Father In-Law Just Recently Diagnosed With Aggressive Prostate Cancer.... Could Use Some Advice Please

[AntContreras]

Hi all. My father in law who just turned 60 , was recently diagnosed with aggressive prostate cancer and just hoping to get some insight , advice and opinions on his results. And also what options should he consider exploring.

He recently got bloodwork done for something unrelated to health issues and a PSA test was done. His doctor noticed his labs and saw his PSA was high (7.4 and two weeks later 7.8) and wanted to get him in for a biopsy. It’s a good thing he did , because the results from the biopsy came back positive with aggressive cancer. Here are his results below.

FINAL PATHOLOGIC DIAGNOSIS

A. PROSTATE, RIGHT BASE, NEEDLE CORE BIOPSY:

- BENIGN PROSTATE TISSUE

B. PROSTATE, RIGHT MID, NEEDLE CORE BIOPSY:

- BENIGN PROSTATE TISSUE

C. PROSTATE, RIGHT APEX WITH ANTERIOR, NEEDLE CORE BIOPSY:

- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 4 + 4 = 8 (GRADE GROUP

4), INVOLVING 3 OF 3 CORES (TUMOR MEASURES 4MM IN AN 11MM CORE;

TUMOR MEASURES 3MM IN A 14MM CORE; TUMOR MEASURES 2.1MM IN AN 8MM

CORE) WITH MUCIN PRODUCING

D. PROSTATE, LEFT BASE, NEEDLE CORE BIOPSY:

- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 4 + 4 = 8 (GRADE GROUP

4), INVOLVING 2 OF 2 CORES (TUMOR MEASURES 10MM IN A 12MM CORE;

TUMOR MEASURES 6MM IN A 6.5MM CORE) WITH MUCIN PRODUCING

E. PROSTATE, LEFT MID, NEEDLE CORE BIOPSY:

- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 4 + 4 = 8 (GRADE GROUP

4), INVOLVING 2 OF 2 CORES (TUMOR MEASURES 10.5MM IN A 17MM CORE;

TUMOR MEASURES 9MM IN A 10MM CORE) WITH MUCIN PRODUCING

- PERINEURAL INVASION IDENTIFIED

F. PROSTATE, LEFT APEX WITH ANTERIOR, NEEDLE CORE BIOPSY:

- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 4 + 3 = 7 (GRADE GROUP

3), INVOLVING 2 OF 3 CORES (TUMOR MEASURES 9MM IN A 15MM CORE;

TUMOR MEASURES 4MM IN A 6MM CORE)

- PROSTATIC ADENOCARCINOMA, GLEASON SCORE 3 + 4 = 7 (GRADE GROUP

2), INVOLVING 1 ADDITIONAL CORE (TUMOR MEASURES 6MM IN A 12MM CORE)

After the results and receiving the bad news of the biopsy the doctor scheduled him a Bone Scan and CT Scan to find out if the cancer is spreading elsewhere. Results just came back today and thank god there has been no spread thus far.

His Doctor (at Kaiser) is recommending him to get the prostate taken out and said there is little to no chance of sparing nerves. He is getting a second opinion with a recommended doctor again at Kaiser to see if they agree.

If anyone could please give any advice or recommendations that would be awesome. It has been a rough time and I just want to make sure we help him explore all avenues.

Thanks so much in advance.

[6357axbz]

They have it right. Remove the prostate, either surgery or radiation. From the info u provide he has a curable cancer.

[AntContreras in reply to 6357axbz]

Thank you for the reply. So removal is indeed the best option I’m taking it? Thank you again

[6357axbz in reply to AntContreras]

Removal versus radiation??? I’m not qualified to say which is better but some here are and will probably respond soon

[Tall_Allen]

What he has is called "high-risk" prostate cancer. The type of therapy that has the best track record at curing high risk PC is called "brachy boost therapy." This involves a combination of external beam radiation to a wider area plus a brachytherapy boost to the prostate plus 18 months of adjuvant hormone therapy. This has much better oncological outcomes than either surgery or external beam radiation alone. Cure rates are in the 80-90% range for patients like him. The downside is urinary toxicity - mostly short term irritation.

prostatecancer.news/2018/03...

Especially because of the PNI, the external beam radiation should include his pelvic lymph nodes.

I have no idea if he can get it at his Kaiser - I know some Kaiser facilities have the expertise to do it, others don't.

It's a good idea to pay $300 for a second opinion on his biopsy report from Epstein at Johns Hopkins (and only from him).

pathology.jhu.edu/departmen...

[AntContreras in reply to Tall_Allen]

Thank you so much for the reply. We live in Sacramento, CA and was wondering if you had any recommended doctors for out near this area. I did mention to him about the 300$ for the second opinion on his biopsy but he didn’t seem up to it. I think my wife and will just pay to get it done if he doesn’t mind anyhow though. It can’t hurt.

Also how does the typical or average patient brachy boost therapy results compare to removal of the prostate. Just curious because I believe from what he says, his doctors seems pretty set on prostate removal through robotic surgery being the best option.

Thank you again.

[Tall_Allen in reply to AntContreras]

"Also how does the typical or average patient brachy boost therapy results compare to removal of the prostate. "Obviously, you didn't read the article.

"Just curious because I believe from what he says, his doctors seems pretty set on prostate removal through robotic surgery being the best option."

That's because he is talking to urologists.

[AntContreras in reply to Tall_Allen]

I did read the article, it’s just a little hard for me to understand.. But thank you again for the info. I really appreciate it.

[Tall_Allen in reply to AntContreras]

Ask questions. It directly answers your question. What did you not understand?

[AntContreras in reply to Tall_Allen]

I reread and it makes a little more sense. Just confused cause I’m taking it as BBT being better for the earlier years but as time goes on Survival rate is about the same.

Curious to know about comfort of life after each. Obviously they all suck. I know there are a lot of pros and cons to each. Guess I’ll have to look more into that. I’m just trying to get as much info I can to help give him the best additional knowledge and options.

Any negative sides your aware of when it comes to the hormones for 18 months?

[Tall_Allen in reply to AntContreras]

What the article says is that "10-year overall survival" is not the best measure of success because most of the men who die within 10 years die of something else other than prostate cancer. You can see the clear advantage of brachy boost therapy (BBT) if you focus instead on prostate cancer-specific survival and survival without metastases. Prostate cancer-specific mortality rates were cut in half by BBT, and metastases were only a fraction compared to the other treatments.

The late-term urinary side effects are higher with BBT compared to just external beam radiation. Surgery for high-risk patients is often followed by salvage radiation, which is a terrible combination in terms of side effects - one gets the worst of each. Because the surgeon often has to "cut wide" in high risk patients, there is often lasting incontinence and ED. Salvage radiation impairs healing and can add urethral stenosis because the anastomosis is irradiated.

18 months of hormone therapy has been found to improve outcomes with BBT in high risk cases:

prostatecancer.news/2020/04...

The typical side effects include loss of libido, hot flashes, mood changes, fatigue, loss of muscle mass and fat accumulation. Rarer side effects include loss of red blood cells, cardiac effects, and loss of bone density. There are medical solutions to those if they are troublesome. When testosterone comes back, the side effects disappear.

[diatom in reply to AntContreras]

Diagnosed July 2018PSA 56 Gleason 9

Biopsy positive 10 out of 10 core sample

My urology oncologist recommended external beam radiation +brachytherapy +lupron(18 months)

No serious side effects. Basically fatigue.

PSA undectable

[maley2711 in reply to AntContreras]

THIS may help.......from MSK and includes some of what Allen has provided for you, but perhaps more digestible for a rookie (like most of us!) researcher ? It dsicusses all the radiation options for different PCa risk levels......looks like MSK offers all the options.....not every facility does? I'd think the best plaace to contact would be one that offered all the options? I did note that MSK uses SpaceOar, whereas the UCSF I believe can use a Viewray for that they believe negates the need for SpaceOar that is used with other SBRT equipment.

mskcc.org/news/what-every-m...

[Justfor_]

I had similar biopsy and after almost 6 months of 8 hours 7 days per week of studying and information gathering, I finally opted for removal. My thinking for this is long and I have expressed it many times here, so no need to reiterate.

[AntContreras in reply to Justfor_]

I will look into your post and thread thank you

[maley2711 in reply to Justfor_]

How would I and others here find your previous comments on why you chose RP??

[Justfor_ in reply to maley2711]

Yes, search is not helpful. In a nutshell:

1) I don't believe there is cure, only "treatments" to impede progression.

2) Progression, as in any self-doubling system, is exponential.

3) The exponent differs from person to person and generally advances with time for the same person.

4) An exponent close to zero leads to a quasi-stabilization state called remission or "cure" by some.

5) Each treatment, lowering the burden, brings the exponent down (but not to zero)

6) After diagnosis our life follows a saw-tooth sequence (progression + treatment= one tooth).

7) Each treatment incurs a QoL cost. The further down the saw-tooth sequence the higher the cost.

8) Some believe that hitting it hard using multiple treatments at once will zero the exponent. I don't.

9) I believe in cascading all available treatments in an effort to maximize the number of teeth without letting the exponent run astray.

10) In this scenario RP is undoubtedly the first tooth.

[maley2711 in reply to Justfor_]

Ok..evryone is entitled to his/her own beliefs.....and studies do seem to agree with some of what you state.

[mja511]

I had a similar biopsy - with PSA 10 and Gleason score 9 - and had a similar decision to make. I'm 63, and work full time. I opted to have my prostrate removed. I had surgery on 7/28/2020 - so it's still early - no incontinence and 1st PSA was 0. My decision was based on I just wanted to get this behind me and start living again.

[Sisira]

I was diagnosed with organ contained PCa of Gleason 9 in March 2015. I was treated immediately with the most aggressive protocol because I didn't want to take a chance with this beast. My PSA then was 7.5 and I was 69 years.Protocol was RRP( open surgery ) + IMRT ( radiation ) + 2years hormone therapy ( Zoladex ).

I didn't suffer any side effects other than complete impotence. For more than 5 years now I have been in very stable remission with my PSA not going above ZERO!

With all the advice you receive ask the question from yourself should he take a chance with a high risk PCa?

Best for your final decision!

Sisira

[leach234]

I can recommend 3 great surgeons in LA.

Reiter at UCLA

Ahlering at UCI

Wilson at John Wayne Cancer institute (Santa Monica)

[leach234]

One more point. I used Ahlering at UCI. I was also a Gleason 8 and he specializes in no ED and no incontinence after surgery. People fly in from all over the world for his skills. Mitt Romney used him for his prostate cancer and he could have gone anywhere. IF ANYONE CAN SAVE YOUR NERVES ITS HIM! He has one of his surgeries on you tube. 2.5 years out I have no ED and no incontinence. PSA has remained <0.02! He has done over 2,000 surgeries. Practice makes perfect!

[maley2711 in reply to leach234]

congrats!!

[Murk]

Only thing I could add is to make sure you talk and work with highly skilled medical specialists. Travel if you must, They make the difference...