Hello - My story starts with a PSA at 13.8 [Jan 2019], up from 4.2 [May 2016]. It was retested at 13.87 [Feb 2019]. I completed TRUS biopsy in Feb 2019. Results were 3 of 12 positive; 1 core Gleason 3+4 in L anterior apex involving 15% of 1 of 3 cores; 1 core Gleason 3+3+ from R lateral [microfocus of adenocarcinoma] & 1 from R anterior apex Gleason 3+3, with 1 of 3 cores in R anterior apex involving 30% of 1 of 3 cores. I completed at CT bone scan - results negative for metastasis. I met with the Surgeon who felt active surveillance might be a good plan, subject to further info from an MRI. I completed a 3T MRI in Apr 2019 - prostate volume 47 ml, PSA density 0.28 ng/ml/ml - they noted 3 tumors, with one described as "focal lesion within L apex and mid gland peripheral zone - PI-RADS4 - no evidence of extraprostatic extension, no pelvic lymphadenopathy". Given these confirming results the Surgeon suggested treatment - surgery or radiation. Thus I would forgo a fusion-directed biopsy. I've also met with the Oncologist who discussed my situation, described as "favourable intermediate-risk prostate cancer, clinical T1c". We discussed different radiotherapy - LDR & HDR brachytherapy, external beam radiation alone, and Sterostatic Body Radiation Therapy [SBRT] - which they suggested might be a good course of treatment in my case. I've since been trying to educate myself, reading Dr Scardino's Prostate Book, checking this site and reviewing articles and videos.
Questions - Any value pursuing the fusion directed biopsy? How are people's experience with SBRT?
Thanks
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Benz_16
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Your current diagnosis is low risk PC (not favorable intermediate risk), and as far as you know now, you are a good candidate for active surveillance (AS). For most experts, AS requires at least a confirmatory biopsy, preferably mpMRI/US-fusion targeted within a year of your initial biopsy. Until you have such a biopsy, all you know is that you have an area identified as suspicious for higher grade cancer. PIRADS 4 is not a diagnosis. There are many false positives. It makes no sense to me to get radical therapy based on avoiding a biopsy.
Tall_Allen is way more knowledgeable about this stuff than I am but, looking at that chart, I'm inclined to agree with your doctor's "favourable intermediate-risk prostate cancer" stratification, and also to agree that treatment is warranted.
Treatment is not side effect free. It should be avoided if it isn't needed. But in your case, with a PSA that tripled in two and a half years, if that rate of growth continues you aren't going to get more than a year or two of active surveillance before treatment become imperative and the chances of success are less than they are now.
As for what treatment to get, I really don't know. Personally, I believe that the skill and commitment of the doctor and his staff are tremendously important. I'd rather get surgery from an outstanding surgeon than radiation from an average radiation oncologist, and I'd rather get radiation from an outstanding RO than surgery from an average surgeon. The outstanding doctors usually also have opinions on the best treatment - though I wouldn't be surprised if, even with them, there's a lot of "this is the way we've always done it." Besides that, for radiation, the cost of equipment is very high and different hospitals have different equipment. Doctors can only use the equipment available at the hospitals where they practice.
I had HDR brachytherapy with supplemental EBRT and Lupron. It apparently worked since that was in 2003-4 and I haven't needed any more treatment since then. However I had T2c, Gleason 4+3, and an obvious extraprostatic extension of a tumor that showed up on MRI, so my treatment might be overkill for your case.
If you search for success rates for the different treatment modalities you'll find claims that are all over the map. Here's an article reporting a 98.6 percent 5 year freedom from biochemical failure with SBRT: ejcancer.com/article/S0959-... It's very hard for me to believe that number, but it does come from a highly reputable institution (University of Texas Southwestern). Even if they're off by a factor of 2 or 3 it's still a good result.
Hi Benz, I'm 52yo also newly diagnosed through fusion biopsy 3 weeks ago..
Last year I was wandering around with a high psa of 9,6 or so and with no right diagnosis..I had a fully negative 12 core biopsy last September.
But now this fusion biopsy just uncovered a tumor hiding in the transitional zone, mostly on anterior left apex..Dr said this is among the hardest ones to be reached..
I had 11 cores cancer free, one with 5% gleason 6 and the suspicious fusion hit core came out 50% positive, gleason 3+4..
So, if it werent for this fusion procedure I'd probably remain unchecked for a long while..
So you've had a positive biopsy and MRI. Sounds to me like the doc's advice is the right one. I was diagnosed with Gleason 6, 1 core above 50% and considered low risk. Sent biopsy to Epstein to confirm and to get Oncotype DX which raised me to favorable intermediate. Look at the NCCN scoring chart as mentioned above. I opted for hypo-fractionated IMRT (20 treatments, higher dose than traditional). This was a middle ground between traditional IMRT (40+ treatments) and SBRT (5 treatments). Results are better than traditional and there's not enough historical data for SBRT for my tastes. I felt radiation was better for me than surgery because side effects are slower onset so you have time to deal with them and it seems they are less than surgery anyway (you damage the urinary tract and muscle in the prostate rather than remove it completely and it usually recovers). You have to weigh that against the fact that the prostate is still there whereas surgery removes it completely (radiation kills cancer cells or renders them unable to divide during treatment). Outcomes are equivalent according to studies. I didn't opt for AS because I believe that the longer the cancer stays alive, the more chance for it to metastasize (I'm 59 and have a lot of years ahead of me). You already have a 3+4 so it seems logical that your cancer is only going to get worse and require treatment at some point anyway so why wait? My rad onc center had an advanced IMRT machine so if you go that route make sure you have access to the best.
Make your own decision as to what you wish to do and with who doing the imaging and taking biopsy cores. I have not met the doctor or talked with him but have talked with some who have been to him. He will not turn your prostate into a pincushion. I am told he is an expert at determining whether or not to biopsy.
Avoid the fluoroquinolones if you do get a biopsy. Cefdinir and Rocephin are viable alternatives to the very dangerous Cipro and Levaquin.
If your Gleason grades are correct you should be able to control your cancer to a great extent with diet and supplements. Following a healthy diet and taking the correct supplements may stabilize if not lower your PSA and may also stop the progression of the cancer.
Greetings Benz, You've come to the right place for valuable information and camaraderie.
Good luck, Good Health and Good Humor.
j-o-h-n Thursday 06/13/2019 5:46 PM DST
Are you in the US, or UK? I noted the odd spelling of favorable. There are a number of treatment options for you to research and consider. There's no immediate rush so consider your options and get second opinions. I had HIFU surgery for my gleason 8 (in one core; 7 in 3 cores and 6 in one core; of 12 cores).
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Opinions requested – biopsy pathology report
Advice - Surgery or Radiation?
newly diagnosed Gleason 7 3+4 
Diagnosed 4+3
Here we go.......
