Newbie with a newly diagnosed dad -- questions!

Allison · New User Joined: 28 May 2008 Posts: 7

Hi everyone. My dad (aged 68, in excellent health) was diagnosed a few weeks ago with prostate cancer. Here is his story in a nutshell. He had a rise in his PSA to a little over 2 one year ago and had a prostate biopsy which was negative. His PSA this year rose to a little over 4 and he had another biopsy which showed one specimen out of 12 being positive (not sure what percentage.) His Gleason score is a 6. The doctor sent him for a bone scan and CAT scan of the pelvis.

The bone scan showed a couple of odd spots, one in the shoulder (he has arthritis) and one in the sternum (he fell and injured it many years ago) and the CAT scan showed that one of the fat pads around the prostate is "missing." The doctor said this might be due to the tumor invading the area, although the DRE was totally negative and he has no symptoms. He is now being sent for an MRI. I think this doctor is very old fashioned in his thinking and is creating more stress than is necessary with all these tests, although I do appreciate his thoroughness. (I am an RN but this is not my area of expertise!)

My dad is insisting on the robotic prostatectomy and has an appointment with a fairly well-respected surgeon in our local hospital. Although, his urologist stated in the unlikely event that the cancer has spread, only radiation will be available.

Any thought or opinions on anything I have mentioned? I respect your expertise in this area! Thank you!

Replicant · Moderator Joined: 01 Nov 2006 Posts: 205

Hello Allison!

Well, let's start with the Gleason 6. That's a very common, if not the most common Gleason score men get diagnosed with, at least in the U.S. since PSA screening started. It indicates cells that are "moderately differentiated." Cells that are well differentiated are not cancer, and cells that are very poorly differentiated indicate aggressive cancer.

It would be unusual for a man with a PSA of just over 4, a Gleason sum of 6, and normal DRE, to have disease that had spread to the lymph nodes or seminal vesicles. You can see this for yourself by using the Partin tables on the Johns Hopkins website: http://urology.jhu.edu/prostate/partintables.php . The odds are 83% in favor of organ confined disease, a slight chance of extraprostatic extension, and almost zero chance of lymph/seminal invasion.

I've never heard of the issue the doctor has raised about the fat pad. I have no idea about whether that's significant or not. In the absence of other information, I would assume it is important and worth checking out.

As to robotic surgery--I am an alumnus of the Da Vinci procedure. I've read quite a bit about it since. There is a steep learning curve, even for experienced urologists, and it's important that the doctor be very skilled with the machine--optimally, he should have done at least 70 prostatectomies with it. Until the surgeon has done lots of procedures with it, the odds of positive margins are higher than with the traditional, open surgery.

Radiation does offer the benefit, as the urologist said, of hitting cancer outside the prostate as well as inside. So if there's a little local spread, it could take care of it. That's an advantage of radiation. Another big advantage: it ain't surgery! Make no mistake, a prostatectomy is major surgery. Patrick Walsh likens it to neurosurgery in its complexity.

The major DIS-advantage of radiation as a primary treatment, in my opinion, is that salvage is very difficult and risky if radiation fails. Salvage prostatectomies are sometimes done, but they are technically challenging and there are high rates of horrific side effects like fistulas and sometimes complete, untreatable incontinence. So if a man chooses radiation and then his PSA starts to rise again after treatment, he has a tough road ahead. On the other hand, if surgery is the primary treatment, and then PSA rises, salvage radiation is very common and carries mainly mild, temporary side effects if any at all.

So the choice of surgery vs. radiation determines the "fall back" position that is available should PSA start to climb again.

It's very hard with prostate cancer to tell whether it's spread to distant locations in the body. It's not very likely with those numbers, but there are no guarantees and no way to rule it out. It could be ruled IN by a scan, but it would be unusual for a bone scan for example, to show PCa mets until PSA was over 20 or so. There could be micro mets that wouldn't reveal themselves for months or years. Or not! If there is microscopic, distant spread, neither radiation NOR surgery will be curative. In that case, a patient usually goes on hormone therapy (ADT) and/or chemo, in a palliative effort to stall the disease and lessen the symptoms.

You have to evaluate the options, weigh the probabilities, make a decision and take action, knowing that no one has complete information about the situation. When you think about it, that's how we make many decisions every day.

I hope that helps. I'm sure your dad is glad to have a medical professional in the family. Good luck!
_________________
Replicant

Dx Feb 2006, PSA 9 @age 43
RRP Apr 2006 - Gleason 3+4, T3a, N0M0, pos margins
PSA 5/06 <0.1, 8/06 0.2, 12/06 0.6, 1/07 0.7.
Salvage radiation (IMRT) total dose 70.2 Gy, Jan-Mar 2007@ age 44
PSA 6/07 0.1, 9/07 <0.1, 12/07 <0.1, 4/08 <0.1
http://pcabefore50.blogspot.com

Sephie · Regular Joined: 24 Apr 2008 Posts: 10

Except that he had a Gleason score of 7 (3+4) after biopsy. My husband was 57 years old at diagnosis and in excellent health. The urologist walked us through the options for his stage (clinical T1C), age and prognosis. Since the DRE didn't reveal anything, and since my husband's PSA was under 10 (it was actually 6.3), we had a pretty wide open field in terms of treatment.

Watchful waiting or active surveillance: no treatment just constant monitoring and the chance for repeated biopsies should the PSA continue to rise. This is more often used in older men whose life expectancy may not exceed 10 years. It also carries the risk that the cancer could spread in between check-ups. Doctor said he would definitely not recommend this in my husband's situation.

Radiation (whether external beam or seed implants): good option but the use of radiation as a primary treatment eliminates it in the future should the cancer rear its head again. Doctor also said that radiation is not a benign treatment and that the risk factors associated with it should not be taken lightly.

Surgery (radical prostatectomy): another good option for my husband but it is major surgery. The beauty (if one can call it that) of having the prostate and seminal vesicles removed is the opportunity to have a complete pathology done on the specimen which provides a more exact staging of the disease.

We had done our research in advance and had decided that surgery was the option we wanted. Wherever possible with any type of cancer, the goal is to get it out of the body, and this was the driving force behind our decision. Should the cancer return in the future, we still have radiation as a treatment option.

John (my husband) had a robot-assisted laprascopic prostatectomy on March 18. It was a 5 hour operation (this is MAJOR surgery) and he came through it just fine. After the pathology report came back, we found that the cancer was a bit more invasive than revealed by the biopsy but the surgical margins, seminal vesicles and blood vessels came back clean so he is in good shape.

With surgery, the only follow up is regular PSA tests. The theory is that once the prostate is removed, there should be no cancer cells left in the body. A consistent PSA of zero (or very close to it) following surgery is a good indication that the surgery was successful in removing the cancer. With radiation, the prostate is still there and still making PSA. If the PSA bumps up (which it can do), then you face another ultrasound, biopsy, etc.

Surgery is not for everyone, and since this is a major operation, the decision should not be made lightly. We are convinced that in John's case, surgery was the right choice but every person is different. Both radiation and surgery can carry significant risks, and your dad has to decide which risks he can live with.

I hope that this information has helped. If I've misstated anything, I hope that someone (Replicant?) will come back and correct me since I am by no means an expert in this disease.

Allison · New User Joined: 28 May 2008 Posts: 7

Thank you both so much for your replies. My dad is scheduled for his robotic prostatectomy on July 2nd. They still do not have the MRI results but went ahead and reserved the OR time anyway.

Again, thanks so much for all the wonderful support and information provided by this site, it's awesome!!

Allison · New User Joined: 28 May 2008 Posts: 7

My dad got the results of the MRI. The spots on his bone scan were just arthritis and the missing fat pad was miraculously found! Wink

The doctor did tell him there was some sort of bump on the fat pad but he would remove it during the prostatectomy anyway. We have breathed a small sigh of relief with this news but will feel much better after the surgery is done and he is home!!

In

Allison,

Congratulations on the news of your Dad- i've been following your story. I'm happy to hear he is home and everything so far at the moment is going good.
_________________
Thinking of you Inica

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