Introduction

Hello, forum folks.

My (otherwise healthy 55yo) husband was just diagnosed with G6 PCa on Monday. I’m a medical coder and thus am more comfortable with medical terminology than he is, so I’m acting as his advocate.

The thing about his pathology is that 11 of 12 cores are positive, with the 2 highest cores being 95% and with PNI in 4 cores on the right side. I’m curious to know if any of you had the same kind of path results and what kind of treatment plan was recommended and chosen.

We live on the coast in rural far Northern California, but fortunately have a hospital in town with some sophisticated RAD/ONC treatments such as IMRT/IGRT/SBRT. We have a consult with one of their specialists on Wednesday. Surgery options locally are limited to an open (retropubic) RP, so we’re getting a consult at UCSF and will get info on RALP. Luckily, a brother lives nearby because it’s a 6-hour drive to get there. My husband’s eldest brother works for the NIH and was able to set him up with a tumor board review by the urologic cancer group at NCI. That should happen Tuesday, we understand.

I look forward to hearing any pearls of wisdom you can share from personal experience. Thanks so much!

—Victoria

Even if there were some guarantee that there is no high-grade core somewhere in his prostate (no such guarantee exists, of course), there is too much G6 to seriously consider active surveillance.

I'll let other talk about the RP vs RT decision (and the various types of RT), but will say only that *IF* he chooses surgery, the most important factor influencing ontological, urinary, and potency outcomes is in your hands: choosing a highly experienced surgery and not the approach (open, laparoscopic, or robotic). If you look at studies designed to compare approaches, open and robotic are very evenly matched. open, if I remember, averages a 1/2 day longer hospital stays and perhaps 100 cc more blood loss. I had an open, but if I were choosing a surgeon for a RALP, I would want one who has done at least 1000 procedures.

All the best to you and your husband!

Djin

Post Edited (DjinTonic) : 7/24/2021 7:32:49 PM (GMT-6)

Thank you all for your input. I agree that active surveillance is not a wise choice, and so do Paul’s urologist and PCP. It’s more a question of surgery and/or radiation, along with any other pharmaceutical options deemed necessary/prudent by the specialists. Interestingly, my husband’s PCP warned against radiation before surgery, saying that radiation can cause complications with surgery, but you may know more, having lived with prostate cancer.

The specialist I’m hoping we can see is Dr. Raj Pruthi, a urologic onologist/surgeon who specializes in prostate and bladder cancers and has pioneered some robotic surgical techniques and uses them in surgeries. He uses new developments in imaging and molecular diagnostics and his research focuses on surgical innovations, better surgical outcomes and improvements in quality of care. He’s chair of the UCSF Department of Urology, went to med school at Duke with postgraduate training in the Stanford urology department, including through a fellowship in prostate ultrasound and cancer.

Michael, your guess is pretty close: we live in Eureka.

Hi Victoria and welcome. I’m a low volume Gleason 6 who chose aggressive treatment over active surveillance. All of the accepted treatments offered high success rates and I chose SBRT since it only involved five radiation treatments. I have no unpleasant side effects and my situation appears to be the norm. No matter what treatment your husband and you select I always recommend seeking out the very best practitioner and team you can find. The best can make a huge difference in outcome. Good luck in your search and keep us posted.
Terry

Welcome to our club...sorry you need to be here. I'll agree with the other suggestions to have his slides sent to Johns Hopkins for second opinion. Epstein's lab there does nothing but prostate pathology, they are the best. All most of had to do for that is ask his Urologist to arrange it.

Nothing irritates me more than the "you can do radiation after surgery, but not surgery after radiation" line. Usually spoken by a Urologist (a surgeon), it is nothing more than a sales pitch. It is just true enough to count as 'truth'. If a man has radiation as primary treatment, then surgical removal of the prostate is a really, really rough surgery. That being said, it also assumes that primary radiation will fail, AND it suggest that you only get one shot at the apple if radiation is chosen as primary treatment. Both very much not true.

We recommend getting surgical information from surgeons, and radiation information from radiation oncologists. It really IS that simple.

I'm a surgery patient, 6+ years out. I went into the OR as G6 in one small area, and came out G7 with multiple focal points in all 4 quadrants of the gland. Which shows only that needle biopsy is truly a shot in the dark.

With his pathology, I agree, treatment is in his future. Now is your time to take the time--fortunately, PC tends to be slow growing, so a few weeks or even longer will not likely have a significant effect on his situation.

For the record, also, my PC was organ contained, my PSA went non-detectable 3 months post surgery, and has stayed there for 6 years. I have no issues with ED, and only minor, occasional issues with continence.

Best of luck to you in this research phase--it is likely the most important part of the process. We see in here, over and over, that the most significant common thread of men who have serious regrets about their treatment choice is that they took the first opinion of what to do and ran with it in a few days or weeks--this is regardless of the actual outcome of their treatment. Those who did the research and made an informed choice are much more satisfied that they did the right thing--even among those who had a poor outcome.

Halbert, thanks for your well wishes! In our case the comment about surgery after radiation was Paul’s PCP who has nothing to gain but probably not a great deal of experience in the subject. We credit her with keeping on top of his rising PSA and referring him to the best urologist in our area. That urologist urged us to do research and get second opinions, setting an appointment three weeks later. I have no quibbles with either of them but agree that we need to consult specialists outside our isolated rural community. And that’s what Paul’s PCP recommended we do too. As for research, in less than a week I’ve become a PubMed expert!

Vee, i don't have much to add to the great advice already given. Just want to welcome you, and commend you on your apparent solid knowledge base you have already compiled . Decisions on primary treatment are one of the most important, if not the most, important part of the process.

One comment, 11 OF 12 cores positive, and 2 of those cores being 95% cancerous, i would suspect that a second opinion might get you an upgrade to a higher gleason score/grade. The question is, what would you do with that information. With you not considering Active Surviellance anyway, would it change the treatment choice? Just something to think about.

I dont recall seeing mention of an MRI in your posts, unless i missed it. An MRI might tell a lot about whether the cancer has escaped the capsule, and that might help to inform your decision as to surgery vs radiation.

I'm no expert, just some things to think about

Thank you, Pratoman.

I think you’re right about the potential for regrading. That’s been my suspicion as I started researching various aspects of the pathology report. I found a great journal article titled “Findings in 12-Core Transrectal Ultrasound-Guided Prostate Needle Biopsy That Predict More Advanced Cancer at Prostatectomy” (American Journal of Clinical Pathology 2012, 137:739-746) that led me to that line of thinking. Not what I wanted to hear, of course, but knowledge is power, right?

I kind of expect that once we get hooked up at UCSF they’ll suggest a multiparametric MRI. That’s not something we can get locally, though.

Vee - watch out for the effects of information overload as you get rolling with his journey. His and your mind will take some time to process all this information and keep it balanced. Researching papers is standard for many here and if look hard enough, you can find a study that comes to a different conclusion than the last one you read. You feel good then you feel bad based on the last paper you read and search for another.

Prostate cancer grows slowly yet many patients want to move at warp speed to get it fixed which tends to result in rushed decisions. That being said, your are doing very well assimilating information at a rapid pace. Your husband needs to do something in due time and the decision will become more obvious as you get a few more consults, tests, scans behind you. Good luck and pace the effort.

Thanks for that input, Mumbo. Paul is definitely not overdoing it on the information front. Perhaps I’m compensating for his being in shut-down mode, but doing research is a coping mechanism for me. That said, I’m ready to take a day off. Wednesday is a consult with a local RAD/ONC and we may have an e-consult with a urologic oncologist at UCSF, and a tumor board review at the National Cancer Institute should happen Tuesday.

"my husband’s PCP warned against radiation before surgery, saying that radiation can cause complications with surgery, but you may know more, having lived with prostate cancer."

ahh yes. the surgeon plying his craft. to be fair when i was where you are at we were pro surgery. luckily my uro was against surgery

Thanks, garyi. I appreciate you for sharing your experience and have no doubt that you’re right about the biases of surgeons, and informed consent is often a joke. Do you know if hydrogel spacers were used with your RT?