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Cancer: Prostate Message Board

Cancer: Prostate Board Index

[COLOR="DarkGreen"]Hi rswife,

Let me add my own late welcome to the Board! :) I've read the helpful responses you have already received, and I'm glad your mind has eased a bit.

I'll insert some comments in green to excerpts from your post #6 below, the one with the biopsy details. First though, here are some thoughts on issues that have come up in previous posts.

You asked in post #3 whether the doctor's eagerness to have your husband make a decision on surgery in early May indicated aggressiveness. Well yes, I think it does, but aggressiveness of the doctor rather than the cancer. ;) Actually, surgeons, often being black versus white type thinkers (not much gray, and impatient with ambiguity and incomplete closure) who are eager to get on with any job and complete it, have a built-in bias toward rapid decision making. Some, unfortunately, try to hustle their patients into a premature decision to use the surgeon's services. That could be a fine decision, but it is better when the patient really understands the likely risks, benefits and alternatives.

You also hoped the doctor would refer him for a second opinion. It's often best when you can find a respected radiation oncologists, or a medical oncologist too, on your own, often with the help of a good prostate cancer education and support group with a knowledge of local doctors.

Baptista thought in post #5 that a bone and CT scan might be helpful. In the US, two of the major cancer guideline organizations have come out with guidelines advising against the routine use of these scans unless there are unusual circumstances or the the PSA is high (not the usual above 10 but above 20, as I recall it) or the Gleason is 8 or higher. The reason is that the scans are so rarely positive that it is a waste of money for men who have lower PSAs, lower Gleasons, and no special circumstances. In fact, the scans are not often positive for the men with higher PSAs and Gleasons, but in those cases they are at least worth the effort. (Mine were negative, and my baseline PSA was 113.6, my Gleason, upgraded by an expert, moved from 3+4=7 to 4+3=7, and all my biopsy cores were positive, most 100%, in a "rock hard" prostate.) The organizations are the American Urological Association and the National Comprehensive Cancer Network (NCCN)

You asked about HIFU. Unfortunately, despite diligent efforts by talented physicians and enthusiasm, institutions in numerous locations throughout the world, which had started HIFU with high expectations, have all been reporting less than stellar results, in fact, downright discouraging results. HIFU results look decent for a few years after the procedure, but, as patients approach the five year point, many have recurrences, and the success percentage keeps dropping significantly as the years tick by. Unfortunately, that's happening with both Ablatherm and Sonablate HIFU facilities. There is a substantial percentage who continue to do well, but probably those particular patients would have done just as well on active surveillance (except they would have retained more of their money and would have fewer side effects). If you want a therapy with high hype, then HIFU is outstanding, but it suffers if you want a therapy that will deliver solid results. Be wary of HIFU marketing. The promoters have successfully enlisted many of their patients, and there is some dishonesty (or at least there was) at one leading HIFU information clearinghouse. That center quoted a well-known Japanese HIFU series reporting great results. However, those results were for the first year or two after HIFU therapy. The Japanese series updated their data for eight years of practice, highlighting patients with five years of follow-up, and the success rate had plunged by that point. As you might have guessed, the HIFU center failed to report that vital update! :mad: Hopefully HIFU practitioners will figure out a way to make it work well. That may even have happened already. However, that success has not been published.[/COLOR]

[QUOTE=rswife;4735897]Hello Johnt1 and Baptista,

It is good to hear from men who are/have gone through this and are doing well. This has been a huge struggle for my husband, as I am sure it is for all who have received a prostate cancer diagnosis. He is starting to talk about it now. I have shown my husband this site and bookmarked it for him so he can read through it when he feels up to it. For now, he would rather I just relay info to him (not sure why, but it's better then nothing).[/QUOTE]

[COLOR="darkgreen"]I'll add to the chorus that your husband's reaction is typical. I expect that he will continue to become more involved, especially with your help.[/COLOR]

[QUOTE]We've been researching as much as we can and met with another doctor today for another opinion and also have obtained copies of the letter from his urologist as well as the biopsy pathology report. I am not sure if I am supposed to start a new thread/topic with the new info or not. [/QUOTE]

[COLOR="darkgreen"]You are doing fine.[/COLOR]

[QUOTE]I will put it in here for now for reference for anyone reading this.

Per biopsy/pathology report:

PSA 11 28/03/2011[/QUOTE]

[COLOR="darkgreen"]That's a little on the high side, but it is possible that some of the PSA is accounted for by an enlarged prostate and/or by infection/inflammation in addition to the cancer.[/COLOR]

[QUOTE]Specimen "prostate" received in formalin.


Site Core# Carcinoma Gleason Tumor quantitation

RB 2 no
RM 2 yes 3+3 5%
RA 2 no
LB 2 yes 3+4 20%
LM 2 yes 3+3 10%
LA 2 no [/QUOTE]

[COLOR="darkgreen"]So that's somewhere between three and six positive cores out of twelve (the reporting is not clear on that to me), with relatively low percentages of cancer in each, but with some Gleason 7 cancer. However, the grade 4 cancer in that core must be a low percentage. Overall, this is a fairly low risk presentation but with a hint of intermediate risk disease. It's very important that a pathologist who is expert in prostate cancer did the work. If not, getting a second opinion is important. (I've commented further on this below.)[/COLOR]

[QUOTE]Extraprostatic fat involvement: no
Seminal Vesicle invasion: no
Perineural invasion: no
Lymphatic invasion: no
High Grade PIN: no

Diagnosis: Prostatatic adenocarcinoma[/QUOTE]

[COLOR="darkgreen"]Those are all good signs, of course. However, I'm not clear how lymphatic invasion could have been assessed. I'm thinking the pathologist really means that there is no evidence either way as yet.[/COLOR]

[QUOTE]So, from what I understand from doctor, there was no cancer found in the apex biopsy, appears to be contained per biopsy, we were told the stage is T1c, [/QUOTE]

[COLOR="darkgreen"]That's all good, and the T1c is a low-risk characteristic.[/COLOR]

[QUOTE]and their recommendation is still radical prostatectomy, as it is their medical opinion (based on gleason scoring, PSA, DRE, age, and biopsies) that surgery will provide him with the highest rate of success/ "cure" .[/QUOTE]

[COLOR="darkgreen"]Many surgeons truly seem to believe that, but, unfortunately, their high confidence is not supported by modern research. Very well done surgery on properly selected candidates has a strong success rate, and your husband's characteristics, pending confirmation of the Gleason scoring (or initial scoring by an expert), indicate he would be a fairly good surgery candidate, though not ideal due to the Gleason of 7 and PSA that is higher than 10.

However, brachytherapy (radioactive seeds) at a center of excellence has a better, extremely high success rate demonstrated over many years. Moreover, once such seeds patients make it to the five year point, there are almost no recurrences beyond that point. That is not so with surgery, where there is a continued gradual fall off in success until about 30% of all surgery patients have recurred. Years ago there was a problem with "cold spots" with seeds therapy, but that has been solved with the aid of modern imaging systems. Young age, in this modern era, has nothing to do with the appropriateness of radiation versus surgery. Surgery is besting external beam therapy results by a substantial margin, but, for a younger patient who can easily bear well-done seeds, the competition for surgery is seeds, not external beam, and it is very stiff competition indeed! This is based on solid published medical research, and I can give you leads if you would like.[/COLOR]

[QUOTE]Also, said that surgery is the best way to determine that lymph nodes are clear and is the only way to fully grade entire prostate. [/QUOTE]

[COLOR="darkgreen"]That is a key part of the typical surgeon sales pitch, but it is not that relevant. The bottom line is that seeds patients are doing substantially better long-term. For one thing, only a few obvious and easily accessed nodes are sampled by the surgeon; cancer may well reside in a node not sampled. While there is a greater likelihood that remaining nodes are clear, that is far from assurance. You do get a better Gleason picture from surgery. On the other hand, well-done seeds, which are able to deliver killing radiation millimeters beyond the edge of the prostate capsule, get the edge over surgery in that key area. [/COLOR]

[QUOTE]We were told that biopsies were read by qualified and well respected pathologist who has numerous years of experience and expertise in reading prostate biopsy samples. If husband wants, he can have them read by another pathologist, but husband said he did not think it was necessary. [/QUOTE]

[COLOR="darkgreen"]If that's true, then the Gleason is valid. I would suggest asking the name of the pathologist and then communicating with the expert prostate cancer research and treating community in Vancouver, asking what they think of that pathologist. Vancouver boasts world-class experts in prostate cancer. Hopefully, that's where the biopsy sample was sent.[/COLOR]

[QUOTE]We are still waiting for his books to arrive that I ordered the other day. The books ordered are: Invasion of the Prostate Snatchers, The Complete Canadian Guide To Prostate Cancer, Primer on Prostate Cancer: The Empowered Patient's Guide, and Dr. Patrick Walsh's Guide to Surviving Prostate Cancer, Second Edition. These books are ones that seemed to be recommended a lot and we are looking forward to their arrival in the next week or so.[/QUOTE]

[COLOR="darkgreen"]I know that Invasion and the Primer are excellent, and Dr. Walsh's book is excellent on surgery. (He is fairly ignorant about hormonal blockade, but that is far from his forte.) For surgery, he is the acknowledged world leader.[/COLOR]

[QUOTE]That's about all I know for now. Thank you again for your kindness, replies, and input. :)[/QUOTE]

[COLOR="darkgreen"]Take care and keep your spirits up,

Jim :wave:[/COLOR]

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