Biopsy results

Michael,thank you for that information how do they remove the HDR seeds
is it taken out like a biopsy core.
Is it true that any urinary problems before Brachy are worse after treatment.

Allen, the Eurologist actually said I wasn't a Brachy candidate because of age (59) and that ''surgery'' (not radiation)
could not be done afterwards, if needed ..it's hard to retain everything.
SBRT looks interesting ,,is there more risk with external beam than seeds.
I am not particullary gone on open surgery. I'm not sure if it would aggravate problems from a previous inguinal hernia operation.

I'm still trying to figure out what pushes G7 3+4 into treatment rather than AS
Is it 5 positive cores, PNI, HGPIN, tumor size (15mm) or the combination.

I think Urologists should be forced to use MRI for targeting biopsies otherwise you could miss it in the early stages.
Prof Barentsz (Pi-Rads Classification) is pioneering the role of MRI.

Logoslidat, perhaps he had got indigestion ..but I didn't bring it up.

Halbert, that certainly breaks down the options.

James

James,
I just replied by email, but I'll state it here too.

Stage
The doctor who read your MRI and deemed it Stege 3. He equivocated that the image quality was sub-standard, however. However, that, along with your PNI, increases your risk. It especially makes surgery a more risky venture. Surgery would probably have to be followed by radiation, which compounds the side effects of both.

Treatments

(1) I don't think you'll be able to find HDR brachytherapy where you are, but you can google it to see.

(2) The standard of care with Stage 3a would be IMRT with a brachytherapy (seeds) boost. That would certainly get all the cancer that has leaked locally around the nerves (the PNI) and would also treat the bulge (Stage 3a). However, considering that you are only GS 3+4, identified on an MRI-targeted biopsy, that may be overkill - but still a highly curative option.

(3) SBRT (CyberKnife) is available in where you are. That would treat the prostate plus and area outside of it. It's done in 5 treatments. There's no more risk than with seeds. Potency preservation is particularly good. There's a link in my signature if you want to read about it.

Post Edited (Tall Allen) : 2/26/2015 3:28:49 PM (GMT-7)

Yes, they are entirely different things. Pi-Rads is a scale for identifying suspicious areas on an mpMRI.

But if your radiologist told you you are stage 3, then you are stage 3. The biopsy is not used for staging. Biopsies seldom identify EPE, only DREs or imaging can do that.

Hi Logoslidat,
Thank you for that, I was starting to think the 3+4 question nobody wanted to touch that subject.
I guess I was thinking that if you tick X no of boxes eg have X no. of cores positive & PNI etc. then that changes the rules on AS
but I guess it's not that simple?
I remember reading 50% in any one core would be the threshold for active surveillance?
I don't particullary want it out (I like holding on to stuff) and as I mentioned earlier I wonder would open surgery aggravate problems from a previous Inguinal Hernia Op.
I like the idea of the SBRT but it seems to cause bowel irritation problems as I already have some hemorrhoid &
diverticulitis issues but I presume these are short term problems.

James

River Road said...

Is it true that any urinary problems before Brachy are worse after treatment. James

According to the 2 RO's I spoke with, the answer is yes.

(Actually, they probably said "It can", or, "Possibly". That's my experience with the way these guys talk).

Post Edited (island time) : 3/1/2015 6:52:13 AM (GMT-7)

Island Time , thanks for your reply.
Urinary problems then might be a reason not to do Brachy as
I have pain urinating and more so if it's an hour or two between intervals.
I notice when taking decongestant tablets (for a cold) makes it worse.

James

Actually, I've consulted 3 RO's (one said it would "be fine"). I've also consulted 3 surgeons.

I'm gonna have to do something. But, you'll have to rely on the group for support. Me? I'm ******* depressed about the whole **** thing.

You're too young for AS and your cancer doesn't lend itself to it. You want to live another 30 years cured. Right now...that option is open to you.

There are many opinions about AS, and almost every AS program has different qualifications. In some programs, like Sunnybrook or UCLA, GS 3+4 is not in itself a disqualifier, but if you have a lot of it, it may be less attractive. Age and # positive cores are not disqualifiers in those programs either. (My personal belief is that AS makes a lot of sense for younger men who can get more quality-of-life years from it.) A lot depends on the monitoring tools you have available to you. If you can have mpMRI-targeted repeat biopsies (preferably with ultrasound fusion), AS is a lot safer than if you don't have that.

On the other end of the AS strictness criteria is the program at Johns Hopkins. They use what is called the "Epstein criteria." That means: GS6 only, PSA<10, Stage T1c or T2a, no more than 2 positive cores, no more than 50% cancer in positive cores, and PSA density ≤.15. I don't think that even they put a life expectancy qualification on it.

Really, there are no standard AS criteria. You have to use your judgment about what makes you comfortable, and you have to have a program that will accept you.

- Allen

James said...
Is existing urinary problems affected by Brachy?

I assume you're asking about LDR brachy - the side effect profile may be different with HDR. It depends what kind of urinary problems. If you're having a problem with urinary retention, that will likely be exacerbated by seeds. Most seed doctors also set size limits on the prostate. There is a danger of urethral strictures from the seed-induced swelling, so if it's already being closed off, there are safety concerns.

- Allen

Size of the tumor is irrelevant for LDR vs HDR.
Saw Palmetto is useless.
Your prostate is enlarged, and may be part of your problem - you should investigate the source of the pain with your urologist. Perhaps Proscar or Avodart will help.

- Allen

That's "Avodart"

SBRT is not more toxic - see link in my signature.

They are both good.
• BT has a steeper learning curve, and it may be difficult for you to find a BT expert nearby. Don't have it done by anyone who is not an expert - it matters a great deal. In the hands of an expert, they are equally good.
• You can have SBRT irrespective of prostate size, and you never need adjuvant IMRT with it, of course.
• Erectile function preservation is superb (which is why I chose it).
• Urinary & rectal toxicity is mild (no Grade 3) and transient. Acute urinary retention is less of an issue - about 3% (of any grade) with SBRT vs about 40% (of any grade) with LDR brachy.
• It requires 5 treatments.

Go talk to an expert about it. Do the same with brachy.

Allen,
Thanks again, how do you retain all that information?
I looked at your link for SBRT ..those results look great.
I notice my Signature stats are not far off yours.
I recall the IPSS symptom score (mine is around 20) being mentioned as a possible issue re Brachy how relevant is that or does taking Proscar or Avodart (as you mentioned) normally solve that problem.

James

If Proscar and Avodart relieve urinary symptoms then why is
existing urinary problems such a red flag against Brachy treatment
I presume the symptoms must return after Brachy treatment?

On the other side I presume there are situations where Brachy is recommended over RP
is ECE for instance a reason not to do RP.

James