What category of Intermediate Risk Am I?

[Nordman]

I am trying to make a decision regarding HT with RT.

I am 78. I have CKD 3b, and a solitary kidney. I am 6.5 years in remission from UTUC kidney cancer. A number of papers indicate that HT could be detrimental to my kidney.

Those with FIR PCa could avoid HT with little risk. The following is defined as:

Favorable Intermediate Risk (FIR):

- NCCN intermediate risk, as defined above, but only those with

- Predominant Gleason grade 3 (i.e., Gleason score 3+4 or 3+3), and

- Percentage of positive biopsy cores <50%, and

- No more than one NCCN intermediate risk factor

Am I FIR,or marginal FIR, or unequivocally UIR? I want to avoid HT.

I believe I am T2c The urologist said T2a because of only a tiny amount of PCa on the right side. I think Tall_ Allen said I was T1c because the DRE was normal - but how good was the urologist in performing the DRE?

Gleason, 3+4, ie 90% of 3 and 10% of 4 on the left side and 3+3 1% on the right side. PSA 13.1 in July 23 and 14.32 Nov 23.

36cc prostate, normal DRE, Grade 2, biopsy 6 out of 15 samples positive. - 9 mm, 5 mm, 1.3 mm - although MRI was 14 mm.

Even if I were UIR, the mean benefit of HT with RT (it will be IMRT) mean overall survival was only 0.7 years longer with ADT. Distant metastasis was improved.

[Tall_Allen]

"Normal DRE" means you are stage T1c, not T2a - your urologist is not following current guidelines. NCCN risk stratification is based on AJCC 8th edition for staging.

prostatecancer.news/2017/03...

[Nordman in reply to Tall_Allen]

Thanks Tall_Allen

The urologist initially said T2a then agreed it could be T2c when I said strictly speaking there was PCa on both sides of the prostate albeit one side was tiny. I take your point re T1c, but I was told that doctors are sometimes not good at DREs. I think you may also have said that. Can I trust T1c? How important is the distinction between T2a and T1c?

Most importantly for me, given my stats shown, am I Favourable Intermediate or Unfavourable Intermediate.? I would really like to get your interpretation. If it was a continuum, am I FIR or URI or hopefully close to FIR? You will gather that I really want it to be FIR or close to it. Due to potential risk to my solitary kidney, I want to avoid HT.

Nordman

[Tall_Allen in reply to Nordman]

As I wrote, "T stage based on DRE only. Imaging is never used. (Nor is biopsy)." It is certainly not based on a "perfect" DRE that you imagine. Almost all patients are T1c (78%) or T2a (13%).

The definitions are as follows:

The NCCN intermediate-risk group is currently defined as having any of the following:

- Stage T2b or T2c, or

- PSA 10- 20 ng/ml, or

- Gleason score = 7

(If multiple risk factors are present, the clinician may optionally deem it high risk

Unfavorable Intermediate Risk:

- NCCN intermediate risk, as defined above, plus

- Predominant Gleason grade 4 (i.e., Gleason score 4+3), or

- Percentage of positive biopsy cores≥ 50%, or

- Multiple NCCN intermediate-risk factors

Favorable Intermediate Risk:

- NCCN intermediate risk, as defined above, but only those with

- Predominant Gleason grade 3 (i.e., Gleason score 3+4), and

- Percentage of positive biopsy cores <50%, and

- No more than one NCCN intermediate risk factor

So, you are clearly favorable intermediate risk.

[Nordman in reply to Tall_Allen]

I couldn't quite get a handle on the criteria despite repeat reading. Many thanks for your interpretation Tall_Allen. I respect your knowledge. It has lifted my spirits. I can now go forward with more confidence regarding my preferred treatment.

Nordman

[GP24]

I suggest you read this trial: nejm.org/doi/full/10.1056/N... If you do nothing you will live for 15 years at least .

[Nordman in reply to GP24]

Thanks GP 24 for the reference.

I am going to read it slowly, and carefully digest it.

I suppose thought has to be given to 'survival' but living with metastatic pain "if you do nothing"!

Nordman

[GP24 in reply to Nordman]

"Gleason, 3+4, ie 90% of 3 and 10% of 4 on the left side and 3+3 1% on the right side." This is (very) favorable immediate risk. I expect that you will not get bone mets that start to hurt during these 15 years.

[Nordman in reply to GP24]

GP 24

You say very favourable intermediate risk, but the UK NICE classification system puts me in the high risk category. The UK Cambridge system puts me in the Group 3 category which is the same grouping for 4+3. Tall_Allen says according to NCCN, I am favourable intermediate. The urologist said I was T2a. When I queried this because of having PCa on 2 sides, he then agreed I was T2c. Tall_Allen says I am T1c because of a non palpable DRE. Another source says that due to my MRI scan showing a 14 mm tumour I am T2c. These different classification systems are all so confusing.

Anyway, being 78 next week, I would love to not have any treatment, and carry on as normal, but am nervous to do that.

Nordman

[GP24 in reply to Nordman]

You do not have to have no treatment forever, you can change your mind any time during these 15 years.

3+4 is favourable intermediate risk. If the 3 is 90% it is very favourable or almost low risk.

[Nordman in reply to GP24]

According to my MRI I have a 14 mm tumour in the peripheral zone of a 36 cc prostate. Would you risk it?

[GP24 in reply to Nordman]

As long as the tumor is within the prostate the risk category will not change. In the study there were 545 men who did risk it.

[j-o-h-n in reply to GP24]

I'll raise you 5...

Good Luck, Good Health and Good Humor.

j-o-h-n

[USAFproudmom]

My husband is Gleason 7 (4+3) Unfavorable Intermediate, T1c. He also has stage 3 CKD with a solitary kidney. He did 45 rounds of RT along with 6 months of Orgovyx with no issues. Nephrologist says his kidney function is stable and unchanged after treatment.

[Nordman in reply to USAFproudmom]

Hi USAFproudmom

Thanks for that encouraging information.

You don't need to answer the following questions. They are of interest because of my treatment decisions.

How is your husband now? Has he any lingering effects from the RT or the HT?

What was his eGFR before treatment, and now?

Did his testosterone level go back to what it was?

Nordman

[Sandy752 in reply to Nordman]

I have been on Lupron for 10 years with no vacations and no change in my solitary kidney function. I lost my kidney to kidney cancer in 1989.

[Nordman in reply to Sandy752]

Thanks Sandy

Thanks for that encouraging information.

I will ask the same questions as to USAFproudmum. You don't need to answer them. They are of interest because of my treatment decisions.

Have you any significant effects from the RT or the HT?

Was your eGFR affected? What is it now?

Did you research Lupron as being safer for your single kidney and function?

What was your Gleason and T stage?

Nordman

[Sandy752 in reply to Nordman]

Effects from 40 doses of external beam radiation were minimal at first and have none now. I had and have the usual side effects from Lupron. 10 years later two major issues are fatigue and hot flashes. My Gleason was 4 + 3 (10 of 12 samples cancerous). Don't recall T stage. I saw a kidney specialist for a number of years and he never mentioned my eGFR . About 5 years ago he said I did not need to see him any longer. I did not research Lupron and kidney function. Neither my urologist (who removed my kidney and did my prostate biopsy) or my radiation oncologist or my kidney specialist mentioned the issue. Your post was the first I heard of it.

[Nordman in reply to Sandy752]

Thanks Sandy752

You should ask for an eGFR blood test which will indicate how well your solitary kidney is performing. My single kidney eGFR is 42, so functioning at about 42%. They usually only give you a figure of up to 60 and not beyond, so 60 could mean 60% to 100%.

Nordman

[Sandy752 in reply to Nordman]

I now recall getting that eGFR number in the past and it was always around 55. I will get it done again,

[MateoBeach]

I wouldn't slice and dice the classification any further: Protect your remaining kidney function and skip the ADT. Impact on results of the RT are likely small and a lesser priority IMO.

[Nordman in reply to MateoBeach]

Thanks for your reply.

I am just trying to calculate the risk of no HT, or even opting for A.S. It's a bit of a dilemma. The problem is if I opt for no HT and get recurrence, then it is permanent HT.

Nordman