Novel thought from the NCCN ~ PSA testing DOES save lives...

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Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/11/2009 12:04 AM (GMT -6)   
The National Comprehensive Cancer Network (NCCN) has issued new guidlines for PSA testing.  Please see the link from the Infolink below:
 
 
Mike Scott's commentary is followed by two comments.  One by Terry Herbert, The wonderful webmaster of YANA, and one by me.  Pardon my sarcasm please.   My thoughts are driven by my well documented protests that reports like the ones from the New England Journal of Medicine that eliminate the under 50 and 55 group as study subjects in two very contraversial studies (with wide disparity as to the effectiveness of testing) are useless.  Please see the link...
 
Tony


 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!

Post Edited (TC-LasVegas) : 8/11/2009 1:40:32 AM (GMT-6)


Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3731
   Posted 8/11/2009 6:15 PM (GMT -6)   
I would have been one of those guys to not get a PSA test then... Just like my GP did.
No family history, no problems, everything working.
The only reason I had a PSA test was by luck. I applied for life insurance. It was 17+. The big C had been busy while my doc and I slept. When would it have been discovered otherwise? When I felt a pain? When my Gleason reached 9? When it fell off?
Where is the study that tracks quality of life? Incontinence, ED. I am single-handedly keeping Kimberly Clark in business. (You're welcome Thomas Falk) And I haven't even tried my own stimulus package to check ED yet.
Would I be sitting here in diapers typing to you right now if my Ca was diagnosed a year (or more) ago when things were not so involved? Lots of questions.
I have not seen anything in the literature on this subject. Only survivability.
Seems like there is a need for a study. I'm sure the data is there.
Age 56. Perfectly healthy with no problems until getting the results of my first routine PSA test on April 8th: 17.8. My GP does not believe in general PSA screening so I did not get results during my 50 year physical.
May PSA: 22.6, 3 weeks later: 23.2.
June 10 Biopsy 7 out of 12 cores positive, Gleason 6=3+3.
Bone scan and C/T scan negative.
----------------------------------------------
7/21/2009 Radical prostatectomy by Da Vinci @ University of Rochester
Left nerve gone, right spared.
----------------------------
7/31/2009: Catheter removed and Pathology report received
Gleason 3+4=7 Tumor size: 2.5 x 1.8 cm location: both lobes and apex.
No Malignancy in Seminal Vesicle, vasa deferentia, lymph nodes 0/13
Prostate mass 56 grams. Pathologic Stage: pT3aN0MX


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/11/2009 8:39 PM (GMT -6)   
Hey Worried,

Just wanted to clarify Gleason. The score doesn't get higher the longer you have it. It really is just a more aggresive form of prostate cancer. Whatever causes the mutation, apparently makes some giys with a G6, 7 8 9 or 10. Kind of like a lottery.

Other than that, I'm right with you. PSA test elimination will save a lot of money to the health care industry. Perhaps the new health care plan will allow for the end of life counseling sessions to start sooner when health care funds get tight !
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/11/2009 9:31 PM (GMT -6)   
Goodlife,
I'm not quite sure what you said here. But let me clarify what I have learned, Gleason can become more aggressive in time in untreated prostate cancer. Thus a G6 can become a G7 or higher. This can be an argument point against watchful waiting and why repeat biopsies are necessary in watchful waiting. There are many recorded cases of this. Once a mutation occurs, it can continue to mutate to even a more aggresive form.

Tony
 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Worried Guy
Veteran Member


Date Joined Jul 2009
Total Posts : 3731
   Posted 8/12/2009 2:32 AM (GMT -6)   
Hey Goodlife, Tony
Do you ever hear of guys with a Gleason of 2+3=5? The lowest I've noticed is 6. Is that because we all just happened to be diagnosed at that point and above?

My point was that if I'm getting blood drawn anyway for a standard 50 year old physical, how much more would it cost to check the PSA box? The docs are already checking HDL, LDL Total and fifty other things. To do the test you have to take time off from work, drive to the vampire station, have them find a vein, poke you, draw tubes, label them, send it to lab, report to doc and bill you. All of those costs are the same if you had one or 51 items checked on the lab request sheet.

My annual physical with my GP is scheduled for 9/9. and the blood work request STILL does not have PSA checked. What The ??? My Uro wants to see me on 8/20 and that lab request only has PSA and a couple of other items checked. Which costs more - getting stuck once or twice? Couldn't I double up and get PSA done when I'm being checked for cholesterol?
And finally my most important point - Would early detection have saved a nerve bundle.
Is my GP a hero with Aqua Choice because he did not request a PSA when I turned 50? Well I showed them! I'm going to cost them big time. (I'm also going to piddle a little on the exam room floor - as if I have anything to say about it.)
Jeff
Age 56. Perfectly healthy with no problems until getting the results of my first routine PSA test on April 8th: 17.8. My GP does not believe in general PSA screening so I did not get results during my 50 year physical.
May PSA: 22.6, 3 weeks later: 23.2.
June 10 Biopsy 7 out of 12 cores positive, Gleason 6=3+3.
Bone scan and C/T scan negative.
----------------------------------------------
7/21/2009 Radical prostatectomy by Da Vinci @ University of Rochester
Left nerve gone, right spared.
----------------------------
7/31/2009: Catheter removed and Pathology report received
Gleason 3+4=7 Tumor size: 2.5 x 1.8 cm location: both lobes and apex.
No Malignancy in Seminal Vesicle, vasa deferentia, lymph nodes 0/13
Prostate mass 56 grams. Pathologic Stage: pT3aN0MX


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2691
   Posted 8/12/2009 8:54 AM (GMT -6)   
Tony,

I'm not arguing. I could even be wrong, but I do know in my case that I went from 0 to 9 in 12 months. It was explained to me that the Gleason 9 is just a more aggresive cancer. You would think that waiting would be inadvisable for anyone if the cancer just gets more aggressive with time, yet we see men who have gone several years here and apparently had no change in the Gleason.

Jeff

I am getting my PSA checked every 3 months. Sometimes insurance companies get a little ouchy over too frequent testing. But I would say, it can't hurt. If it's close enough to the other testing, you can just opt out of the second test if it's a zero.

I think somebody had a post the other day about how Gleason score rating has been changed in the U.S. and that 6 is a minimum.
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks due to anatomical issues with location of ureters with respect to bladder neck.  Try 3 tubes where no tubes are supposed to be for 2 weeks !
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/12/2009 10:23 AM (GMT -6)   
I have seen some 3+2=5's. Rare as they are, they do occur and we have had a couple members here with it.

goodlife,
Gleason if left alone can indeed change but to many it does't. One question that is asked by researchers is whether the cancer mutates to a more aggressive cancer, or if a prostate that has already been susceptible to cancer adds a new more aggressive cancer. Both points are considered valid by oncologists. And of course there is always the possibility that the biopsy missed a more aggressive area of the disease and it did not become apparent until it manefested into a bigger problem. These are the very valid challenges to watchful waiting.

You might remember I posted about my best friends father "suddenly" has recurrent prostate cancer 28 years after the original surgery. His Gleason after surgery was G6. Today he is battling metastatic Gleason 10 prostate cancer. I reviewed the pathology with him, and was amazed on how long he lived "cancer free" and that has now changed. Somewhere this disease became very aggressive. I can't say why, whether they missed the grade 5 cells in 1982 or if grade 3 cells became grade 5 cells. I think it highly unlikely that grade 5 cells remained dormant for 28 years.
 
It is entirely possible a person starts out with G9.  It is also possible that it becomes a G9...

Interesting stuff, I think,

Tony


 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Colin45
Regular Member


Date Joined Feb 2009
Total Posts : 216
   Posted 8/12/2009 11:54 PM (GMT -6)   
Jeff I had a Gleason score of 3+2=5 but this was upgraded to 3+3=6 after the operation What I have been wondering since I have been on here why so many get Gleason upgrades after their operation it seems like you should add one to the pre-op score when you are making decisions about treatment (I must admit I did) or could it be that the cancer is changing in some people I still find it stange that after all this time a path report can still be depending on a persons experience and so vary from one lab to another
 
 
Age 64 From UK now in Thailand Baby boy born 2/14/2009
 First PSA was showing 9.73 on 1/21/09.   on 5/7/09 PSA 9.78  Free PSA 0.83   Free:Total  PSA 0.08 
1/28/09 Biopsy carried out 12 core results show no adenocarcinoma
5/15/0924 Core biopsy results Gleason'S Grade 3+2=5
Involving approx 30% of one out of 12 cores on each side no perineural or angiolymphatic invation identified
One side PIN High Grade Bone scan clear 
Open surgery 7/27/09
Prostate Gland weighting 34 grms
Gleason upgraded to 3+3 Tumour not closeto prostatic capsule Seminal Vesicles not involved by Tumour 6 Lymph Nodes negative for Malignant cells
 


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4186
   Posted 8/13/2009 8:18 PM (GMT -6)   
There was a post on YANA by Terry Hurbert: a few years ago it seems that pathologists got together and stopped reporting G5 and report it as indolant. That's why years ago there were a lot of G5s and now there are very few.

about 3% of G6s become very agressive very fast; we don't know why. about 75% of G6s don't show any progresssion in 7 years and 25% show either biological progression (rise in psa) or clinical progression (upgraded to G7) according to Dr Lawrance Klotz who studied AS. The longest term study was the Swedish study that goes out 12 years, but involves a lot of intermediate risk PC. In the G6 subset (88 patients) there was no matastasis in 12 years. The bottom line as Klotz sees it is that if psa doubling time is greater than 3 years the chance of a G6 matastizing is very low and AS is a valid option.
All G6's that ended up being treated because of a progression have no sign of reoccurrance. These are not long term studies and we don't know what 20 years will show; but the 5 and 7 year data is pretty good for the AS patients.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/13/2009 8:43 PM (GMT -6)   
I saw that and as an advocate I am dead against it. 3+2 or 2+3 is cancer. If they want to eliminate the grade two cells, then they need to call it 3+3 but smaller volume.

Case and point...
If a core is 10% tumor of that core is 4% grade 2 and 6% grade 3, then they can take out the grade 2 and declare the core 6% positive 3+3...There is no reason to not report it in the lab. That is taking the patients rights to know away from them...We are really pressing hard to get the attention on this correctly defined. Luckily there are only a few labs doing this.  The NCCN is pointing this out. So is AJCC...But not ACS...

Grrrr.

Tony


 Age 47 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


Tim G
Veteran Member


Date Joined Jul 2006
Total Posts : 2285
   Posted 8/13/2009 11:38 PM (GMT -6)   

My cancer was a Gleason 5.  The reason for the initial biopsy was the PSA quadrupled in 1 year.  One core was positive. My urologist said if it's in one spot, it is usually in multiple locations. The pathology report showed that mine,uncharacteristically, was in one location only.

I will be interested to see how PSA screening will be handled if we go with government health care, which seems inevitable, now or later.  In Britain, PSA testing is not routinely performed.  A man must specifically request it. 

Even with a Gleason 5, in my opinion there are too many unknowns to mess around with watchful waiting, especially when relatively young. It's like Russian roulette.   

 

 


PSA quadrupled in 1 yr (0.6 to 2.5)  
DRE neg  1 of 12 biopsies pos (< 5%) 
Open surgery June 06 at age 57
Organ confined to one small area Gleason 5   
PSA's undetectable  < 0.1  


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 8/14/2009 7:03 AM (GMT -6)   
Some of my thoughts on this subject:

A standard biopsy at best, is just an estimate. It took 2 no cancer ones with me to lead up to #3, which struck pay dirt. The only reason there was a #3 2 months after #2, is because my dr was experienced enough to trust his gut feeling, he knew something was wrong, and he said he saw a shadowy area in the left side of my prostate. With my rapidly rising PSA, and no other prostate problem symptons, and clean DRE, he knew it was there, somewhere. So #3 was targeted to that area, and bang, 7 cores, 7 positive.

I wish the first biopsy would have found it, I could have been a low grade 6 instead of a pissed off gleason 7.

My GP went by the old standards, not his fault, dont do anything till the patinet hits 4.0 psa. The first time it did, off to the urologist I went.

I agree with a poster above, if your biopsy shows you a 6, then assume it might be an 7. Look just at the stats in our own group, many men were upgraded after surgerey, some stayed the same, and even rarer, the final gleason went down. On the staging side, many were upped to the next grade of staging after surgery.

This will sound like a plug for surgery, but that is a major reason to have surgery ,so the entier prostate can be examined and the other removed parts to give the patient a fuller and clearer picture of where they stand. Something to think about.

They should write a whole book on Gleason 7 situations. Even my own dr gave me a lecture on the erratic way a 7 can act. He said in t he begginning, that a 7 is too dangerous to wait and watch. He firmly believes that a 4+3 will act much more agressive like a gleason 8, while a 3+4 can act more like a high end gleason 6. Its the amount of type 4 in the mix that is determining the agressiveness of the cancer

From my many studies sources and based on the doctors I have spoken with, overwhelmingly they reccomend that gleason 7 cases go to surgery first if the general health of the patient is suitable for surgery.

If it were up to me, PSA testing should be required of all men by age 40 to get a base line. Age 30 if one is African-American and/or have a directly linked relative with PC, i.e. dad, brother, uncle, grandfather. We could save a lot of lives that way.

A cheap blood test doesnt boost up health care costs as much as expensive treatments, long term advance care, hospice, or even the cost of a funeral when one of our dear brothers gives up the ghost to this hell of a cancer.

We need a knowledgable major level Prostate Cancer Czar, that will keep our blight on the front burner in the news, and help eliminate all the idiotic articles about over treatment, testing too much, us having the good cancer, etc. And to push for faster approved drugs for our advanced brothers, and better testing methods that would give the next generation of brothers a better fighting chance then we have.

I will shut up now. Vented enough.

David in SC, I take comfort every day that I am dealing with the "good cancer". LOLLLLLLLLLLLL


Age 57, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
 Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsule, one post. margin, clear lymph nodes 
2009 PSA   2/9 .05, 5/9 .10, 6/9 .11, 8/9 .16
Lastest 7/13 met with Rad. Oncl, considering options, 7/20 Catheter #6 after complete blockage, scarring closed up bladder neck, corrective laser surgery scheduled for 8/18,
meeting with Rad. Oncl on 8/14 about lastest PSA
 
 

Post Edited (Purgatory) : 8/14/2009 7:07:44 AM (GMT-6)


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4186
   Posted 8/14/2009 11:20 AM (GMT -6)   
David,
In your case the rapid rise in PSA and the PSA doubling time of less than a year indicated a serious aggressive PC. A PSA doubling time greater than 3 years indicates a non agressive PC in which one has many more options including waiting for a while. In any event a G7 needs treatment, many G6s do not. I had a doubling time of over 3 years with my G7, and other tests like PCA3 showed it was non agressive and I had the option of waiting for a while. I calculated that my PC had been growing for 13-15 years and was still localized; I probably had 10 more years before it would have caused a problem. PSA doubling time is a major indicator of both growth and agressiveness.
JohnT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DX BPH and continue to get biopsies yearly. Positive Biopsy in 10-08, 2 cores of 25, G6 less than 5%. Scheduled Surgery as recommended.

2nd Opinion from Dr Sholtz, an Oncologist said DX wrong, path shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G 4+3 approx 2.5cm diameter.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and burining urination. Daily activities resumed day after implants.

Scheduled for 5 weeks IMRT in July

JohnT

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