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Overtreatment of Prostate Cancer
Urologists are trained to do invasive treatment, such as prostatectomy, for many levels and types of prostate cancer. There may be a tendency to overtreat since treatment is what they’ve learned and likely constitutes the greater part of their prostate cancer practice. I’m 74 and a nodule was found by my urologist through a digital rectal exam (DRE). He set up both a CT scan and MRI (both covered by insurance - Medicare Advantage - in my case). The MRI reading came back suspicious for the nodule and found one other small lesion that was suspicious. I then had a transrectal ultrasound biopsy which showed cancer in two of 14 cores taken. The small one was Gleason 3+3 and the larger one was 3+4. That put me in the staging group of intermediate favorable. My urologist then had my biopsy tissue sent for a genetic/genomic test by , which was also covered by my insurance). It came back indicating I was in the active surveillance (AS) category, although at the high end. My urologist and I agreed to go the AS route with appropriate PSA testing and likely biopsies going forward. If progression is found, I can then opt for appropriate treatment before any metastasis can take place. And newer, more effective treatments may then be available. My point, and it is only that of an informed layperson, is that Gleason cancer scores of 3+4 are not necessarily an indication for treatment. However, the younger you are, the more likely that 3+4 may require treatment. Always review your particular situation with a trusted urologist. But different urologists can have differing viewpoints on treatment, so second opinions are often appropriate. Excellent YouTube videos on many aspects of prostate cancer are by Mark Scholz MD and Michael Ahdoot MD.
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What a great thread of comments and advice. I completely agree, treatment decisions are personal and - Every man is unique and must make a decision that meets his life expectations. For myself, it is difficult to see how you can over treat prostate cancer, unless you have other life ending illness or you are at an age where prostate cancer will be a non-issue because of its slow growth (most of the time).
I was 56 when diagnosed with prostate cancer (GS 4+3) and went with a radical prostatectomy at a center of excellence (Mayo-Rochester). For myself, waiting for cancer to grow and potentially metastasize did not make sense. Cancer is tricky and any oncologist/surgeon that definitively tells you the PC is confined to the prostate, is in my opinion deceiving the patient. Even with my post RP pathology showing negative margins, I do not know that metastasis did not occur at some point. I pray every day that my prostate cancer is gone for the rest of my life, but time will only tell.
I am big believer that attitude makes a huge difference. Make an informed decision on treatment/hospital and go on with life in the best way possibly. For myself, I am moving forward with the goal of 30+ years of PC free life.
Good luck to everyone and pray all goes well with your treatment plans.
Jim
I'm a 8 year PC survivor who PSA jumped 4 to 6. Urg wanted me to consider removal vs Rad. He said if did Rad it would be difficult to remove later. After 2-3 months researching I would have done Proton Rad however it was 6 hour drive to nearest facility. This hastened decision to take it out. According to U my odds were very good for no return & should have a good 10-15 years. PSA good for 2 1/2 years, registered .03. Doubled next 3 qtrs. Tehn began to level off. U had me see Rad & he wasn't worried till reaches .4. It slowly has reached .31 & U wanted me to do Rad & or have PMSA PET scan & chose later. Results, no cancer & totally clear except for lung nodule which will have CT in 3 mos. Prior to & During this whole diagnosis I've never had bladder issues except going once & sometimes twice at night. If anyone has any thoughts please respond.
I am 72 I had 3+4 in less then 5% in one core second opinion downgraded to 3+3 6 my doc wanted operate I went to a radiologist he said I could watch it or he could don5 radiation treatment I went to another doc he wanted to put me on casodex that’s a hormone then I went up to Mayo to look into proton pump that doc said do nothing PSA once a year mri once a year and a biopsy every 3 years also the biopsy sample was to small for a genetic test. So I could not get 2 docs out of 4 give the same opinion on treatment so far just watching it
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1 Reactionhttps://ascopost.com/videos/2021-astro-annual-meeting/amar-kishan-on-prostate-cancer-impact-of-androgen-deprivation-therapy-with-radiotherapy/
It has to be the 40PSA informing your prescribed treatment. But research seems to be showing that the hormone blocks prevent recurrence and metastasis even in low risk patient. You have to balance that for yourself. Are you willing to take whatever risk of recurrence in order to be comfortable and feel healthy now. I suspect I would take the risk and deal with whatever recurrence. Respecting that the oncologists' goal is to rid the system of cancer.
How old are you. It makes a difference.
At 72 look at the studies that show Lupron makes almost no difference in BCFS and OAS at our age if you are over 70. Weeks after i chose radiation the study from England was published showing the 15 year survival was the same if you did nothing, has a RP or did radiation. At 74 that makes me 89. People talk like they want to live forever, but quality of life means something too. I don't want to wind up in a nursing home as my sister works in one and say you don't want to go there.
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2 Reactionscraftsmanctfl: I was 69 last year with 3+4 and a 10.2 PSA. One out of the 5 RO's suggested AS. I had treatment with narrow margin radiation in Jan/Feb 2023. For me, I did not trust that during a three month stint between testing, that the cancer would not spread. There were no guarantees from any doctor on that note. I did not want to take that chance and potentially cause additional modes of treatment because I waited (hormone, chemo...). Quality of life was an issue that I did not want to leave to chance, if possible.
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1 ReactionWell, the PSA of 40 may be why they are doing triplet therapy based on what you describe...intermediate high risk.
Even with your scans,that PSA may have micro-metastatic disease, too small to be seen with even today's most sensitive PCa imaging.
The questions is, how long "should" your ADT be...!?
Not sure you'll find a consensus, either on this forum or in your literature research. I can say this, six months may be too short, 36 months too long, anyon saying lifetime, no...
Most will say 18-24 months. In my case, when we did triplet therapy in Jan 17, the plan was 24 months. Based on my response, PSA dropped to undetectable quickly and stayed there, Dr. Kwon agreed to 18 months. That brought me 4-1/2 years off treatment, no cure though, What would 24 months have brought, we'll never know since I am a study of one and we can't clone me and compare the two! My PCa is not "curable," or at least that's mainstream thought. It is manageable, particularly since it has not spread to the bones or organs. Yours may be, a question you may want to ask yourself and your medical team...is this a shot at a cure, if so, will the 24 months versus 6, 12, 18 better achieve that outcome? There are no guarantees though..
On this go around, my local oncologist in concert with my radiologist are recommended 12 months in combination with SBRT. They felt six months was too short, 24 months too long based on my clinical history and current clinical data from labs and Plarify scan.
A starting point for discussions with your medical team may be the NCCN Guidelines, this link may get you started - https://jnccn360.org/prostate/for-your-patients/nccn-guidelines-for-patients-prostate-cancer-advanced-stage/ These guidelines are a starting point for the standard of care in treatment of various stages of PCa.
Kevin
SPPORT trial findings may be helpful.
Also rising PSA after treatment Jan 2023 video PCF.org.
BCR (PSA .19) immediately after RP led to radiation treatment of the whole pelvic region (WPRT) together with the pelvic lymph nodes.
Also 4 mos of ADT.
I thought that I saw the SPPORT trial recommendation was 4 - 6 mos ADT for intermediate PCa and 18 - 24 mos for aggressive disease.
however , I have not been able to re-locate that information.
My Gleason score was a 9, together with 8s.
However my Rad Onc prescribed 4 mos ADT.
2 "radiation buddies " received 6 mos ADT.
And I am not entirely sure why my ADT course was only 4 mos.
I chose Center of Excellence for treatment, so I am having faith.
1st PSA 6 mos following completion of 37 radiation txs (66.6 gy) and ADT undetectable. I will feel better if PSA remains undetectable for at least a couple more tests, but so far so good.
Sincere best wishes.
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3 Reactions@kujhawk1978 wrote "I can say this, six months may be too short, 36 months too long, anyon saying lifetime, no…"
Reminder for anyone reading this out of context: "lifetime, no..." applies to ADT only if the prostate cancer hasn't already metastasised. Once you have metastatic prostate cancer (castrate-sensitive or -resistant), then it's "lifetime, yes..." as far as I've learned so far (or at least, as long as you're in active treatment rather than final palliative care).
But yes, there's good evidence going back over a decade that it's fine to take treatment "holidays" from ADT, for months or sometimes years (until your PSA rises significantly again), for non-metastatic prostate cancer — in consultation with your oncology team, of course (don't just unilaterally decide to stop taking it).