Is surgery my only reasonable option?

I have been five years reading posts in this forum as a candidate but now I guess I am a full member. Good stuff for those like us unfortunately forced to be interested in this topic.
My PSA started to climb this year from a baseline around 5 to 7.6 this year. I have a positive mpMRI and later a positive cognitive-systematic biopsy. Cores were only marked by side, but it is clear that one of the positive cores did not come from the suspicious area. In my non-expect opinion I could qualify as a low risk patient but my urologist told me that stage is cT2b (?) due to the contralateral positive core that he describes as a bilateral tumor extension. I understand that this clinical stage is not correct (not cT2c either) since only visible or palpable lesions qualify for T2 and therefore stage would be T2a. He also told me that true G6 is intermediate risk and it spreads often (?).
He does not like the AS approach anyway. He tried to convince me about HIFU but he later realized I do not qualify due to my enlarged prostate. Apart from these remarks, he has been very professional and helpful during five years of counseling.
I understand that my pirads5 lesion and fast increase of PSA are of some concern and I trust in the clinical feeling of my urologist. Moreover, my urinary symptoms due to enlarged prostate are also pushing me to surgery. But I would not mind (and was somewhat hopeful) to stay in AS for sometime if I had some certainty that there is not great risk involved. Any opinion will be greatly appreciated. I guess AS is a common option now in many countries for clinical G6 grade.
Juan (Madrid, Spain).
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Age 67.
PSA: 2008, 2.8. 2010-2011, 3.7. 2012-2016: PSA 4.5-5.0 with a couple of peaks (9 in 2013, 6 months after biopsy 2013 and 7 in 2016 after a kidney stone episode). Free: initial (2012) 17% and 2013-2016 around 25%.
2017: February 5.5 (free 25%), May: 6.1(free 25%); July: 7.6 (free20%).
Prostate size from TRUS: 46 c.c. (2013)- 71c.c (2017).
Two 8-core biopsies in 2013. First ASAP in one core. Second, negative.
mpMRI in 2013. No findings.
mpMRI July, 2017: left side posterior medial-apical pirads5 lesion, 2.0x1.3 cm. Some contacts with surface but no deformations. No other findings.
8-core cognitive-systematic Bx in August 2017, 2 cores in the suspicious area (also visible in TRUS, 1.5 cm diameter): 2 pos. cores, G3+3, 1 left (5%), 1 right (3%). Maximum tumor length 3.5 mm, left.

Post Edited (jmadrid) : 9/23/2017 10:56:14 AM (GMT-6)

Hi jmadrid

Just to correct some misinformation from your urologist:
• Your clinical stage is T2a, not T2c. Biopsy results are never used to determine clinical stage
• You are definitely in the NCCN low risk category
• PIRADS 5 is not a risk factor. It only shows areas that may be suspicious for cancer. Only the biopsy shows cancer, not the MRI.
• If your prostate size is interfering with urination, consider taking finasteride or dutasteride to shrink it.
• Many active surveillance programs recommend treatment only when a biopsy detects at least Gleason 4+3

jmadrid,

The bilateral findings would move you from very low risk to low risk, at least under the strict criteria used at Johns Hopkins. But, that is the most conservative opinion.

You have very little cancer, and are certainly not an intermediate risk, in spite of what your doctor told you.

I would think that you could be on active surveillance, but I would also recommend some additional testing. Can you get a genomics test, like OncotypeDX or Prolaris done on your biopsy slides? Either would provide you additional data on how aggressive the cancer could become.

Thank you for your fast and knowledged answers. Not sure of the procedure to have the genomic analysis of my cores, I do not even know if they would give me the slides to revise. Doctors here recommend the place because they have many years of experience in prostate TRUS biopsies but In my opinion they are too old fashioned and cryptical in their reports. I think they did not mark the cognitive cores for the pathologist, at least they insisted that they have taken two of them. Also, my urologist never mention any treatment fot BPH except surgery, he does laser surgery for BPH and HIFU but not RP, this is the reason I have some confidence that his advice on surgery is not for his own interest.

Post Edited (jmadrid) : 9/23/2017 11:01:10 AM (GMT-6)

Jmadrid,

Welcome to the forum.

You asked whether surgery was your only option. The consensus here seems to be no, it's not. I tend to agree. Surgery is an option but available to your but it is neither your only option nor, necessarily, your best option. With Gleason 6 disease you almost certainly have enough time to think things through before you commit to any of the options available.

Have you taken any of the drugs that help with an enlarged prostate? Finasteride and dutasteride work well for BPH. They don't just treat the symptoms, they address the root cause by shrinking the prostate. If you haven't tried either of those drugs you might ask your urologist about them.

Aside from that, I have no particular advice. It is true that urinary problems caused by an enlarged prostate do sometimes support a decision to seek surgery but only when those problems are rather severe and difficult to treat. Prostate surgery has its own set of problematic side effects which can be as bad as, if not worse than, as the problems caused by an enlarged prostate.

you can have RP or not.....doesn't matter.....it's not going to change the cause of your death.....which will be something other than PCa.

You're just not in the "Cause of Death: Prostate Cancer." population...one man's opinion. (I'm a fortune teller...not a doctor )

sorry for the urinary issues. I can see the issue.

(as to your thread's question.....I'd say you have more options )

good luck and take care

jmadrid-

It may surprise you to hear that it doesn't matter,as far as probability statistics are concerned, whether or not you have a true Gleason 6. The statistics are based on biopsy-detected Gleason scores, not what was found to be true post prostatectomy. So the safety of active surveillance was established based solely on a clinical low risk definition: clinical stage (cT1c or T2a), clinical Gleason score=6, and PSA<10. Fortune tellers don't matter, but biopsies do.

There is one kind of brachytherapy - low dose rate brachytherapy (LDR-BT) or "seeds"- that requires that the prostate be smaller. But you said that your doctor practices high dose rate brachytherapy (HDR-BT), which has no such requirement. While it is reasonable to take finasteride or dutasteride to reduce the size somewhat and possibly prevent some urinary side effects of treatment, I think ADT for a low risk man is a very drastic therapy. There is no evidence that either is really necessary with HDR-BT, and ADT is "overkill" imho.

There is no mystery in how reducing the size of the prostate with hormone therapy reduces urinary side effects. BPH often causes enlargement in the transition zone of the prostate that can block off urine flow. There is some radiation-induced swelling that occurs immediately after treatment that can temporarily increase the blockage. As the inflammation goes away, and the radiation shrinks the prostate tissue, the blockage will decrease. Hormone therapy (either finasteride or ADT) reduces the size of prostate tissue, thereby reducing the blockage. It will reduce anyway with time after radiation, with or without the hormone therapy, but the hormone therapy will reduce it faster.

Thanks a lot for your encouraging remmarks. I did not know finasteride is a hormone suppresor, maybe he meant that, not ADT, whatever is the difference.

Hello, you may want to consider a new uro, I did that and the difference was amazing! Denis

I would take issue with the uro's assertion that surgery will be ". . . surely a cure." If you read the research, surgery and radiation as primary treatment both have (for all practical purposes) the same cure rate, but it is not 100% in either case. Hopefully this is just his own hyperbole, but if he actually wants you to believe that, I advise you to read more on this site.

Your G6 PCa can be effectively treated by any of the mainstream primary treatments. You should be able to pick among those readily available with equal assurance of success.

Michael_T,
I just have published a post in my other thread about both SBRT and HDBT with some new details. After new explanations from the radiotherapist both treatments make sense to me. HDBT is in two fractions, one day, and his statistics for 7 years are excellent. Their protocol for SBRT includes a catheter for five days (I do not know why) but this maybe is not a big issue. My apprehension is mainly psicological since practically everybody I know (I mean in person, in this country) has followed the surgery path.

Jmadrid we are traveling a similar path. One thing I try to do is write down my questions in a log, with all my lab's soI have a single place for everything and a better chance of remembering to ask the questions. We both have time, that is the good news.

The debate/decision of surgery versus radiation is almost difficult one, unfortunately. Finding an objective neutral party seems to be the issue. I do think the DRE caution is an important finding.

I read something to the effect that the key to decision making is one research and learn all you can and then find a doctor you trust and have confidence in and then let them guide you.

Keep asking questions. Denis