Recently diagnosed and thinking of next steps

Greetings and happy New Year!

Relatively new member. Have an update and would be grateful for any thoughts.

57 years old.

In July of this year I registered a PSA of 10.5 (taking Propecia for 18 years so the 5.25 reading gets multiplied by at least two). This was prompted by a Life Insurance exam and was my first PSA reading ever. My doctor suggested a biopsy but after spending time researching what folks do when presented with a high PSA I requested that she write me a script for a 3T mpMRI. The results of that indicated two lesions (PIRADS 5 & PIRADS 4). I followed this with a Fusion Biopsy at a leading cancer center. Result was 3 of 16 positive for Gleason 6, two of the cores were targeted (both positive) and the remainder were "random" (one positive). Volume was 20, 15, & 10% of each core and all were on one side. Other data of relevance noted by the Urologist is a free PSA of 9%, and very high apparent PSA density given that my prostate is only 16cc's.

Armed with the above I approached another leading cancer center for a second opinion concerning both the MRI and the biopsy. Results of that upgraded one of the cores to Gleason 7 (3+4) and upgraded an additional core from ASAP to Gleason 6 (on the other side). Pattern 4 is 5%.

EDIT: AFTER RECEIVING THE PATHOLOGY REPORT IT ACTUALLY SHOWS 3 CORES AT 3+4 AND NOT JUST ONE. IN ADDITION CORE VOLUME INCREASED IN TWO CORES

MRI notes for both of the lesions: "broadly abuts the capsule without visualized gross EPE". Both are in the peripheral zone with one of the lesions in the anterior distal apex. Urologist in meeting also suggested some possible complications of the locations. Both readings had a number of other cores that were HGPIN.

I have been doing a lot of research and taking my time as suggested by the above time line.

I landed on a very recent presentation by Dr. Klotz (thanks to this forum!!) to be very pertinent. From everything I read he is one of the pioneers in AS. In the presentation he outlines the boundary conditions and determinants of candidacy for AS, how they have evolved and how his recent data on his large cohort (since 1995) at the University of Toronto is affecting his view on when this is an appropriate strategy and when it is less so. In summary, Dr. Klotz data suggests a markedly higher risk associated with any pattern 4 irrespective of volume. He also suggests that PSA density is unquestionably highly correlated with upgrading. He did partitioning analysis of his AS folks by outcomes showing that for even the most favorable Gleason 7 (3+4) candidates (low PSA and low volume) that they had a 30% metastasis rate at 15 years. I also found related data-rich research from Michigan on the MUSIC AS pool that was also very relevant.

https://www.urotoday.com/video-lectures/advanced-prostate-cancer/video/778-embedded-media2017-06-02-13-54-01.html

I have also discovered by reading the good words in this forum that a prostate cancer diagnosis ultimately calls for the patient to making their own treatment choice.

Anyone in a similar situation or any thoughts related to the above?

Thanks!!

Post Edited (AJMan) : 1/19/2018 6:35:22 PM (GMT-7)

AJman hello and our numbers are very similar. I was pursuing AS until the second opinion of pathology upgraded one core to 3+4 <5%. I also did a decipher test which showed increase risk.

I decided to get treatment based on the risk issue and that most conservative AS programs would not accept me. I took many months to discern treatment choices and landed on HDR-BT. My first treatment of two is in a few weeks then a two-week break and then the final treatment.

If there is anything I can do to help feel free to message me. I am open to talking on the phone about my journey if that would be helpful. Denis

Hi and welcome! Nothing to add to the excellent advice above and you certainly have been on the right track in this diagnostic stage.

Was also a long time Propecia taker. Some say it reduces the risk for Pca. So much for that.

I discontinued right after diagnosis. Don't remember if I was actually advised to but I thought it better to be off it and stay off it so I could be comparing realistic PSA's to each other over time.

AZ Guy said...
Welcome AJMan. I had taken Propecia for 20 years when diagnosed in February. So we doubled the 3.3 to 6.6. As Propecia limits prostate growth, I also had high PSA density. Biopsy showed low volume on one side and Gleason 6. My 3T MRI showed no evidence of cancer. But due to ProstaVision (genetic testing) showing Intermediate Risk and treating the Propecia (finasteride) as a wild card, I decided on the treatment and had surgery. I had a post-op pathology upgrade to Gleason 7, cancer on both sides, and positive margins. As my signature shows, I never had 0 PSA after surgery and am now undergoing radiation and hormone treatment.

I've never found any definitive evidence about taking the Propecia after diagnosis. One RO I consulted thought I should discontinue and most others thought it was OK. So I began limiting use and discontinued after the surgery and the upgrade.

Also AZ Guy..I wish you all the best for your follow up treatment

Its great the thorough research you are doing before deciding. Not to cloud your judgement but your much smaller prostrate does increase the risk of escape or progress beyond the capsule. There is no conclusive evidence but just applying logic of space and time. I have come across an article or two highlighting this risk.

Good to see you jump in AJ, after you've done commendable due diligence. Would you mind telling us what two leading cancer centers you're referring to. You have some of the best ones there are, up in New York. Also, if you'd be kind enough to post your relevant stats below your signature line, it would save us a lot of scrolling, and probably yield you more meaningful feedback.

I think you, like me, and many others, first react to the news of prostate cancer with the hope that AS is all that's needed, and we can go on with life unabated. That is almost never the case. It wasn't for me, and given your description, I don't believe it is for you, either. I totally concur with what RobLee advised, above.

Your exploration for hard and empirical data is the way to go IMO, supplemented by some of our filtered anecdotal reports, if they indicate a pattern. While you have some time, don't dilly-dally. I have no doubt, given your approach, you will find the right answer for you.

Best of luck on the journey!

Post Edited (garyi) : 1/2/2018 11:35:07 AM (GMT-7)

Also thank you very much RobLee....first time I have been called a young man in many years!! Very grateful for your response here.