New diagnosis, in the “grey area” of the 7s

I’m 75, with PSA 6.4 (routine, no Sx) in January. PSA in Jan 2023 was 3.9, with free PSA 43%, considered okay. DREs always negative, including recently (Oct). mpMRI in April showed two areas, in bilateral posterior peripheral zone, PI-RADS 4, no evidence of extraprostatic extension, pelvic metastasis, lymphadenopathy, seminal vesicle, etc. Biopsy was planned for May 2024 but had to be delayed. I haven’t had a PSMA PET scan or genetic biomarker testing (Decipher, etc.). Family Hx of PCa is unknown.

In Sept I had a “random” TRUS/MRI Fusion biopsy. Finding was Gleason 3+4, GG2, Stage 2B, TNM cT1c, N0, M0. 5 of 14 cores (36%) were positive. The slides were re-read by Johns Hopkins, who added perineural invasion in one slide (out of 42) and intraductal carcinoma and “areas of large cribriform morphology” in one core sample. I’m aware that those additional histological elements increase the risk, but how much I’m not sure. Apparently the “wild card” here is the Gleason 4s and the large cribriform morphology.

My urologist recommended radiation and referred me to a RO (same medical system) for a CyberKnife eval. The RO recommended CyberKnife. That seems to be the treatment they’re looking at, at my age and “good health”.

At 75 longevity is part of the decision, It does seem that heart problems, other medical issues, and a remote smoking history can have a big impact on life expectancy, in addition to PCa. Treatment is going to happen, but what kind?

These are good people who are doing what they do. Problem is, we live in a state with university settings but no cancer centers of excellence. I’ve read a good bit, been on this forum and the UK one, seen many of the PCRI videos (Dr. Mark Scholz) and others, and I know I’m in that very gray and indistinct zone of “intermediate risk”. Now that I know more, I’d like to be looked at by the best available. I did have a good interaction with the pathologist at Johns Hopkins (which is farther away, but the travel would probably be worth it). Cleveland Clinic and Duke are closer, but they’re lower on the recommendation list.

I do have concerns about quality of life and especially minimizing urinary and sexual side effects. Radiation and focal therapies seem to be the main options, and I’d like to discuss these with somebody really experienced. So, I guess I’m asking where you all might go for the next step?

Where are you located (where are you travelling from)?

SBRT is definitely within the standard of care for cases like yours. Did they recommend a course of ADT concurrent with the radiation? Or doing so-called triple play (SBRT + ADT + short chemo)? The triple play is a bit of a throw the kitchen sink at it, but with your cribiform pattern it might be useful to consider.

Most of the major cancer centers are used to people travelling in for treatment. Many can help you arrange a stay at an attached hotel or Airbnb type arrangement.

Note: CyberKnife is a type of SBRT (stereotactic body radiation therapy) with specialized equipment. It is being performed at many locations with modern RT equipment now.

RT - I think the Cleveland Clinic is a good location to get treatment opinions for your specific situation. There are many others as well.

https://www.cancer.gov/research/infrastructure/cancer-centers/find

Jim, and RTomasi, welcome to the forum.

RT, not much to add, seems like you have done a good job of researching your situation. As Halbert mentioned, SBRT/Cyberknife would be a good choice based on your Gleason score. I am not sure how the cribriform feature on your pathology would affect that decision though, might be worth asking.

RTomasi said...
Mumbo, part of my question is going to be, if we’re going to do CyberKnife, would I just do it here, or use those who are the best at it, even in they’re several trips away? (What I’ve heard/read is to find the very best you can get at whatever treatment you ultimately choose, and go to them.)

I think physical treatments like surgery and brachytherapy require significant skill and experience. The beam radiation treatments require a different type of team skill set which is based largely on the RO, technicians, and equipment involved. The RO actually only makes the plan and others check the plan and carryout the treatments. It is also important to have doctor's you like and trust at locations that makes sense. SBRT is pretty quick as as noted above so only a couple of weeks out of your life.

Cleveland Clinic and UCLA have a good SRBT program with respected doctors that I have read about. I am sure there are others but those come to mind. I am sure Mayo and MD Anderson can do a good job as well. There is nothing to say that the doctors you are seeing would not do a good job also. Tough decisions.