AT a risk of boaring everyone, here are the highlights of my story that led to a situation I find myself in. Any thoughts or suggestions are highly appreciated.
In November 2007, at the age of 46, I was diagnosed with PCa. (Stats below). Six rounds of chemo to shrink the tumor and address a high-risk nature of my cancer (Gleasson 4+4=8, PSA 28+, family history). Then open surgery at Duke. The pathology report said organ confined disease, except for a single 4mm surgical margin. Gleasson downgraded to 4+3=7 (possibly as a result of chemo). Both my Duke and Sloan Onc felt no further treatment is needed. Post surgery PSA undetectable for 8 months, then started rising again.
So, my thinking was that there is a decent chance that this was a local recurrence and I would need to do radiation treatment. What I thought I need to decide is where to do the treatment - locally in Central New Jersey or at Memorial Sloan Kettering - MSK - in Manhattan. In conversation with the local Radiation Onc, he brought up radiation to lymph nodes as part of the treatment. I though it makes sense - a little extra insurance. Then I went to MSK yesterday and my world has changed once again.
Turns out MSK has requested my pathology slides and did their own post-surgery study. (Not sure how this works and why I never saw the results - thoughts anyone?). MSK found multiple focal extra prostatic extensions, in addion to what Duke reported (positive margin, perineural invasion).
The conversation went something like this. Doc, We reviewed your history and it would be right to do radiation to prostate bed and it would be wrong not to do it. (So far so good, I expected this). Me, Do you think lymph node radiation is in order. Doc, the lymph nodes were negative on the pathology report... you could do HT with pelvic radiation if you wanted to be most aggressive, but this is a gray area. Me, HT? Why HT? Doc, it does not make sense to irradiate pelvic area without HT. The radiation doze that could be delivered to pelvic nodes area is a lot smaller than prostate bed, so alone it does not kill the cancer. HT helps radiation kill the cancer cells. At this point I am very troubled. I read about HT with Radiation, but thought they were independent weapons, so you could do radiation with HT, or radiation followed by HT if it does not work. Doc (looking at my chart again), You had a pre-op PSA of over 30, I am looking at your pathology results and it is consistent with someone who's PSA was in the 20s; this PSA had to come from somewhere - you might have had micro mets prior to surgery. You definetly need to consider radiation with HT - Casodex and Lupron. Two month prior to treatment, two months during the treatment, and six months after. Me, if HT "softens" the cancer for radiation to work better, why do you need HT after the treatment. Doc, We don't know, but it has significan survaval benefit. The theory is that radiation continues to work even after the treatments are done and HT helps it.
We left it that I need to make a decision between radiation to prostate bed vs. radiation (including pelvic nodes) and HT. So now I have questions....
- How could two reputable institutions read the same pathology differently
- Does "focal EPE" still means stage 3?
- What is the "standard" treatment for T3a PCa with positive margins?
- Why did the MSK Radiation Onc did not lead with radiation + HT recommendation, but delivered it as an afterthought, in response to my question?
- What alternatives do I have in addition to the two he outlined?
- Anybody out there with similar staging - what treatments did you choose and what was the rational?
Thanks a lot to all of you PCa brothers (and sisters) out there who encourage me every day by your stories, your advice, your humility and your determination!
Greg
Previous 5 biopsies over 4 years negative
PSA going from 3.8 to 28
Father died from PCa @ 78 - normal PSA and DRE
Dx Nov 2007, age 46
PSA 29, Gleason 4+4=8
Decided to participate in clinical trial at Duke
6 rounds of chemo (Taxotere+Avastin)
1/8/2008 |
33.90 |
1/11/2008 |
29.50 |
1/31/2008 |
38.20 |
2/21/2008 |
32.00 |
3/13/2008 |
26.20 |
4/3/2008 |
26.60 |
4/24/2008 |
20.60 |
followed by RRP at Duke (Dr. Moul) on 6/16/2008
Gleason downgraded 4+3=7, T2c N0MX, one small positive margin
PSA undetectable for 8 months, then
2/6/2009 |
0.10 |
4/26/2009 |
0.17 |
5/22/2009 |
0.20 |