Biopsy follow up meeting questions?

Sorry, I accidentally posted here answer intended for another thread so I had to erase it .

Sorry to welcome you to this crappy club, but you are among friends! You are only three years older than me and today I'm 3 months out from having my prostate removed, which is quite often the recommendation at our age given that we might see problems from radiation in our natural lives.

I was only 3+4, but at 4+3 you are slightly more advanced than I was. My decipher was 0.68. I was able to get it removed with no side effects often reported (ED/incontinence).

Some food for thought:

• Inquire about a Decipher test, it will indicate if your cancer might be worse than anticipated and allows you better discussions about treatment.

• Make sure you start booking other consultations now, before you feel rushed to do so. Urology, medical oncology and radiation oncology are good specialties to book with. I did 9 in total, 3 from each category.

• Book time with a pelvic floor therapist NOW to get your pelvic muscles strengthened to aid in recovery and help prevent ED/incontinence if you are able. You should start doing proper kegels now. A pelvic floor therapist can help you master this now so that not only are you prepared but if you need them after surgery then you are ready to hit the road running rather than trying to figure it out after you discover a problem.

• Book time with a personal trainer to hammer your abs, it will aid in recovery but can also have impacts on ED/incontinence. Plus it's just better to be in as good of shape as possible before any treatment. You should do this now as well.

• Talk to a penile therapist, usually a urologist, about steps you can take now. They will likely want you on 5mg of Cialis a month beforehand just to keep the nerves active and firing. Mine also put me on L Citrulline, which is a natural supplement that can help stimulate the nerve bundles that powers your erections.

• Read posts on here. Some are really long personal blog posts that focus on entertaining your learning, but in other posts there's a lot of really deep dives into actual technical stuff that you'll find helpful.

These are some things that are items you can take of now. You will be overwhelmed with information, tasks, doctors appointments and just a flurry of life between now and treatment.

Ask if there’s going to be a PSMA PET scan to make sure it is not in anywhere else in your body.

Find out if there was anything else in your biopsy intraductal, cribriform, seminal vesicle invasion, or any other unusual result.

It would be interesting to know what percentages of the cores was 4+3.

it’s always nice to have your full biopsy report saved for future reference.

You of course, want to discuss what they feel your best treatment would be. Are you going to speak to a radiation oncologist as well as a surgeon? Are there other options besides that? There are other treatments that might make sense, Cyberknife SBRT , HIFU , NanoKnife , Cryotherapy and TULSA-PRO. Ask the doctor? Get second opinions if you want to be proactive.

If they’ve already made a decision on radiation, what would it be specifically? How many treatments of what type of radiation?

If they want to do surgery, are they able to spare the nerves?

Let us know what happens.

You have several treatment options which you will want to consider - surgery or radiation. As you go through the consultations in the next few weeks it may become clear which is best in your case.

I have noticed that there seems to be a trend to start men on some form of ADT drugs right away after a positive biopsy result - I assume this is to arrest the progression of cancer during the time of decision making and getting scheduled for whatever treatment you decide on. So to answer your question re: what questions to ask your doctor: I would ask whether they use ADT as a treatment starting pretty much immediately?

All the best to you as you move forward in this process. This is a great forum for getting really good information from men who have already started into this process of dealing with prostate cancer.

Thanks for the reply. Here are the actual results from the biopsy. The first two are the cores that were positive from the pattern coring, the last one is the three cores from the lesion shown on the MRI. Meeting with Urologist to start this week.

Gleason score 4 + 3 = 7
Percentage of pattern 4: 80-90%
Grade Group: 3
Tumor involves 80-85% of overall specimen (1 of 1 core).

Gleason score 4 + 3 = 7
Percentage of pattern 4: 80%
Grade Group: 3
Tumor involves 40-50% of overall specimen (1 of 1 core).

Gleason score 4 + 3 = 7
Percentage of pattern 4: 90%
Grade Group: 3
Tumor involves 30% of overall specimen (3 of 3 cores).
Most affected core is involved by tumor over % of its
length.
Perineural invasion: Present
Cribriform glands: Present

I am meeting my doctor on May 1st for biopsy follow-up. Entire left side 3+3 with couple of 3+4. I am 56. No symptoms, nothing. PSA increased from 1.4 to 3.3 in the last couple of years, so primary said see an urologist. MRI indicated one leison on the left side. But did not identify any other spot. But biopsy results were positive outside the leison also! You get a lot of good advise in this group.
These are the questions I am going to ask:
1. With two cores 3+4 with less than 5% 4, what are my options. My research says AS or Radical Prostatectomy. But others here have advised not to rule out Radiation.
2. Sample D was outside the leison. How come the MRI did not pick that up?
3. Do the results mean the entire left side has cancer?
4. Chance of Metasis due to Perineural Invasion?
5. How can the biopsy say Extraprostatic Extension: not identified?
6. Can I get a PSMA PET Scan?
7. Can we do genetic testing?
8. Is Focal Therapy an option?
9. What is the cancer stage?
10. Is Tulsa-Pro a good option?

Questions to the doctor:
1. Since when are you practicing?
2. How many RP have you performed?
3. What are the common complications you have seen in your patients.
4. Anything else I can think of between now and Thursday morning.

After May 1st, I am going to see a Radiation Oncologist and an Uro-Surgeon at Sloan-Kettering for second/third opinion. By the third week of May I should have a good idea. Good luck with your treatment.

Last thing in the list is one of the big issues “ Cribriform glands: Present” means that your cancer is more aggressive than 4+3. Regular SBRT radiation cannot completely remove Cribriform, you need more radiation or surgery.

Perineural invasion can be removed by radiation or surgery so it’s not an issue.

There was a high percentage of 4 in the cores. Tumor involvement was over 50%.

It would be useful to know the size of the cribriform, If it’s over .25 mm then it is more serious

Hey 54, @jeffmarc has given you excellent info and perspective. Your age is also a consideration.
If you are relatively young, surgery is a good option since cribriform pattern is a more serious issue and this type of cancer ‘could’ recur in the future; you could then have radiation.
If you are older - say 75 and up, you have to discuss life expectancy with your doctors. General health - good/not so good- is also a factor.
High Dose Brachytherapy + SBRT/IMRT is a good alternative if you are not a candidate for surgery (advanced age, poor health). The seeds give a big initial killing boost to the cribriform area and the follow up radiation treats the gland/margins. Standard radiation protocols alone may not eradicate the cribriform cells. Best,
Phil

Interesting timing. We’re going through this right now with my oldest brother. He had his biopsy on 15 April (Gleason 4+3=7) and is having his follow-up consultation tomorrow. (I was diagnosed with PCa in 2012, went on active surveillance; later was treated in 2021 with proton radiation + ADT for a localized 4+3=7.)

My first advice to my brother was not to start discussing treatments just yet. Learn about them, but get more informed about the status of the cancer (aggressiveness/seriousness) first:

Of the 9 different Gleason scores, yours is 3rd lowest (intermediate unfavorable); so, don’t panic. You’ll be fine.

Try to keep your emotions in check, otherwise that may muddle your thinking.

What % were 4 and what % were 3? (Your 80%-90% are high.)

From the PSA test, what was the % Free PSA, PSA Doubling Time, and PSA Density?

From the MRI report, was there extracapsular extension or seminal vesicle invasion?

From the biopsy report, was there cribriform pattern, perineural invasion or intraductal carcinoma? (You should ask more questions about your cribriform pattern and perineural invasion. Cribriform pattern is often associated with more advanced disease.)

Ask them for a biomarker (genomic) test.

Ask them for a genetic (germline) test.

Ask them for a PSMA PET scan. (You probably do not want to start ADT right away after a positive biopsy; the lower the PSA, the less sensitive PSMA PET scans are at detecting PCa. After the PSMA PET scan, if there will be a delay in treatment, then maybe ADT……..)

Ask for a 2nd opinion of the biopsy tissues (and the MRI scan if desired).

Ask for another consultation once you get in more definitive information.

Begin getting quarterly PSA tests.

Take notes; ask questions; take more notes. Repeat…..

My brother is 78y now; he had his very first PSA test just last year, so he’s way behind on the count. I started getting PSA tests at 45y; so, I didn’t “get hit out of the blue” when I was diagnosed at 56y. At 57y, you’re also a bit late in testing but, there’s no better time than the present.

Again, no need to start discussing treatments yet; there will be time for that. Take it one step at a time.

Once you do start leaning towards a certain treatment, then start into those pre-treatment activities. (And it won’t be them making a decision on which treatment; it will be you making the decision based on their advice and recommendations and your informed decision about treatments and the quality-of-life you desire.

Once my brother starts leaning towards treatment, I have treatment-specific questions for him.

Depending on his full diagnosis, at 78y and with other comorbities, doing nothing may be an option as well.

I hope some of that commentary for which we’re going through with my brother will be of use to you. Good luck!

Thanks for all of the replies and great advice. I have been tolling this board for a while with my fingers crossed that I would not need to join your club. My PSA scores had been slowly rising over the last year and I am grateful my GP decided that I needed to go to Urology after my SPA hit 3.8 last fall. It was 4.8 in February and 4.2 last week at Mayo. I know its just the very beginning of what I hope is a long journey, but all we can do is keep our head up and march on.