Treatment Options

[Vortex12]

PSA 4.7 (over 2 years it double and then doubled again)

This is the Pathology report

A: Prostate gland, left lateral posterior, biopsy:

Benign prostatic tissue with mild chronic inflammation, no tumor present. B: Prostate gland, left lateral mid, biopsy:

Benign prostatic tissue with mild chronic inflammation, no tumor present. C: Prostate gland, left lateral anterior, biopsy:

Benign prostatic tissue, no tumor present. D: Prostate gland, left medial posterior, biopsy:

Benign prostatic tissue with mild chronic inflammation, no tumor present. E: Prostate gland, left medial mid, biopsy:

Benign prostatic tissue, no tumor present. F: Prostate gland, right medial posterior, biopsy:

PROSTATIC ADENOCARCINOMA, GLEASON SCORE 7 (4+3), WITH 70% GLEASON PATTERN4, GRADEGROUP3, 17 MM FOCUS.

G: Prostate gland, right medial mid, biopsy:

PROSTATIC ADENOCARCINOMA, GLEASON SCORE 8 (4+4), GRADE GROUP 4, 6 MMFOCUS.

INTRADUCTAL CARCINOMA IDENTIFIED. H: Prostate gland, right lateral anterior, biopsy:

PROSTATIC ADENOCARCINOMA, GLEASON SCORE 8 (4+4), GRADE GROUP 4, 7 MMFOCUS.

I: Prostate gland, ROI #1 vol. 0.65 cc, right base peripheral zone, PIRADS 5, biopsy:

PROSTATIC ADENOCARCINOMA, GLEASON SCORE 7 (4+3), WITH 80% PATTERN 4, GRADEGROUP3, THREEFOCI (9 MM, 8 MM AND 7 MM) INVOLVING SEPARATE TISSUE CORES. J: Prostate gland, right medial posterior base, biopsy:

Benign prostatic tissue, no tumor

I am leaning toward Proton therapy (even though the science is unclear) and no Hormone Therapy.

I want to choose the path of the least possible side effects

I would prefer active surveillance, but have been told that is not an option

Any help would be appreciated

I am currently at MD Anderson but am will to go somewhere else if needed

If you want to go to MD Anderson and are having difficulty getting in, sign up for a PSA screening.

Thanks in advance

[Tall_Allen]

You have "high risk" PCa.

The next step should be a PSMA PET/CT to rule out distant metastases.

You will need hormone therapy with the radiation. You may be able to get away with 1 year if you have brachy boost therapy, but 2 years if you opt for external beam with protons. There are fewer side effects with high-dose-rate brachy boost therapy than with low-dose-rate brachy (seeds) boost therapy. It may be hard to find such a specialist in Texas, but you can travel for a 1-day brachy boost and get the rest of the external beam therapy (about 25 treatments) done locally.

[Vortex12 in reply to Tall_Allen]

Thank you, will meet with MD Anderson on the 18th

[Vortex12 in reply to Tall_Allen]

Would it be reasonable to gamble that the Gleason score is overrated and actually a 7 looking at the biopsy results?

[Tall_Allen in reply to Vortex12]

No. Why would you just make it up because you want it to be true? You have to deal with things as they are. You can get a second opinion from Johns Hopkins if that would give you more confidence, but based on the large amount of pattern 4, I'd bet it won't change.

[Vortex12 in reply to Tall_Allen]

First, thank you for your help. And thanks to the other that have been kind enough to reply. For me, MD Anderson has been a cattle car operation. It reminds me of the movie “The Doctor”. I needed a transperineal biopsy (antibiotic resistant) and I had to make a real effort to get it. The first time I saw the Doctor who did the biopsy was 5 minutes before the procedure. Dr. Justin Gregg did an outstanding job, with virtually no side effects. The job of telling me I had cancer was outsourced to someone I had never heard of. I’m not complaining. My point is I need to educate myself on what option is best for me, and be prepared to ask for that. My goal is to have the least side effects and 5 years of the best quality of life possible (currently 66). My first choice was to gamble the Gleason is too high based upon the science that Gleason scores do not always correlate post pathology after prostatectomy. My understanding from what you said, given the fact my PSA has doubled twice and the fact I have too many “4s” that would be a sucker bet. In light of that fact, I am leaning towards Proton because of the chance of less side effects or HDR brachytherapy, which was posted in this thread, and I just learned about. I am leaning against ADT because I am pre diabetic and overweight. (I have had one amazing life) From this forum I believe there is a Doctor at a Medical School in Oregon that I could consult with about the benefits and risk of ADT for my situation. I need to suggest the best treatment that gives me the best chance if I decide not to do ADT. Once again thank you for your kindness and help. And thank again to the others that have offered their suggestions.

[Tall_Allen in reply to Vortex12]

You can manage weight and blood sugar, but 1 year of ADT makes a big difference in the effectiveness of BBT. You only get 1 shot at this.

Side effects are not less with protons:

prostatecancer.news/2016/08...

prostatecancer.news/2016/08...

[Oatmeal2]

Hi, agree with Tall_Allen. Get a PSMA PET scan to rule out Mets. My husband was diagnosed with Gleason 9, high risk at the end of August. He went for 26 treatments of IMRT and is taking monthly Firmagon injections for 24 months. He hasn’t had too many bad side effects from the ADT or from the IMRT. (Knocking wood 🪵)

If you want curative treatment, the ADT may be necessary. Gleason 8 is high risk. The proton therapy hasn’t really been proven to be more effective than IMRT, and good luck trying to get your insurance to cover it since it is substantially more expensive.

[maley2711]

If PSMA Pet is negative, this may address some of your question about ADT......

urotoday.com/conference-hig...

The more the ADT , the greater the metastasis -free survival.....but other negative repercussipns...remember, none of these are predictive for YOU....just probabilities!

I believe the most worrriome possible SE from brachy boost is urinary retention....maybe stricture, not sure. HDBT apparently better SE results

[maley2711]

Consider yourself fortunate in having convenient Anderson access !!!!!!!!!! Bet they have a highly experinced HDR expert?

[Volcanologist]

You may want to get a multi parametric MRI to determine the size or scope of lesions. HDR Brachytherapy may be an option.

[CancerConcierge]

I agree with the recommendations for a PSMA PET/Ct scan. You have high risk PCA. active surveillance is not an option.

My husband was diagnosed with very high risk PCA in August , Gleason 9 ( John Hopkins said Gleason 8) , after many years of active surveillance for low volume Gleason 6. His PSA at the time of diagnosis was 46.6 .

PSMA PET/Ct two and a half months before the biopsy showed that PCA was contained in the gland.

He had 28 proton treatments at Mayo in Phoenix, and is on Orgovyx, Abiraterone and prednisone, recommended for two years....following protocol for high risk, localized PCA from the Stampede trial. The radiologist did not recommend Brachytherapy, perhaps because of previous Green Laser treatment.

MD Anderson in Houston has a Proton Therapy Center.

[Murk]

PSMA scans only CONFIRM if PCa has spread / moved, it is not an indicator that it hasn't! My Doc said it was optional for ADT for me but admitted percentage of a cure was higher. He recommended Orgovyx and only side effects for me after 2 months are a couple of hot flashes at night and a 5-10 lbs weight gain.

[Ahk1]

NO active surveillance