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63 yo, live in Europe, diagnosed w/ PCA in Aug 26 and hard to decide
Hi all, I´m 63 yo, recently retired, live in Europe and was diagnosed in mid August. My father was diagnosed with prostate cancer at age 57, that is why I checked my PSA annually since 2010. This April it came back with slightly over 4.0 for the first time, so I decided to get an mpMRT which showed a Pirads 4 single lesion in the posterior, right peripheral zone of the prostate. A subsequent fusion biopsy resulted in a Gleason 3+4 (7a) diagnosis (favourable intermediate) with 8 out 12 samples taken from the lesion positive, however with only 5% of gleason 4 in all positive samples. No perineural invasion, -no lymphovasular invasion, tumor extension in samples 7-27%, one sample 50%. Another 12 systemic samples taken from the prostate were all negative.
I have used the past 2 months to look into all treatment options and their respective pro and cons and need to come to a decision. My last PSA value taken this week was 3.95, so it seems to be quite stable...
a. Active Surveillance: my urologists says that I could bacically do it, but I should expect that I will need definitive treatment sooner or later. Because of my family history (father prostate cancer, sister breast cancer), I am unsure whether it may be too risky and I should do it. In my country it is difficult (very expensive, to be paid out of pocket) to get genomic tests such as decipher or germline tests (for e.g. BRCA 1/2). I am anxious not to miss the "window of opportunity" for treatment, e.g. radiotherapy without the need of ADT
b. Focal Therapy: HIFU would be possible, but due to the location of the lesion there is a risk that the right nerve bundle gets thermally affected with ED a consequence. Cost would be borne by my health insurance in full within the framework of a clinical trial.
I will have a consultation re IRE next week. This might allow to spare the right nerve bundle, but as IRE is considered as "experimental" here, it could only be done in a private hospital at cost of around 20-25 K EUR. All Urologists and also Radiooncologists have advised against focal therapy, especially against IRE because of lacking long term outcome data and relatively high recurrence rates. Same as for active surveillance I wonder, if my family history is an argument agains focal therapies.
c. Radical Prostatektomie: due to the potential side effects profile and although it is most urologists´primary recommendation, this is my least preferred option
d. Modern radiotherapy /SBRT with MR Linac (Elekta)
This could be done at a university hospital in 5 sessions. Cost would be fully borne by my insurance. ADT would not be necessary. Side effects are in my view more "tolerable" than those of RALP
So those were my options.
My local urologist would in principle support active surveillance (although there are caveats) , is against focal therapies, accepts my aversion to RALP and would support a decision for SBRT/MR Linac.
Would very much appreciate your thoughts. Thank you!
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As you consider AS option, appears you will need to weigh how the biopsy was performed. 12 targeted samples to the 1 lesion, is alot of samples taken in a small area. 8 positive cores in a small area, may need to be “filtered” in the decision-process.
Based on the 12 non-targeted cores being negative, you can discuss with your medical team: Does it appear cancer is confined to the 1 lesion? If so, with 12 targeted cores, is the 5% Gleason4 a good representation of the lesion? If so, discuss AS for 6-18 months. Discuss best-thinking of when next MRI and Biopsy would be performed, if AS is chosen.
As you evaluate treatment options, can you find a surgeon skilled in Retzius-Sparing RP surgery?
Best Wishes.
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Hug
1 ReactionPersonally I would do 5 sessions of SBRT with a 4 month course of ADT. This would put you in the 85% "cure" rate. No way I would do RP with your stats and as a 3+4. You could skip the ADT but I think it would really add to you being cured if you did ADT 6 weeks before the SBRT and a few months after. If you really wanted to get into the 90-95% cure rate you could do HDR brachytherapy boost, 5 sessions of SBRT & 4-6 months of ADT. This triple therapy is the cutting edge treatment being done at all the COE's with great success. Wishing you the best in what ever treatment you decide.
Certainly your aversion to RP is not uncommon and you appear to have evaluated your RT options as those do. Many also have aversion to RT side effects and prefer RP. You are going through your decision making process, and it is your decision to make as to what you are most comfortable with. I am sure you will get recommendations but caution regarding anyone who unequivocally says don’t do this.
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Hug
3 Reactions@lojewski 1) Risk on AS usually related to how fast PSA increases. Was PSA over 3 for several years before it went over 4? If yes, then AS is reasonable. Primary benefit is no side effects. At your age and disease, it is almost certain to progress to the point that treatment is required. As mentioned in another post it is easy to miss the point where ADT is not required. Probably easier if RP was planned treatment since you would be okay as long as contained in the prostate. Almost all genes such as BRCA are not on Y so risk is 50% if your father's cancer was gene related and those genes double the risk from 1 in 8 to 1 in 4.
2) Focal therapy has the highest probability of leaving sexual function as is. RP eliminates ejaculation even with complete nerve sparing (90%+ of fluid is from prostate) and RT usually cooks the prostate enough to do the same (about 75% chance). If getting a focal therapy, make sure it is done by an expert. Did you get consult for both HIFU (anal) and Tulsa-Pro (urethra) delivery?
3) Radiation side effects have gone down with modern equipment with better aim. The MR Linac is the best such that quite a few centers in USA will not use it for prostate cancer (other cancers have more exacting requirements). It is the way to go if deciding on RT. Your RO can tell you how much radiation will hit rectum, bladder, etc. based on the plan. With that machine it will be very close to plan. I had no long term side effects from radiation (CT adjustments at beginning, but not active in treatment like MRI) except going dry. Had a little urgency right after treatment. No bowel symptoms. No ED but sex and orgasm different than before treatment not in a good way. A few have posted different & better; most different and worse. One reason AS and Focal are tried even with the risks they have.
4) As has been mentioned RALP-RS (posterior) and RALP-SP (anterior) do not cut the ligament and have much better continence results than the standard RALP procedures. However, you will need to find an expert surgeon in using the technique chosen to get excellent results. Wheel1 (posted response) had RALP-RS.
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3 ReactionsAccording to the NCCN Guidelines ADT is not indicated in this case.
@jim18
1. PSA was over 3 since early 2024. Did not "trigger the alarm" at that time because it was still under 4. Yeah, I really want to avoid ADT as long as it is possible. Currently 2 different ROs and my urologist have stated that ADT is not required in conjunction with RT...
2. I only had consult for HIFU, but as mentioned, although possible it might damage the right nerve bundle due to the peripheral location of the tumour. They could not "guarantee" the outcome...TULSA is hardly available in my country and based on my research might not be suitable due to the peripheral/posterior location of the tumour. Will have IRE consult next week.
3. MR Linac i.e. MR guided SBRT is available (Cyberknife would also be available as a second option). Already had my MR Linac SBRT consultation and all I would have to do now is to make appointments for the treatment sessions..
@lojewski
I Finished my 5 SBRT Mridian treatments in February 2023. The Mridian is comparable to the Elekta unity. What they can see in real time, they can treat. I had 3+4 Gleason, 10.2 PSA and a low Decipher. I did have spaceoar. I feel incredibly lucky and blessed that my situation has worked out the way that it has with my treatment.
I have had Little or no real issues. My urination is normal as are my bowel movements. I am in no pain. My erections are not as hard as they used to be. I get tested every three or four months for my PSA.
For me, I would never have considered active surveillance. No doctor will ever guarantee to you that it won’t grow at a specific rate, or grow at all. They are educated guesses. I wanted it treated and to move on. If I had to make that decision again, I would do it the same way, except maybe adjustments in the biopsy.
Thoughts (about each of your comments)…….
Even without access to genomic tests (such as decipher) or germline tests (for e.g. BRCA 1/2), they say that when a 1st-degree relative has prostate cancer, it increases the odds by 50%. (Plus other family solid tumor cancers probably increases the odds a little as well.)
Consider having your “Free PSA” tested along with your next “Total PSA.” PSA exists in two forms - attached to certain blood proteins and also unattached (i.e., “free”). % Free PSA is the ratio of unattached PSA to Total PSA in the blood. A higher % (above 25%) suggests more benign conditions, while a lower percentage (under 15%) indicates less benign conditions.
If you decide not to get treatment at this very moment, see what other (possibly inexpensive) biomarker tests they MIGHT offer: FoundationOne®Liquid CDx; Guardant360; Caris Assure; Prolaris; OncotypeDx; 4KScore; EpiSwitch PSE; Phi Prostate Health Index; SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS), ExoDx. Each provides information that might help in your decision.
Since you have a “4” in your Gleason score (albeit a small percentage), there is increased chance of metastasis (compared to a Gleason 6). Will they approve a PSMA PET scan? That information might impact your treatment management decision.
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a. I’m a supporter of active surveillance — when it’s appropriate. I was on active surveillance for 9 years (2012-2021), using that time to dig deep into learning about prostate cancer, and ultimately deciding on a treatment regimen just in case I ever needed to make that decision…..which eventually I did.
b. Can’t answer that one. I was not a candidate for focal therapy, having more than one lesion. Actually, though the risk of spread is certainly higher with not being treated (compared to surgery or radiation), recent data show that it’s not that much higher (see this study out of the UK: https://www.nejm.org/doi/full/10.1056/NEJMoa2214122). Plus, not jumping too quickly into treatment, and using the time to gather more information while still closely monitoring, buys you time to take advantage of medical advances before making that final decision.
c. With the success rates of localized prostate cancer treatments - no matter surgery or radiation - being statically equivalent, it all comes down to side-effects and quality-of-life (or as that paper concludes, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”). The possible/likely side-effects of surgery didn’t fit my quality-of-life prifile.
d. MRI Linac is a good option. (Is that the technology that provides continuous, real-time live imaging of the prostate during treatment, and can even pause the beam if the prostate position shifts?) (If they administer the radiation well - and don’t overshoot the prostate, hitting otherwise healthy tissues and organs - the risk of side-effects is very low. What radiation doesn’t hit, it won’t affect. (I had 28 sessions of proton radiation, and had only 1 day of adverse side-effects, and none since; that was 5-1/2 years ago. My most recent PSA was 0.366.)
You mention that “ADT would not be necessary.” ADT typically isn’t recommended for a low-grade 7(3+4) without other significant risk factors (which you don’t appear to have). However, there is an ArteraAI Prostate Cancer test that looks at the biopsied tissue characteristics to determine if ADT would be beneficial (or not). Is that test available/affordable to you?
> If you choose radiation, will you be using a rectal spacer (SpaceOAR, Barrigel, or BioProtect)?
Choose well.
@lojewski
You have too many positive cores with 3+4 to consider active surveillance. I know people with 3+3 that waited to be treated and ended up 4+5. Once cancer starts, it doesn’t usually become milder. It becomes more aggressive unless it’s treated..
You had a lot of of cores with cancer. You don’t show us your T score. Were you a T2b? That would mean it’s on both sides of your prostate so focal therapy doesn’t make a lot of sense. SBRT radiation does.
@lojewski It comes down to how you value quality of life vs. trying to get the best treatment now available for eliminating the cancer. With AS you just monitor, IRE is the middle ground where you get rid of current cancer and monitor it for recurrence. IRE recurrence is much worse with 4+3 than 3+4. Search for IRE posts. Some posters have had success with IRE for many years. Since you will still have a functioning prostate, a recurrence can be an entirely new lesion that developed.
Since SBRT radiates the entire prostate it has a much lower rate of recurrence. If the radiation was limited to the area of the lesion it might be close to the side effects of IRE; however, I have never heard of a RO do partial treatment of the prostate like they do with lungs, brain, etc. just focusing on ablating the lesion with SBRT.