My dad , 83 , diagnosed with pc with mets to bones as per mri and psma.
Not done biopsy yet as nervous to put dad through it and one oncologist said it’s not needed as the treatment would be ADT but then 3 other oncologists say it’s good to get it done as we would know what exactly we dealing with and can do genetic testing on it etc.
One oncologist said we can just take a biopsy sample from a rib where the PMSA shows the cancer Is there and that would save him the trouble of bleeding etc which would happen in a regular prostate biopsy. Any thoughts on this ?
Also , is there a risk of spreading the cancer more of a regular biopsy is done ? And what are the realistic chances of getting an infection due to a trans rectal biopsy if done at a good hospital setting.
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How many oncologists do you have? In my humble opinion a biopsy is a good idea. It will tell you how aggressive your Dad’s prostate cancer is which is good to know. Not the nicest procedure for an 83 year old man depending on the number of samples they decide to do.
consulted 4 before deciding who we felt most comfortable with 😊. One was a surgical oncologist who said biopsy not needed but the other 3 medical oncologists said we must do it but I still don’t understand if the line of treatment will be ADT anyways , how would Gleason matter
There is absolutely no purpose to having a prostate biopsy after there are known bone metastases. It will not tell you anything you don't already know and will not make any changes in his therapy.
There is also no purpose to having a bone biopsy unless there is reason to suspect something abnormal or a secondary cancer. If it shrinks after ADT, it is normal prostate cancer.
The genomics of tumor tissue changes over time as mutations accumulate. The tumor tissue should then come from his mets, which represent the most progressed cancer. It is always best to get the most recent metastases before deciding on a therapy. There are no genomic mutations now (neither from prostate nor mets) that are actionable.
Gleason score does not in any way dictate whether abiraterone would be effective. Only the fact that there are metastases drives the use of additional medicines, not Gleason score. Your father should have "triplet therapy" regardless of Gleason score.
I suggest you fire that oncologist. He clearly does not understand the first thing about how therapies are given.
What I understood from what you have said is he should start triplet therapy now , given that he has bone metastases and later when that may stop being effective , one can take a tissue sample from a recent metastasis for the genomic testing - it is not needed to take a tissue sample as of present for genomic testing.
Most doctors here seem to only give the bicalutamide and Lupron initially and then see later if anything more needs to be added at older ages
Btw , is chemo given at 83 age - he is in otherwise good health.
Also, apart from infections risks and some bleeding , are there any other risks in getting a biopsy - I don’t want to but can’t help it if the doctors insist.
Triplet starts with Lupron and 10-14 days of bicalutamide. Then either abiraterone or darolutamide is added, and chemo is begun. Age is not a contraindication for chemo if his health status is good.
Prostate biopsies can be painful (at his age he should not have general anesthesia). There is a risk of sepsis and of spreading his cancer. Tumors in his prostate have already shown their ability to spread metastases. Why would you risk spreading more?
The only reason I can think that this doctor is recommending a biopsy is that he can make more money. Is that possible in India?
"I don’t want to but can’t help it if the doctors insist." I know doctors in India are more paternalistic, but can't the patient just refuse a needless, invasive procedure. It is not standard of care anywhere in the world.
There was one uro-oncologist surgeon who said no need to do a biopsy but told us to do a PSMA instead which we did. He has trained at Cleveland clinic and practiced there for a while before coming back to India.
The other medical oncologists said - oh we need to prove it is prostate cancer and biopsy should be done. I asked does the PSMA not already prove it - so they said no !!
Well, the older Indian doctors are paternalistic but the younger ones lesser so.
You have made some very compelling points regarding biopsy. I think I will stick to the first doctor who said no need for biopsy. He said we start with ADT( bicalutamide and lupron) and later when it stops working , he has a team of medical oncologists who will take over. Did not mention the chemo though Will ask him about that . Generally in India chemo seems to be kept for later when ADT stops working. Even the abireterone etc seems to be kept for later after seeing how effective just the Lupron is.
Sincere gratitude for your very valued opinions 🙏🏻. God bless you
It is NOT when Lupron stops working. Even before triplet therapy was discovered, abiraterone or docetaxel was started immediately. Triplet therapy found that all 3 should be started at the same time.
I did show to a doctor at Tata memorial too who handles a lot of prostate cases. He too said a biopsy should be done ! 🙄. Though he did mention that additional therapies like second line adt and chemo could be considered depending on dad’s general health. The problem is Tata Memorial is overflowing with patients , unlike private hospitals so it’s very difficult to get treated there.
Regarding your comment on the risk of biopsy having the cancer spread more - I did ask the oncologist and he said “‘oh it’s already gone to some bones so it’s already spread so why are you worrying about that “ -
would you have any thoughts on that ?
Also , is a PSMA which lights up , conclusive for prostate cancer ? It felt weird when one doctor said no and that only biopsy can confirm
The ONLY reason to ever do ANY diagnostic procedure is if it can potentially make a difference in therapy. If your doctors want to put your father through a painful and dangerous procedure for no purpose, I would find new doctors. I feel sorry for your father.
I don't understand why the ridiculous doctors there seem convinced that your poor father needs to have some kind of biopsy, even though there is no reason for it.
so this is what the oncologist said when I questioned him again about why biopsy and can we avoid it 🙄-
-“ it is always good to know exactly what one is dealing with. And nowadays some NGS - next generation gene sequencing etc can be done and that needs tissue sample and not from bone. Sometimes there is a rare chance that a prostate cancer can be neuroendocrine or lymphoma of the prostate for which treatments are totally different and so it’s wise to get the biopsy done.”
He said even after knowing all this If we still want to go ahead with treatment without biopsy he would do so after taking a written undertaking from us.
Those are incredibly ignorant replies.Are you sure you want him for your doctor?
"always good to know exactly what one is dealing with" In that case, everyone should have a prostatectomy, since that is the only way to know with certainty. Consider: if a biopsy shows only GS 3+3 or GS 3+4, you will know the biopsy missed the cancer, because there are metastases. If GS 4+3 - GS 5+5, the therapy will be exactly the same as without the biopsy, because there are metastases. A biopsy is uninformative when there are metastases.
"NGS - next generation gene sequencing etc can be done and that needs tissue sample and not from bone. " You would not do a tissue genomic test until after he is castration-resistant because there is nothing you would do differently because of it. He is lying to you when he says "not from bone." Bone is exactly what they would biopsy. And they would take tissue from the largest and most recent bone metastases, because genomics change as the cancer progresses and mutates.
"Sometimes there is a rare chance that a prostate cancer can be neuroendocrine or lymphoma of the prostate" Rare is right! You would not suspect neuroendocrine in his case, because his PSA was 18, his bone metastases were PSMA-avid, and they were sclerotic. Neuroendocrine occurs in about 2% of newly diagnosed men, and they would have very low PSA (<2.0), no PSMA-avidity, and lytic bone metastases. Primary lymphoma is even more rare, has no PSA, no PSMA-avidity, and always shows only enlarged lymph nodes, not bone metastases.
Are you sure you want an oncologist who lies to you?
Hello Tall Allen , I only read your recommendations , among all questions asked by patients , as they are perfect , full of good sense and expertise Best regards
My understanding is the biopsy result would only make a difference if your father wanted to participate in the future in some trials which insisted on an available biopsy sample. If based on his age and health he is not concerned about that, then seems like a biopsy is unnecessary. There may not be any suitable trial available now or at a future date even if he wanted to participate.
you are a very good advocate for your father. You were lucky to receive so much info from TallAllen here. A resource I find useful is UroToday. There the physicians specialists discuss the research and best practices.
Thank you 😊. He means the world to me and I want to do everything I can. Yes I am blessed TallAllen has given so much guidance but I am kind of lost as most doctors here in India seem to insist on a biopsy. I will check urotoday. Thanks and I wish you the best too 🙏🏻
Legally they need a biopsy as proof of cancer diagnosis for insurance to process treatments for cancer. Dad was exactly 83 when he was diagnosed on his 83rd bday. They took a biopsy form his hip, it was a piece of cake for him, they gave him a little versed in an IV and he never even remembered it or felt it. Dad has done lupron, xgeva, radiation, xtandi and casodex and he was diagnosed at 83 with mets from skull to ribs to spine and pelvis, stage 4.....he will be 91 next thursday. Good luck to you and your dad!! We never got a gleason. What's your dads psa? his was 1240.
Wow that is an encouraging story 🤗🙏🏻 So you are saying they just took the biopsy from the hip bone mets and not prostate ? Why no Gleason score ?
How has his experience been with ADT and xgeva ? What kind of radiation has he done - did he have bone pain ,
Dad’s PSA is 18 but he was taking the medicine for bph for many years and I read that can reduce psa somewhat but doctors dismiss that. He has mets in some pelvic bones and a couple of ribs
I'm not sure they can get a gleason if its from a bone, they never gave us one and its not in his records. Anywhere cancer has spread they can get a biopsy, it will be prostate cells in the rib because its the original cancer cells.
He has done fine on ADT, they used casodex first then lupron and then xgeva for the bones, then when that failed he had one pelvic met reactivating so they did one blast to his entire pelvis of radiation and then that took care of that met.
He's had some bone aches and back aches over the years but nothing that he's taken pain meds for, which is crazy. He had some hot flashes and complained of his penis shrinking from the meds.
They started him on Xtandi three years ago, he's done well until last year he started having headaches and I dont want to discourage or scare you but they didnt' want to do a head CT but I insisted because his headaches were intense, his psa at the time of the head CT was 1.2 and bone scan was good. To our suprise, the cancer had snuck into his CNS fluid and gone to his brain, this is "extremely" rare . At that point he had to do 10 rounds of whole brain radiation and steroids, this was july 3, 2023, this was the hardest on him at 90 years old, he lost alot of weight and had confusion, but bounced back and he will be 91 next thursday, still here, still watching his football and moving around the house with his walker, doesnt really have that many headaches and even just recently had cataract surgery because he wanted to see the tv more clearly.
I really think every few years they need to throw in a head scan just to check, my dad is a rare case but it happened to him. Good luck, I'm sure you'll have your dad around for a long time, try not to get too upset, if your dad shows good response to treatment, thats the best sign that he'll be around for many years to come. I have cherished every minute with my dad and asked every question I have wanted to ask him cherishing every moment.
Thanks. This is the only point that TallAllen’s excellent advice did not reference. (Here in the States) I suspect my insurance carrier would balk at some of my expensive drugs if the biopsy were not performed in some fashion. They do make a distinction between “chemical” (PSA) and radiological diagnostics.
No, jaw pain at all he's still on xgeva, year 8 now. xgeva really knocked down the size of the mets in the bones the first 6 months. Thanks! I will say a prayer for you and your dad as well. Feel free to reach out anytime if you have any questions
My question would be why take a chance when they know he has Metastatic prostate cancer? The recommended treatment will be the same either way. They did the same to me needlessly. There is no benefit in poking around except financial.
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