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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="DarkGreen"]Hi Ronnie,

Welcome to the board, though I join you in regretting that you've had a reason to seek it out. :)

Kcon and daff have already posted some sound advice, and I would like to underline the value of the Primer. To a lot of us, it is the bible for prostate cancer, though there are other good books too.

I'll insert some comments in green in an excerpt from your first post of 8/23, below. Jim[/COLOR]

[QUOTE=multiplmiggs;4063524]I was diagnosed on 7/23/09 with prostae cancer. Prior to this lovely news, I was on Flomax and had all of the typical enlarged prostate symptoms no need to list them.

[COLOR="darkgreen"]It is good to find out how large your prostate is. The doctor doing the biopsy should have recorded this, based on the ultrasound that is normally used to guide the biopsy. You are entitled to the information; in fact, it's smart to request a copy of the report from the doctor doing the biopsy, if there is one, and the biopsy report itself that was prepared by the pathologist.

It is highly likely that your enlarged prostate accounts for some of the PSA by itself, apart from any cancer. The research-based rule of thumb is that every cc or gram of non-cancerous prostate tissue will produce about 0.066 units of PSA. You can multiply the gland size by that number, then subtract from your latest PSA number, giving you a pretty good estimate of how much PSA is associated with the cancer. The Primer covers this on page F4. For example, if your prostate is 50 cc in size, then 50 X 0.066 would account for a PSA of 3.3; if your latest PSA was 6, then 6 - 3.3 = 2.7 would be due to the cancer, roughly.[/COLOR]

My PSA for about 1 1/2 was hovering around 3. Then it stared to creep and climb, subsequently, the # 6 appeared on my latest PSA. My doc said since I have known you, you have steadied at 3ish. We should do the biopsy.

[COLOR="darkgreen"]Do you have the dates and specific PSA scores, and the version of PSA test that was used for each, and whether the same lab did the analysis? If not, your doctor should be able to provide that important information. It's very useful to know whether the PSA is now going up at a rate of more than 2.0 per year; if so, that's a strong but not conclusive indicator that more aggressive treatment is appropriate than needed if the PSA "velocity" per year is 2.0 or lower, especially if a lot lower.

Your past PSAs are not a perfect indicator of your present PSA velocity; for instance, say your PSAs taken a year apart suggest a PSA velocity of 2.0; however, it's possible that the true PSA movement started three months ago; it might be downward from a higher peak from say a half year ago, or it could now be climbing at a rate of 4.0 per year, just to pick one example. However, the past recent PSAs (last year or so) can help limit the possible range and suggest the likely velocity.

You did not mention your "stage", which is primarily based on the Digital Rectal Exam (DRE) that the doctor does. If you don't remember exactly what the doctor said about that, ask his staff for a copy of the case notes. Also, were just two cores positive? Out of how many cores, and what was the location of the positive cores? What percentage of each positive core was cancer?[/COLOR]

The results came back carcinoma 3+3 6 and 3+3 6, with a gleason # of 6 and rated moderate.

[COLOR="darkgreen"]You need to find out if the pathologist who did the review was a general pathologist (covering men, boys, women, girls, all kinds of conditions, including many kinds of cancer at various stages), or whether he or she more or less specialized in prostate cancer pathology. Many local hospital vets will be of the first variety; while they are right more often than not, a very substantial proportion of their Gleason grades are either too low (unfortunately more frequent) or too high. It is really wise to get a second opinion. That's because the Gleason score is so important in decision making.

Dr. Nick Vogelsang is one of the expert doctors treating prostate cancer in your area (Nevada), and his office would probably be willing to recommend an expert second opinion pathologist. The Primer also has recommendations on page 50.[/COLOR]

A gift from Agent Orange

[COLOR="darkgreen"]From a fellow vet of that period who never got close to Vietnam, thanks for your service![/COLOR]

I am 61 years old. He explained to me that if we did absolutely nothing at all to treat you, you wouldn't die for another 10-12 years. therefore, we should do the Seed/Pellet radiation procedure vs the radical removal of the prostate.

[COLOR="darkgreen"]The first sentence is probably accurate if not an underestimate of survival time, but the second definitely does not follow from the first, a fact firmly established by research: it's much too restrictive! :(. You may have already picked that up from the comments by kcon and daff. Seeds can be a fine approach with the right case, as can radical surgery, but there are other options. The more usual ones include external beam radiation (EBRT), which these days should probably be in the form of IMRT (Intensity Modulated Radiation Therapy), ideally with IGRT (Image Guided Radiation Therapy that precisely locates the prostate target each session and/or limits its movement), or arguably proton beam therapy, or cryo surgery. Hormonal therapy might be appropriate as a booster if your case turns out to be more challenging than it appears at the moment.

Also, and very importantly, Active Surveillance (AS) could be your best option. Leading prostate cancer treatment centers, including leading doctors, are now concurring that that is a great option for truly low risk men, and you may be one of them (pending confirmation of the Gleason score by an expert, etc.). Basically, AS involves putting the cancer on probation and monitoring it carefully, especially for the first two or three years, during which time there is a high likelihood that any bad-acting cancers will declare themselves, at which time we can throw them in the slammer for good with radiation, surgery, cryosurger, etc. The great news is that a clear majority of truly low-risk men are able to stay on AS long term with an excellent quality of life and excellent control of the cancer. For the minority of bad-actor cancers, timely detection is a virtual certainty with sound monitoring, and treatment deferred to that time is proving virtually as effective as earlier treatment. There are some open questions, such as the likelihood that deferred attempts at nerve-sparing surgery will be as successful - just not enough information to know yet. If you are interested, there are some threads on this board with good information on AS. (One of the longest and largest AS programs, at the U. of Toronto, was started late in 1995; about 60% of its AS patients have been able to stay in AS long term. That 60% to say 66% appears to be a likely long-term success statistic for many institutions.)[/COLOR]

He said that the Seed process has only a 20 year history and the results are very good. The radical removal operation has a 50 year history with very good results as well.

[COLOR="darkgreen"]That's probably not a bad way for a doctor to explain the history for a brand new patient, but there's more to the story. New style radical prostatectomy was pioneered by Dr. Patrick Walsh of Johns Hopkins, with his first nerve sparing prostatectomy in 1982, and his breakthrough in reducing blood loss perhaps a few years earlier (maybe a few years later). Prior to his breakthroughs, surgery was not such a great option - lots more burdensome side effects, including some dangerous risks, than after his work; his techniques have become fairly widespread today, though recently morphing into robotic assisted surgery. The first seed implant guided by transrectal ultrasound and a seeding template was done just a few years later in 1985 by Drs. Ragde and Blasko in Seattle. Seeds have improved since then, but basically you can see that effective modern surgical and radiation seeding have been around for about the same length of time.[/COLOR]

But of course it is my choice. I have no clue which way to go, but I am researching.:dizzy:

[COLOR="darkgreen"]Yes - dizzy indeed and confusing! But, your case appears strongly to be one of those where it pays to learn about the disease, become a bit empowered, and aim well before you fire. Unlike pancreatic and lung cancer, and even unlike breast cancer, most prostate cancer is fairly slow growing. But, even better perhaps, no other cancer has a biological marker like PSA that is so highly efficient for the vast majority of patients in indicating their situation. It is not so good and certainly not definitive before diagnosis, but afterwards it is remarkably accurate in most cases (with allowance for the aggressiveness of the cancer per the Gleason score).[/COLOR]

Thanks and take care.

[COLOR="darkgreen"]Prostate cancer is a disease we should not ignore, but these days there is great hope, there are great prospects for prostate cancer patients, especially patients with low-risk case characteristics.

Take care and hang in there,

Jim :wave:[/COLOR]
[COLOR="RoyalBlue"]Hi John,

Prostate cancer decision making is tough for many of us, and with some complicating features in your case, your decision was going to be even harder than average. There are some very encouraging things in what you provided below, and I'll insert some thoughts in blue this time. Jim[/COLOR]

[QUOTE=JohnM141;4072269]Jim, thanks as always for your reply, even if it was somewhat discouraging for me to read. You are right, I am not 100% at peace with my decision to have surgery, but that is what I am about to do in a week.

[COLOR="royalblue"]One of the really encouraging things you said was that your case was staged as a T1c. :D That itself moves you to the good side of the odds, and other facts suggest that it will be better than the coin flip indicated in the Partin Tables; I'll cover that below. With a Gleason 7, a moderately aggressive cancer, you can see the rather big difference there is between a T1c and a T2. :)

Therefore, it makes sense to either go for a curative treatment soon - like your surgery this week, or knock the cancer back on its heels for a while with some hormonal therapy. :cool: The wrong course, as I see it, would be to wait and do nothing for a while, a delay which could allow the cancer to move into the T2 range, lowering your overall chances of success, at least with surgery. :([/COLOR]

Maybe it's something like buyers remorse, or just plain fear that I am feeling, I don't know. Throughout all of this, I have not had the benefit of an impartial expert to say to me "this is what you have to do". My surgeon/urologist naturally recommended surgery so that is the path I took, after trying to learn about all the other alternatives.

[COLOR="royalblue"]Unfortunately, the experts usually do not want to direct you to a certain course when they know there are a number of good options with no clear way of deciding among them. The facts you have provided now make it pretty clear that surgery does give you a quite decent shot at a cure. :) I think most of us have some doubts about our choices along the way, but I have a hunch you will feel more confidence when the game begins next week. The waiting is usually the hard part.[/COLOR]

So the surgery train is leaving the station and I am about to jump on. It's the Gleason 7 that is bugging me and giving me the doubt I have that surgery will cure me. You asked for my stage and it is T1c and my PSA was 4.1 and a retest a month later returned a 3.4.

[COLOR="royalblue"]That is some very encouraging information! :D For one thing, you are entitled to go back to those same Partin Tables and now look up the odds using that latest PSA of 3.4, which takes you to the Partin Table for PSAs ranging from 2.6 to 4 rather than 4.1 to 6, the one used in the earlier post. The odds of organ confined disease for a T1c, Gleason 4+3=7 cancer are 58%, rather than the 52% for the best case stage in the earlier post. A 6% improvement over 52% is about a 12% true improvement.

Perhaps even more encouraging, you have demonstrated a negative PSA velocity, going from 4.16 to 3.4! :D The D'Amico teams' key research on PSA velocity demonstrated that a rise of more than 2.0 in the year prior to surgery (and radiation) added more risk than was reflected in indicators like the Partin Tables that considered stage, Gleason score, and PSA, which was the big news, but, conversely, they also demonstrated that velocities lower than >2.0 indicated [U]lower risk[/U] than you would otherwise expect, and the lower the PSAV, the better. (They looked at and graphed success curves for PSAVs of <0.5, 0.51 - 1.0, 1.01 - 2.0, and >2.0.) In other words, your negative PSAV suggests fairly strongly that your odds of success should be quite a bit better than the odds in the Partin Tables. If it were me, I would be visualizing at least a two out of three chance of success - a whole lot better than a coin flip! :cool:

For example, I'm looking at the key 2004 study, the one dealing with outcomes after surgery, at Figure 1.a for the percent of recurrence after surgery at the ten year point depending on PSA velocity (PSAV) prior to surgery. The most favorable group on the chart is patients with a PSAV less than or equal to (<=) 0.5 per year, which is where you would be. Their projected recurrence rate at ten years was just about 30% (keep in mind that many of these recurrences would be quite mild, often requiring no further medical intervention). In contrast, the recurrence rate for men with a PSAV greater than 2.0 was about 55% at the ten year point - nearly double.

Figure 1.c provides information on projected death from prostate cancer for various pre-op PSAV rates. The rate for men with a PSAV like yours is so low at ten years that it is hard to read on the chart - looks to be a fraction of a percent, with the other two favorable PSAVs (0.51 - 1.0 & 1.01 to 2.0) very close to that - perhaps ranging from <1% to 2%; also all these survival lines are basically flat after 3 1/2 years - virtually no deaths after that through the ten year point. In sharp contrast, the death rate for men with a PSAV greater than 2.0 in that year prior to diagnosis is, at the ten year point, about 15% and climbing.

Regarding Gleason score, while also important in predicting outcome, it appears that the PSAV prior to diagnosis is much more important.

I do want to say, for the benefit of anyone reading this with a PSAV greater than 2.0 before diagnosis, like mine, that history for men [I][U]treated in this study[/U][/I] does not dictate outcome for men [I][U]treated now[/U][/I]. There have been many and major improvements in prostate cancer care. But the information does indicate that we need more aggressive attention. Also, PSAV that likely has a big part of it due to prostatitis would be hard to compare to this research.

You also asked what the surgeon said about saving nerve bundles and he said he thought I was a good candidate for that, thank God, but he was basing that on the biopsy report (two pathologist opinions) and not the actual slides. He will receive the actual slides on Tuesday. So it is a coin flip for me whether I made the right decision for surgery. Thanks for your help.[/QUOTE]

[COLOR="royalblue"]The pathologists are almost surely better able to interpret the Gleason scores than the urologist, unless he is quite exceptional. You said that one pathologist had practiced for 32 years and the other for just 3, but at least you are getting inputs from two certified pathologists with assessments that are quite close. While it is not clear whether either specialized or got special training in prostate cancer pathology, which would be ideal, getting near concurrence from two is encouraging.

Personally, I think you've given the decision an excellent shot. At this point a prayer would be in order :angel:, and you have mine, but I don't see much value in worrying, if it's possible for you to avoid it. Some of us just can't avoid worrying, and if that's you, at least you might be able to avoid worrying about not being able to avoid worrying. ;)

Best of luck to you this week.

Take care,


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