Reliability of Pre-Op PSA

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BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 4:29 PM (GMT -6)   
Pardon me if this has been noted before, but it seems to me that more often than not, the pre-op Gleason from biopsy is often less than the post-op pathology. Not always, but a troubling percentage of the time? It would seem to me that this is as important as any of the "averages" that we toss out there, being that Gleason # is a primary way we describe the PCa?
 
If, for arguments sake, we know that Gleason is actually higher than initially stated 75% of the time (a non scientific number), wouldn't that impact the decision of many patients as to what treatment they choose?
 
I use myself as an example, I was given an initial 3+4=7, and I remember telling my wife when we went to post op meeting last week that I was warned that Gleason is often higher upon closer look. And sure enough the urologist says "sorry to tell you, the pathology came back suggesting the cancer was more aggressive than your original biopsy, it is a 4+3".
 
I guess my point is that "if" the majority of the time Gleason ends up being higher that initially stated, isn't that rather important to factor into your specific equation. I certainly HOPE that it's not, for ANYBODY, but.
 
 
 
 
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Piano
Veteran Member


Date Joined Apr 2008
Total Posts : 847
   Posted 6/10/2010 4:52 PM (GMT -6)   
I agree, there seems to be a tendency for post-op Gleason to be higher than pre-op. I guess simply because the pathologist gets to have a really close look.

In my case, I dropped from a 4+5 to a 4+4, but had I known that beforehand, it would not have changed my treatment choice. Likewise your 3+4 to 4+3, probably would not have changed your treatment choice. It is a factor for Active Surveillance, where the difference between 3+3 and 3+4 might trigger a decision for treatment.

But in other cases, I don't think it really matters -- post treatment, we all get to watch (and worry about) our PSAs. :-)
Pre-op:
Age 63 at diagnosis, now 65.
No symptoms; PSA 5.7; Gleason 4+5=9; cancer in 4 of 12 cores.
Operation:
Non-nerve-sparing open surgery on 7 March 2008.
Two nights in hospital; catheter out after 7 days.
Post-op:
Continent; no pads needed from the get-go.
Pathology showed organ confined and negative margins. Gleason downgraded to 4+4=8.
PSAs:
6-week : <0.05
7-month: <0.05
13-month: 0.07 (start of a trend?)
19-month: 0.09 (maybe)
25-month: 0.2 (yes, bummer)
ED:
After a learning curve, Bimix injections (0.2ml) worked well. From 14 months, occasional nocturnal erections. At 18 months, "graduated" to just the pump.


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 6/10/2010 5:05 PM (GMT -6)   

An important question is when they do change, why do Gleason scores usually go up but seldom go down?

Suppose you go to a urologist who performs a biopsy on you and sends the specimens out to an independent laboratory for evaluation.  That independent lab has no incentive to skew the results one way or the other, it gets paid a set fee just for doing the evaluation.  Let's say the laboratory comes back with a Gleason 3 + 3.

Now you decide to go to a major cancer center to have a PC surgeon perform a radical prostatectomy on you.  Your removed prostate gets sent to that cancer center's pathology department for evaluation.

Your cancer is whatever it is, regardless of what Gleason score is slapped on it. 

Say you live 19 years after the operation before succumbing to prostate cancer.  The PC business is very competitive, both among cancer centers and among doctors.  Which is better for the cancer center and the surgeon when they compile their statistics - that after treatment you lived 19 years with a Gleason 3 + 3 or that after treatment you lived 19 years with a Gleason 3 + 4? 

Since Gleason scores are highly subjective anyway [imagine if they reported Gleason scores to two decimal places - how could one meaningfully distinguish between a 3.23 and a 3.24?], is it really that surprising that Gleason scores post-op are sometimes higher than those pre-op?

Zen9

 

 


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 6/10/2010 5:10 PM (GMT -6)   
Bob,
 
This is an important topic, but the bottom line is that you get the best available data on the biology of your cancer, and then you make a decision based on that.
 
So what does "the best available data" mean?  It might mean different things for different people.  One one end of the spectrum, some advisors would tell you not to make any decision until you have a 3-D color doppler image, or at least a saturation biopsy.  [Don't know what those terms are?  Rather than detail them here, one can easily Google them.]
 
What is much more widely recommended is to have your biopsy samples read as a second opinion by a pathologist who is expert in reading prostate samples.  There have been a number of recent threads on this topic...here's one example:  Second opinion lab recommendation.
 
The reason that post-PR pathology results in Gleason scores sometimes being upgraded is exactly as you speculated...because the biopsy is merely a sampling, and sometimes misses more aggressive pieces of tissue.  However, the rate of upgrade is not 75% as you speculated; it is more in the 20-30% range (so, not the "majority" as you speculated)...which is still high, but recognize that a biopsy of 12 samples pulls out about 1% of the total tissue in the prostate.
 
hope this helps explain...

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/10/2010 5:10 PM (GMT -6)   
Remember, the pre-treatment Gleason is at best an estimate based on a few core samples. If you choose surgery, then they do pathology on the entire removed gland, plus whatever else they remove, and can then study the whole thing. That's why there is a certain gamble when making a primary treatment choice. In rare cases it goes down, often it stays the same, and as you pointed out, a good number actually goes up. Some would argue against this next point, but that is one advantage of having surgery, because it will give a fuller picture of what's really going on with the cancer.

With a satuation biopsy where they take a lot of cores, there are probaly less changes in the pre- and after gleason scores, because they are taking so many more cores, that are more likely to see more of tumor if it is present,

David in sC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, 5/24 put in Cath #17


goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 6/10/2010 5:13 PM (GMT -6)   
It may be more an indictment of biopsies than Gleason. The pathologist can only read what he/she sees.

Many of us have 12 point biopsies, while some uro's do 16, 24 or 32 point saturation biopsies.

This whole topic is a strong argument for surgery and the ability to flop the entire prostate on the table and tell us exactly what we are dealing with. Others find it a strong argument for other procedures such as color doppler and other tests that do a better job of defining the PC.

Certainly second opinions are very important for these very reasons as well.

This PC can be a real son of a gun.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01


BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 5:20 PM (GMT -6)   
Zen, I really didn't contemplate that equation when I posed the question. I assumed that even in "competative" institutions, there is nobody really "keeping score" to that degree... that a 3+3 lived 19 years and that "beats" a 3+4 that lived 19 years. I'm not aware of an acculative score based on such criteria that is either kept by these institutions, and certainly not one that I as a patient could get my hands if, if they were.

I looked at it as all entities being completely ethical and providing their best opinions... the "lab" gets a sample with a number, they dont know "me" or remember "me" from the pre-op biopsy to the post-op biopsy.. I wouldn't think?

My perspective on the reasoning for the high percentage of gleason scores going up upon post-op pathology was that pre-op biopsy is typically 12 pinpoint size samples of a prostate that effectively consists of 10,000 "pinpoints" worth of matter. Anotherwords, the sample is so very small by it's very nature that it is impossible for it to come anywhere close to the pos-op pathology biopsy which allows them to splice the entire prostate from one end to the other. So pre-op IS the preverbial needle-in-the-haystack, which is better at identifying that there IS a cancer present, than it is as determining the degree of the cancer. And the point of my positing this as a subject is that This Would Be Important To Consider, if indeed it is true.
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Zen9
Regular Member


Date Joined Oct 2009
Total Posts : 314
   Posted 6/10/2010 5:25 PM (GMT -6)   

Then by your logic, given a large enough sample, wouldn't you expect to see Gleason scores going down about as often as they go up?  Doesn't happen, does it?

Zen9


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 6/10/2010 5:25 PM (GMT -6)   
But Bob, the patient should simply get the "best available data" and make a decision base on that. It makes no sense to make a decision on what it might be if the data you have is wrong. Know what I'm saying...?

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 5:31 PM (GMT -6)   
Casey, I was posting my reply before I got a chance to read your post, sorry. I agree with what you;re saying , absolutely, but was just noting a "trend" that stood out to me, that post gleason seemed higher than pre gleason a significant number of times.. and I based that on reading the sigs of our co-members. 75% may be strong, it wasn't scientific as I noted.. not at all. But I think that if one were to go through each members sig and put a number on the "lower" vs the "higher", would would see Higher prevail in scary numbers. I personally think that the number of "higher" vs "same" is significant numbers. There isn't a person here who wouldn't junp sky high to go down a number on either side of the gleason, nor who's heart would skip a beat every time it goes up 1. Using our members, I do think the higher post op numbers are startling.
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 5:36 PM (GMT -6)   
To all me fellow fellows here.. dont anyone get excited about the subject i'm contemplating with this post. I am not attemting to suggest anything about anone's treatment or decisions. I am simply noting that I notice there is a significant number of post op Gleasons that are higher than the pre ops. Thats all. I am not making a statement that anyone take any action based on that observation, ONLY that if it is a valid observation, it would (may) be one that some may want to put into the pot when measuring the 15,000,000 OTHER factors each of us has to weight in fighting this disgusting monster. UPDATE 6/10/2010. As time goes on, we'll see if my crappy attitude changes one way or the other. After all, there is a physical toll and an emotional one.. just as there is physical healing, and emotional healing. And there is maturing too.


First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!

Post Edited (BobCape) : 6/10/2010 4:43:26 PM (GMT-6)


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 6/10/2010 5:36 PM (GMT -6)   
BobCape said...
Casey, I was posting my reply before I got a chance to read your post, sorry. I agree with what you;re saying , absolutely, but was just noting a "trend" that stood out to me, that post gleason seemed higher than pre gleason a significant number of times.. and I based that on reading the sigs of our co-members. 75% may be strong, it wasn't scientific as I noted.. not at all. But I think that if one were to go through each members sig and put a number on the "lower" vs the "higher", would would see Higher prevail in scary numbers. I personally think that the number of "higher" vs "same" is significant numbers. There isn't a person here who wouldn't junp sky high to go down a number on either side of the gleason, nor who's heart would skip a beat every time it goes up 1. Using our members, I do think the higher post op numbers are startling.

 
 
 
Yup, more go up than down.  There are case studies out there with percentages that vary, but roughly 5% go down and about 20-30% go up.
 
Mine went up...but guess what, it was an after-the-fact shrug of the shoulders for me.  It made absolutely no difference in anything I did after I received my post-surgical pathology report.  The only thing that matters with regard to PC cure after surgery is whether your PSA goes up. 

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 5:39 PM (GMT -6)   
And mine went up, and it also was an after the fact, non determinant factor to me. I cant say it was a "shrug of the shoulders" because I would MUCH rather is be 3-4 than 4-3, if only because it' allowed be to sleep better for 15 minutes a night.
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/10/2010 5:43 PM (GMT -6)   
Zen:

Why would you even imply that there is some conspiracy theory about other motivations being done on a removed prostate. That's absurd at the least. I just don't buy into these dark theories. You did say correctly, that the cancer is what it is, both before it is removed, and after it is removed.

The real reason for the change is as simple as already stated, much more to look at post surgery, then the volume in the cores removed during a biopsy. Nothing more, nothing less.

Just not into conspiracy theories. There's no motivation or hidden agenda for the surgery center or hospital to class the post surgery specimen higher or lower than what it is. In some cases, where there is a close call, it is subjective. True type 4 cancer cells are distintly different looking than type 3 cancer cells. And if the patient goes the extra step, and it gets a second pathology opinion, more likely it will be the same.

What is a shame, is when some one is basing a period of AS on a single biopsy pathology report, let's say, it showed a Gleason 6. That patient is always going to be gambling that the last core taken just missed the bulk of an even larger tumor area, and area that might be Gleason 7 or higher. I wouldnt want to chance AS on anything less than a large number of cores, as commonly done in the saturation type biopsies, it would be less likely.

I will use my own case as an example. First biopsy, negative, but quite a bit of HGPIN present. PSA still racing upwards. A year later, second biopsy, negative but even more HGPIN found, as well as some suspicious shadows on the scan portion. Me - I wanted to wait a full nother year to do another biopsy if needed. Uro was deeply concerned about all the HGPIN and shadows found, talked me into to 3rd biopsy 6 weeks later, roughly. Didnt want to do it, but went along with it. 3rd biopsy - only 7 cores, all in the shadows, left side of prostate, all came back positive with fairly heavly % of cancer.

If I had gambled and had my way after the 2nd biopsy, I can only imagine what would have been found a full year later, with my PSA almost tripling the last year.

David in SC
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, 5/24 put in Cath #17


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 6/10/2010 5:44 PM (GMT -6)   
BobCape said...
And mine went up, and it also was an after the fact, non determinant factor to me. I cant say it was a "shrug of the shoulders" because I would MUCH rather is be 3-4 than 4-3, if only because it' allowed be to sleep better for 15 minutes a night.

Right on!
 
Bob, have you contacted Dr. D'Amico's office in Boston yet?
 

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 6/10/2010 6:10 PM (GMT -6)   
The real question is what are you going to do with the information. You have already had the surgery; your only decision is do I have immediate radiation or immediate HT for 2 years or do I wait for my psa to start rising. Most individuals would opt to wait for a psa rise before doing anything.
Again if you have a 30% chance of your gleason rising, is it going to influence your treatment option; I doubt it. Coincidently the 30% is the number of AS patients that progress.
The real question after surgery should be is the cancer contained or has it escaped.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 6:12 PM (GMT -6)   
Casey, I haven't even had my post-op meeting with Dr Babayan @ BMC as of yet. That will be this coming week. At this point, I have no reason to believe that I am in anything other than very capable hands. Also, I chose Babayan based on reputation and experience with Robotic, and after much study. I actually left my initial uro simply because robotic was not available to him, and he dealt with a much older class of patient (due to where we live). Also, I was fortunate for my insurance to let me get that 2nd opinion (and urologist), even if I wanted (and we ALL would prefer to have THE best handle out care), I dont think my insurance would allow me to go expert hunting.


First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 6/10/2010 6:18 PM (GMT -6)   
BobCape said...
Casey, I haven't even had my post-op meeting with Dr Babayan @ BMC as of yet...
Ahhh.....sorry, I didn't remember the exact details correctly of your case; only remembered a few details.  Sorry to have jumped the gun.
 
best wishes...

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 6:19 PM (GMT -6)   
John T, that is the question I intend to ask. In my case they said I was margin positive, and they rate it t3a... so I assume they assume it has indeed escaped. Even before meeting with Dr Babayan, they have me setup with appts for rad oncology...I'm not SURE I want to go that route.. which I will discuss with babayan next week. What I dont get, they remove the prostate - it goes to pathology - they say positive margins, but that doesn't tell anyone WHERE else it may be. So how do/Could they know where else it is at this point?
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 6/10/2010 6:48 PM (GMT -6)   
Zen - I hate to think that doctors are manipulating my Gleason scope for fame and profit. I'll have to step away from that bit of speculation.

Bob - I am one who decided to go straight to radiation, without waiting for a PSA rise. My 4+4 upgraded to 4+5 (yes, there was cancer in an area that the biopsy would not have "seen"), and it was "out" with positive margins in multiple places. How can I speculate where it might be - I can't, until it is advanced enough to show up on a scan, at which point my decision point would already be long gone. Granted I would not have selected that treatment, but surgeons and oncologists with no monetary interest (not even paid for an Nth opinion) were adamant that I do it immediately.
My insurance paid for a second opinion, but after that, I would have to start inventing money, so ...
My best to Bostwick, who wrote off 6 of the 12 cores of the biopsy - only 6 covered by insurance.

BobCape
Regular Member


Date Joined Jun 2010
Total Posts : 416
   Posted 6/10/2010 7:40 PM (GMT -6)   
So 142, it was by speculation (educated assessment) of where they were to give the radiation? Prostate bed being the logocal 1st location, I guess?
First ever PSA test Jan 2010 @ 51 years old. 4.0.
Digital exam in March 2010 showed 1 side hard, other soft.
Biopsy, positive in 3 of 12.
Davinci @ Boston Medical Center, May 17, 2010.
Was suggested prior to it was likely contained.
June 1 advised 3+-4 was really 4+3 per pathology. Pos margins.
Catheter removed June 1.. 1 pad/day, doing ok. ED, but not in rush.
Sore as heck down there, but doing much walking with my wife.
To meet with my Uri (1st meeting since) June 17 - 1 mo point, to discuss.
BMC already has me setup to meet with radiology.
Felling a little better each day. Cant tell if my expectancy just went from 10-15 down to 5-7, the information out there appears to be all over the place. I WILL NOT radiate my insides to the point of being a veg for the sake of a few years. QOL is primary to me. Selfish I guess. I pray for all of you as I do for myself, but must remember that i've had a pretty good 50+ years, and know others who have lost their children to disease.. so I dont have the nerve to complain!


Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/10/2010 7:51 PM (GMT -6)   
The assumption is always the prostate bed, the former home of the diseased prostate gland. Its an educated guess at that point. Its also possible cancer cells have long gone up nerves and micro metastisis are taking place, but it takes a long time for anything like that to be big enough to show up on scans. So the hopes is to start at the prostate bed. My radiation oncologists said, that if recurrance happens fairly quickly with a postive margin on the pathology, that can be a good sign, that it is still local, with the hopes of radiating the bed will kill off what made it to the other side of the margin. I am no doctor, but her logic makes some sense.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, 5/24 put in Cath #17


John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4269
   Posted 6/10/2010 7:51 PM (GMT -6)   
Bob,
Positive margins just mean they have identified that the cancer extended beyond the surgical margin. They cannot identify that you have micromets, which is cancer that is beyond the prostate bed and into the blood stream or lymphnodes. At this point everything is just an estimate. With a G7 it is very possible that even if you have a positive margin it will never progress or that it is just in the bed which can be handled by radiation. Your low psa is one indication that it is still local. This is a decision that you will have to make based on very imperfect information. If you had a G9 or a G10 the probability that the pc has excaped into the blood stream with a positive margin increases dramatically and it would be appropriate to start HT immediately and skip radiation.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology 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. G7, 4+3, approx 16mmX18mm.

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. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7084
   Posted 6/10/2010 8:06 PM (GMT -6)   
Bob,

Yes, as Purg and JohnT have explained much better than I could. But to add to JohnT's discussion, I am not interested in HT, so radiation in hope that it is not distant is my option.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 6/10/2010 8:08 PM (GMT -6)   
Like 142 above, I have no interest in the HT path if my ugly beast returns either.
Age: 57, 56 dx, PSA: 7/07 5.8, 7/08 12.3, 9/08 14.5, 10/08 16.3
3rd Biopsy: 9/08 - 7/7 Positive, 40-90% Cancer, Gleason 4+3
Open RP: 11/08, Rht nerves saved, 4 days in hospt, on catheters for 63 days, 5th one out 1/09
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incontinence:  1 Month     ED:  Non issue at any point post surgery, no problem post SRT
Post Surgery  PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, next one:  July
Latest: 7/9 met 2 rad. oncl, 7/9 cath #6 - blockage, 8/9 2nd corr surgery, 8/9 cath #7 out 38 days, 9/9 - met 3rd rad. oncl., mapped  9/9, 10/1 - 3rd corr. surgery - SP cath/hard dialation, 10/5 - 11/27 IMRT SRT 39 sess/72 gys ,cath #8 33 days, Cath #9 35 days, 12/7 - Cath #10 43 days, 1/19 - Corr Surgery #4,  Caths #11 and #12  same time, 2/8-Cath #11 out - 21 days, 3/2- Cath #12 out - 41 days, 3/2- Corr Surgery #5, 3/6 Cath #13 out - 4 days, Cath #14- 27 days, Cath #15 - 26 days, Cath #16 - 31 days, 5/24 put in Cath #17

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