 30%. All Gleason 6. Uro recommended Surgery. 2/10 Sent slides to John Hopkins for second opinion. 5%,5%,20% AND A CHANGE on 4th with small foci and 80% discontinuous. Went to second urologist 3/19 and he said I could do any treatments including Active Surveillance. Went to oncologist and he also said for me to consider active surveillance. 4/19 PSA 3.5. I am 58 years old. I had a MRI in May that showed a Pirad 4 lesion. Then progressed to a Fusion biopsy that upgraded the Gleason 6 to a 3-4 grade. I now will have a 28 fraction(Hypofraction)IMRT treatments starting late August.

  2. #2
    Welcome to the Fourm, Ducky! Kudos to you for learning more about PCa and the various paths after your diagnosis. Am I correct that the JH second opinion change was only in the amount of G6 in one core, and not a grading change (?). ASAdvocate can fill you in on different guidelines for AS candidacy, but as you probably know, borderline cases become a matter of personal choice. Note the hedging in your docs' advice: "could do," "consider." Evidently "joint decision making" in your case falls more on you BTW, could you add your age in your signature?

    One question is the rate at which G6 lesions might continue to arise/grow, the subsequent PSA increases, and the consequent imaging/biopsying down the road. Related to that is the chance of some pattern 4 (G7, either 3+4 or 4+3) forming/lurking around. As you may know, a portion of men who assumed they were G6 and choose surgical treatment are upgraded to G7 when the whole prostate is examined.

    You might get some information that can help your decision-making from genomics testing of your biopsy slides. e.g., Oncotype dx (sample report) -- especially if your scores come back either low or high. An MRI for AS entry will give you additional info.

    If you are undecided about treating now (which I'm inferring is the case), I don't see why you can't do AS at least for now. You can treat either when the AS program reveals it's time, or whenever you decide you want to.

    Other Forum Brothers familiar with the Cleveland program can give you more advice.

    Best wishes,

    Djin
    Last edited by DjinTonic; 04-28-2019 at 10:15 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3 -
    2013 TURP (90→30 g) path neg. 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
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 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 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day check)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015

  3. #3
    Regular User
    Join Date
    Apr 2019
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    Yes, the Hopkins report was only a volume change and stayed 3+3 gleason. I am 58 years old. As far as the active surveillance I don't believe I would ne a candidate for their program as one of their protocol is <2 cores positive. I don't know if Cleveland clinic would and will find out next week. I live in WV so the major cancer centers are 3 to 4 hours away. I am scheduled for MRI next week.
    1/2019 PSA 3.24, UP FROM 2.8 3 Months earlier. Had Biopsy 1/19 with 4 cores positive in both sides of prostate. 5%,5%,20% and 30%. All Gleason 6. Uro recommended Surgery. 2/10 Sent slides to John Hopkins for second opinion. 5%,5%,20% AND A CHANGE on 4th with small foci and 80% discontinuous. Went to second urologist 3/19 and he said I could do any treatments including Active Surveillance. Went to oncologist and he also said for me to consider active surveillance. 4/19 PSA 3.5. I am 58 years old. I had a MRI in May that showed a Pirad 4 lesion. Then progressed to a Fusion biopsy that upgraded the Gleason 6 to a 3-4 grade. I now will have a 28 fraction(Hypofraction)IMRT treatments starting late August.

  4. #4
    Quote Originally Posted by Ducky View Post
    Yes, the Hopkins report was only a volume change and stayed 3+3 gleason. I am 58 years old. As far as the active surveillance I don't believe I would ne a candidate for their program as one of their protocol is <2 cores positive. I don't know if Cleveland clinic would and will find out next week. I live in WV so the major cancer centers are 3 to 4 hours away. I am scheduled for MRI next week.
    You can also do AS with a/your uro and not enrolled an institute's program, as long as your doc follows a protocol (IMO, preferably one of the stricter ones). When I discussed AS with my doc (obviously not for myself), he said "my protocol is probably closest to JH's--some out there are pretty loose-goosey"

    Clearly if choose AS, you can treat if you next biopsy-core profile worsens. Good MRI, genomics, and PSA reports would weigh in favor of AS.

    Djin
    Last edited by DjinTonic; 04-28-2019 at 10:42 PM.

  5. #5
    Quote Originally Posted by Ducky View Post
    I live in WV so the major cancer centers are 3 to 4 hours away. I am scheduled for MRI next week.
    Since your in West Virginia, you should know that you have a leader in brachytherapy for prostate cancer right there in Wheeling. I've known this since I was diagnosed, a fellow prostate cancer patient who I met in person recommended Wheeling Hospital if I went for that (I'm in Pittsburgh)

    http://www.theintelligencer.net/news...-cancer-study/
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  6. #6
    Senior User
    Join Date
    Jan 2019
    Posts
    459
    Quote Originally Posted by Ducky View Post
    I have tried to educate myself for 3 months since my diagnosis. There is so much information and I feel like you folks could maybe help me along my journey. I am thinking on trying to be excepted into the Cleveland Clinic active surveillance program. Would you all have the treatment now or seek the surveillance protocol?
    Based on what you believe, you are 100% curable, but you would not be the first man to discover post surgery that a higher grade cancer went upsampled during biopsy. Then what?

    Your age says get it treated.
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 R-LESS (Robotic Laparoendoscopic Single Site Surgery) outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)

    ADT - 6/3/19
    ART - 8/5/19

  7. #7
    Senior User
    Join Date
    Nov 2018
    Posts
    237
    I don't know that much about AS but don't think I could do it with 4 positive cores even if they are Gleason 6. To me you never really know if there is a higher grade there or if that is all there is. However you don't have to rush to make a decision. Just my opinion.
    DOB 1955
    63 at dx
    3/2018 PSA 4.05 DRE normal refer to URO small town
    10/2018 PSA 6.28 DRE normal
    Bx 11/2018 12 cores 3 pos one 5% left mid two 50% left base
    GS 3+4=7 T1c
    Appt Mayo Clinic Phoenix Az 1/4/2019
    Dr. Paul Andrews recommend
    MRI 2/27/2019 Mayo AZ
    RALP 2/28/2019 Mayo AZ Dr. Paul Andrews
    Path: GS 3+4=7, Tertiary Gleason Pattern none, Grade Group 2
    Tumor presents moderate to extensive volume mainly on the
    posterior portion of prostate. Largest tumor nodule measures
    8 mm.
    Prostate: 21g 3.5 x 3 x 3 cm
    EPE: Absent
    Bladder Neck Invasion: Absent
    Seminal Vesicle Invasion: Pos (left seminal vesicle)
    Margins: Pos left lateral base and central base margins 2mm focus each
    Lymph Nodes involved: 0
    Lymph Nodes examined: 16
    Nerves spared right side only
    Path Staging (AJCC 8th Edition)
    Primary Tumor pT3b
    Regional lymph nodes: pNO
    Distant Metastasis: Mx
    Continence 99% 9 weeks
    ED Present
    PSA 4/17/2019 <.10
    PSA 5/2/2019 <.007
    PSA 6/10/2019 <.10
    PSA 8/1/2019 <.007

  8. #8
    Regular User
    Join Date
    Apr 2019
    Posts
    14
    Thanks everyone for the reply. I have been advised that I do another Biopsy in six months from original diagnosis(1/19). If any change I would have treatment right away. Most of you folks know there is a new biopsy method being used that was pioneered not far from me in Cumberland MD. I think Hopkins is using it and maybe Cleveland Clinic. Transperineal Biopsy with little infection worry. I am worried about surgery as I have a friend that had the robotic done that is still impotent after 1 year.
    1/2019 PSA 3.24, UP FROM 2.8 3 Months earlier. Had Biopsy 1/19 with 4 cores positive in both sides of prostate. 5%,5%,20% and 30%. All Gleason 6. Uro recommended Surgery. 2/10 Sent slides to John Hopkins for second opinion. 5%,5%,20% AND A CHANGE on 4th with small foci and 80% discontinuous. Went to second urologist 3/19 and he said I could do any treatments including Active Surveillance. Went to oncologist and he also said for me to consider active surveillance. 4/19 PSA 3.5. I am 58 years old. I had a MRI in May that showed a Pirad 4 lesion. Then progressed to a Fusion biopsy that upgraded the Gleason 6 to a 3-4 grade. I now will have a 28 fraction(Hypofraction)IMRT treatments starting late August.

  9. #9
    Yes, TP biopsy has the advantage of no antibiotics and a near-zero infection rate. Also talk to your uro about a mpMRI followed by a targeted biopsy.

  10. #10
    Senior User
    Join Date
    Jan 2019
    Posts
    459
    Quote Originally Posted by Ducky View Post
    Thanks everyone for the reply. I have been advised that I do another Biopsy in six months from original diagnosis(1/19). If any change I would have treatment right away. Most of you folks know there is a new biopsy method being used that was pioneered not far from me in Cumberland MD. I think Hopkins is using it and maybe Cleveland Clinic. Transperineal Biopsy with little infection worry. I am worried about surgery as I have a friend that had the robotic done that is still impotent after 1 year.
    I realize everyone is different, but the ability to have an erection in hospice seems a fools goal.
    DOB 5/1957

    PSA - 11/2010=1.9, 6/12=2.3, 12/13=2.19, 12/14=2.64, 3/17=5.29, 3/17=3.91, 6/17=3.47, 12/17=4.50, 12/17=3.80, free PSA low risk (local (Uro, “My opinion you don’t have cancer), 8/18=5.13, 10/18=5.1, 10/19 ISO PSA 56% risk cancer. All DREs negative.

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative, (Uro opinion “This has been going on for a year”.... ah, more like 2 years ). Bone scan/CT negative

    2/25/19 R-LESS (Robotic Laparoendoscopic Single Site Surgery) outpatient Cleveland Clinic,

    3/6/19. Pathology - Grade Group 4 with Intraductal Carinoma
    T3aNO, GS8, 21 mm unifocal tumor 10%. -7 Nodes, - SV, - Margins, - PNI,
    - bladder neck neg., +LVI, + EPE non focal apex/mid lateral 1mm max extension, Cribriform pattern present. Decipher .86 High Risk.

    PSA 3/27/19 .03. (29 days)
    4/25/19 <.03. (58 days)
    5/25/19 <.02. (88 days)

    ADT - 6/3/19
    ART - 8/5/19

 

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