Second Opinions in Prostate Cancer

I understand that you’re nervous. I’ve been in your shoes and felt the same way. If you have ANY questions regarding what to expect or how to prepare before surgery or during recovery (non-medical in nature of course) don’t hesitate to email me privately and I’ll do my best to help you. I received a lot of very useful advice from others that went through RP and it helped a lot in my recovery. You’re going to do great and taking a huge step towards being cancer free is a great birthday present. STAY POSITIVE! 👍

@rick137, there have quite a few great replies to the discussion you started here. Are you getting the information you were looking for? What question remain?

opinions good to have Find actual cases

@colleenyoung

Colleen:

Many thanks for your inquiry. At the time I initiated the thread I did not have any personal need for second opinions. I almost certainly will seek a second opinion on my course of treatment since the initial phase of Lupron plus proton is now excluded.

KR, Rick

One man's Pilgrim's Progress with PCa:
2023-08-21: Classical urological symptoms from enlarged prostate
2023-08-11: OHSU (Oregon Health Sciences University)
-DRE showed enlarged prostate; PSA=17.5ng/ml
2023-09-25: OHSU
-PSA=18.5ng/ml
2023-10-23: OHSU MRI (As later interpreted at Mayo Clinic PHX)
-Prostate Volume = 77cc, PSA density=0.21
-Lesion 1: 6.04cc; PI-RADS=5
-Lesion 2: 1.79cc; PI-RADS=5
-Lesion 3: 0.60cc; PI-RADS=3
-Left seminal vesicle invaded
2024-03-28: Sonora Quest Laboratories
-PSA=37.30
2024-04-01: Mayo Clinic PHX Fusion Guided Transperinal 12 Core Biopsy
-ROl#1: Prostatic adenocarcinoma; Gleason score 9 (4+5), grade group 5, 2mm (13% of core, < 5% of the
total tissue)
-ROl#2: Prostatic adenocarcinoma; Gleason score 6 (3+3), grade group 1, 5mm (30% of core, 10% of the
total tissue)
-ROl#3: Prostatic adenocarcinoma; Gleason score 9 (4+5), grade group 5, 3 foci (aggregate length 27mm)
involving 3 cores (81% of the most core, 77% of the total tissue)
2024-04-18: Mayo Clinic PHX PSMA Ga68 5.31millicurie PRT/CT Scan
-Numerous tracer-avid nodal disease at the following locations:
-Right common illac/presacral region
-Clustered left external iliac nodal disease
-Right external iliac region
-Right pelvic sidewall region
-Right perivesical region anterolaterally
2024-04-25: Mayo Clinic PHX
-Initiated Lupron therapy: 45mg for 6 months
-Testosterone: Free=10.2ng/dL; Total=517ng/dL
2024-05-09: Mayo Clinic PHX
-Informed by RO my stage is cT3bN1M0
2024-05-13/14: Mayo Clinic PHX
-Preparation for Proton Therapy: Insertion of fiducial markers in prostate; CT/Simulation; high resolution
MRI of pelvic region
2024-05-15: Mayo Clinic PHX
-Informed by RO that I am not a candidate for Proton Therapy until certain tumors can be reduced;
because of abnormal bowel geometry, Proton Therapy would be “challenging”
2024-05-17: Quest Diagnostics
-Ordered by MO May Clinic PHX; PSA=24.96ng/mL
2024-05-28: Mayo Clinic PHX
-Consultation with MO

Chose treatment path to maximum tumor volume reduction? Or for maximum systemic therapy given the two options are not complementary. That is the question. To say I am looking forward to consultation with MO is an understatement.

Rick

robertmizek: My RO said if I have a biological re-occurrence then radiation would be done again. Your words seem to contradict that. Where did you read that " If you choose radiation for primary therapy... and often additional radiation to the prostate and the prostate bed is off the table as well leaving only ADT and chemotherapy as salvage treatment options."

Great question and like most things with PCa, the answer is complicated.

As I understand it, if RT was used in primary therapy, further RT may be a viable option to radiate areas that were not previously treated with radiation. Let’s take a scenario where Brachytherapy used as primary treatment. Let’s say that prostate cancer returns outside of the prostate in the lymph node basin. The lymph node basin might be able to be radiated potentially as a cure or disease management. Let’s take that idea a step further and say that there also is distant metastasis, perhaps in bones. RT might be an option there as well. In that scenario, without a doubt, your RO would be correct.

Let’s take another scenario where brachytherapy is used as the primary treatment. The radiation field includes the prostate bed. The cancer returns within the prostate and also local lymph. That was my situation. Salvage radiation was considered for the prostate along with two years of first and second generation ADT. In my case, the location of the lesions were adjacent the urethra such that a portion of the urethra would be within the radiation field for any hope of a cure and the risk of a resulting stricture from re-radiation was unacceptably high. Additionally, it was determined that the risk of permanent urinary and fecal incontinance was unacceptably high if the prostate bed was re-radiated. These risks were not discussed with me when I got my first opinion but they were discussed when I got my second opinion. I had salvage RP and will get salvage RT to the lymph node basin soon and have started two years of first and second generation ADT.

In my mind, the question is whether your RO was talking about additional radiation to areas that were not previously treated under primary therapy, or if he/she was talking about re-radiation of tissue previously treated in primary therapy which, depending on circumstances may or may not result in one or more morbidities.

Re-radiation is not the standard of care, as I understand it. You may find the following published medical paper interesting: https://ascopubs.org/doi/10.1200/JCO.23.01391

Best wishes for success on your journey with PCa.

I am 3.6 years into my advanced prostate cancer journey. 4 years ago I didn't know what an oncologist was. It was the first year of my retirement, signs, symptoms, primary care visits, urologist visit, middle of the night ER visit which tuned into an overnight stay. 2am, after a bunch of test and a scan the ER PA diagnosis me with Advanced Prostate Cancer. Within in hours I was introduced to my urologist. Googled "Urologist." After educating myself on advanced prostate cancer I determine the best path to follow was find a Research/Teaching Cancer Institute and give it a go. Mayo was it, but it was too far away. I found one. OHSU (Oregon Health and Science University Knight Cancer Institute). My oncologist encourages me to take an active role in me cancer treatment education, recommending cancer symposiums, consultation with other oncologist, which I have. I epically happy with my cancer care.

2010 PSA 6.4 Gleason 3+3 Diagnosis: Slow localized PC. Underwent 10 weeks of proton radiation therapy at Loma Linda Hospital. Zero or .1 PSA until 2015 when yearly PSA tests begin to show slight increase. Each year the level has increased gradually. Last two year moreso: May 2023: 3.47; May 2024; 4.53.

I have TricCare (retired US Army); I use the VA now at The Villages in Florida. I have requested an MRI scan to validate the return or no of PC.

ANYONE ELSE HAVE THE SAME METRICS..POST RADIATION YEARS WITH INCREASED PSA. Please comment.