Nomogram Value for Newly Diagnosed?

[Jellostone]

Hi, recently diagnosed at 52 with G4+3 and PSA 12. Currently in research and decision making mode, and have been waffling back and forth between RP and the RO’s suggested triple play of Brachy, EBRT and TIP.

But when I enter my stats into nomograms like at MSKK, I’m seeing just a 25% probability of the PCa still being organ contained—so would I be foolish to opt for surgery with such odds of the horse already being outside the barn? Is this really such a tough decision??

Emotionally I want surgery (sort of), but rationally, I’m just not seeing that it makes much sense with these odds.

Thoughts? Thanks

[gamma909]

Sorry to hear of your diagnosis. Nomograms are helpful but still boil down to probabilities just like a lot of the other PCa research/advice. You may want to collect additional information if you have not already done so - genomic testing would let you know how aggressive the cancer is and an MRI could help confirm the containment. Unfortunately, it is hard to know if PCa is truly contained - e.g., there could be PCa cells that have already escaped. In addition, researchers are not 100% certain exactly how PCa may spread. I am sure you will get plenty of other opinions and advice here. Good luck.

[Tall_Allen]

What is TIP? Do you mean ADT?

I agree with your assessment. As you can see in this article, surgery for intermediate risk patients had 5-10 year progression-free survival of only about 53%, while SBRT or brachy-boost therapy are in the range of 85-92%. These are not randomized so small differences may be due to patient selection, but a large difference like that suggests a real benefit to SBRT or brachy boost therapy.

pcnrv.blogspot.com/2018/10/...

[Jellostone in reply to Tall_Allen]

Yes, thanks. By TIP I mean ADT. (Been reading Dr Scholz who calls it TIP). Thanks for the link.

I’m fairly high volume 4+3, too, so thinking I’m probably in the upper zone of unfavorable intermediated risk that is closest to high risk. Even though a pre-biopsy MRI didn’t show any EPE.

I’m young and hear that surgery is more common at my age, but I want to take my best shot at cure in the first shot. And if it’s outside the gland in any way, then the triple play seems to be that best first shot.

Still have more scans and docs to meet, but I’m surprised to feel less inclined toward surgery. Not where I thought I’d be, mentally. Thanks

[ETA: Having read your post, TA, at that link, the “much higher late term urinary and rectal toxicity” does get my attention! Admittedly, I need to better gauge the cumulative side effects of the triple play.]

[Tall_Allen in reply to Jellostone]

You might want to look into SBRT, which may have fewer side effects. I think I speak for all newly diagnosed men when I say that "just cut it out" is a natural first reaction.

I agree with your risk assessment. NCCN allows one to call it "high risk" when there are multiple intermediate risk factors (GS 4+3 and PSA>10 in your case). Brachy boost certainly has better outcomes than surgery for high risk:

pcnrv.blogspot.com/2018/03/...

SBRT for high risk is considered experimental, but I think many SBRT specialists would treat you.

If you can afford $2800, you can get a PSMA PET scan at UCLA, which may give you more assurance that it is contained. The waiting time is 6-8 weeks, so you might want to begin ADT.

Recovery from radiation as well as surgery is better in younger men - so that should not factor into your decision.

[Jellostone in reply to Tall_Allen]

Thanks TA. Will see how my local scans go (Boston) but keep the UCLA PET scan option in mind. Would SBRT join brachy and ADT or would it just be SBRT and ADT?

Do you recommend any SBRT or brachy or RO docs in Boston? I’d be open to travel too, if that helps my odds.

[Tall_Allen in reply to Jellostone]

It would be SBRT monotherapy, which is why side effects are so low. In Boston, a good choice would be Irving Kaplan at Beth Israel. If you can travel and want to get the PET scan at UCLA, I would recommend my RO, Chris King.

[Daddybearblue in reply to Tall_Allen]

Thank you for the recomended read, Saving Your Sex Life by Dr Mulhall. Ordered from Amazon. Read Prologue and Chapter 1 then since I already had RALP fast forwarded to Chapter 7, Penile Rehabilitation and Preservation. Ninety days after procedure NDPSA, and if it remains there in June the AMS 700 LGX will be implanted. We're to 5 months now. Thanks for the help that you offer in your post. Just told one of my buddies, who took me to RALP about this wonderful forum. He had same surgery as me from same URO about 4 months earlier and was struggling with all of what we have to deal with this disease. I told him that he would get support and answers to his questions from these wonderful brothers who have helped me more than I could say. Thanks again, Tall. Arlis

[Jellostone in reply to Tall_Allen]

TA, for brachy/IMRT, is Dr Zelevsky the best in the northeast and worth going to from Boston? (Not rejecting SBRT, just putting it to the side for a moment) Have also seen Nguyen and D’amico also recommended in Boston. Thanks

[Tall_Allen in reply to Jellostone]

When you get up to that level, I'm not sure there is a "best" - they are all excellent- they just have different specialties. I wouldn't travel to NYC from Boston for an RO when there are good ones right there.

[Jellostone in reply to Tall_Allen]

Many thanks, Allen!