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Thread: Point & Counterpoint: Should Active Surveillance Be Used for Gleason 3+4 PCa?

  1. #21
    Senior User
    Join Date
    Nov 2018
    Posts
    220
    Djin I know I wouldn't have been any candidate for AS and not what I trying to say. As usual I wasn't clear. I was trying to say it would just be scary not knowing if something else was there since biopsy etc doesn't give a good whole picture of the prostate and what's there. The only reason I mentioned mine was when had biopsy I was on the forum and what I read was I was a favorable GS 7 if there is such a thing and it wasn't a huge amount and was just in one area with low psa so things looked pretty good that would have a very good chance for a cure unless more found or GS upgraded after RALP. Even Dr. Andrews at Mayo was positive at my consult. Of course biopsy was correct no change in GS or the area of the cancer was found however had the one seminal vessel involvement. All I trying to say was it's just scary to wait because whatever biopsy etc shows the tests are not good enough yet to know what could really be there. So wasn't trying to disagree with you. I'm just not always clear on what I'm trying to say.
    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 positive one 5% left mid two 50% left base
    Gleason 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: Gleason 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: Positive (left seminal vesicle)
    Margins: Positive left lateral base and central base margins 2mm focus each
    Lymph Nodes involved: 0
    Lymph Nodes examined: 16
    Nerves spared right side only
    Pathologic Staging (AJCC 8th Edition)
    Primary Tumor pT3b
    Regional lymph nodes: pNO
    Distant Metastasis: Mx
    Continence 99% 9 weeks
    Post Op PSA: 4/17/2019 <.1
    2 Month PSA: <.007

  2. #22
    Quote Originally Posted by Another View Post
    A question, what are the percentages of the general category of genomic testing "low risk" of adverse conditions being discovered or realized? It is my understanding they can range as high as 10%.
    Another, I can't give you a single answer to that. You would have to look at the study linked in post #16 -- the percentages change as you change the cutoff you use in the Decipher score (see Table 3). You can also see how Decipher (alone) compared with a traditional risk-evaluation tool (CAPRA) alone. This use of (at least) Decipher for (any?) adverse pathology on RP for men in AS is, I believe, new. In it's biopsy version, it was originally validated for predicting Pattern 4 or 5 at RP, 5-Year Metastasis Risk, and 10-Year Prostate Cancer Specific Mortality (and has yet to be validated for predicting any adverse pathology). "Any adverse pathology" is tricky, because there are evidently PCa's that are locally aggressive, but not metastatic.

    But getting back to AS candidacy, I don't think docs would say "Well, by traditional evaluation you are not a candidate for AS, but your genomics are good, so let's go ahead with AS anyway." Rather "By traditional evaluation you could do AS; however your genomics aren't good, so I'm recommending treatment." Or "By traditional evaluation you're right on the borderline for AS, so I'll let your genomics decide and give you a go-head for AS only if testing shows low (or very low) risk."

    There are different ways of measuring risk: chances of a 4 or 5 pattern at RP for G6 men; 5-year risk of metastases; risk of adverse path being found at RP.

    See also Post #6, a case study showing how a genomics test (OncotypeDx) was used for re-evaluating a G6 man already in an AS program.
    Last edited by DjinTonic; 06-25-2019 at 06:03 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) path. neg. for cancer; then 6-mo. checkups
    6-06-17 DRE: nodule R and 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
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar 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
    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
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

  3. #23
    Quote Originally Posted by Southsider View Post
    When I was diagnosed in January 2014, I was told that 90% of men choose treatment with 70% of all men choosing surgery. So that would be close to the numbers Parikh is citing
    Actually, as this chart from the SEER data shows, surgery was chosen by about 42 percent of all PCa men in 2013. It has since dropped some due to lower risk men choosing choosing AS. The 2013 data further shows about 17 percent not having treatment. I assume that included watchful waiting for men with limited life expectancies.

    https://www.advancesradonc.org/cms/a...g-0001_lrg.jpg
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA 4.4, fPSA 24, PHI 32
    Hopefully, I can remain untreated. So far, so good.

  4. #24
    Quote Originally Posted by nmguy View Post
    Djin I know I wouldn't have been any candidate for AS and not what I trying to say. As usual I wasn't clear. I was trying to say it would just be scary not knowing if something else was there since biopsy etc doesn't give a good whole picture of the prostate and what's there. The only reason I mentioned mine was when had biopsy I was on the forum and what I read was I was a favorable GS 7 if there is such a thing and it wasn't a huge amount and was just in one area with low psa so things looked pretty good that would have a very good chance for a cure unless more found or GS upgraded after RALP. Even Dr. Andrews at Mayo was positive at my consult. Of course biopsy was correct no change in GS or the area of the cancer was found however had the one seminal vessel involvement. All I trying to say was it's just scary to wait because whatever biopsy etc shows the tests are not good enough yet to know what could really be there. So wasn't trying to disagree with you. I'm just not always clear on what I'm trying to say.
    NP, nmguy! Studies point out that there are also men who are psychologically not suited for AS--who want the cancer out--even though they may be excellent AS candidates. And you are correct, biopsies are not accurate enough (witness all the down- and upgrading at RP). Even serious cases can slip through AS programs. That's why IMO genomics should be looked at as a further safeguard for those choosing AS.

    Evidently the scientific jury is still out as to whether there is such a thing as favorable G7 (3+4) suitable for AS.
    Last edited by DjinTonic; 06-25-2019 at 06:26 PM.
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. biopsies, PCA3 -
    2013 TURP (90→30 g) path. neg. for cancer; then 6-mo. checkups
    6-06-17 DRE: nodule R and 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
    SM EPE BNI LVI SVI LNI(16): negative, PNI+, nerves spared
    pT2c pN0 bilat. acinar 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
    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
    02-25-19 (18 mo) 0.015
    05-22-19 (21 mo) 0.015

 

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