I'll add my story of a guy who had his cancer revealed on his 10th (!) biopsy at age 69.
I had had many (negative) biopsies over the years from a rising, but fluctuating, PSA caused by a 20+ year history of BPH (no prostatitis). Finasteride and tamsulosin helped, but my stream progressively weakened until I needed a procedure. I chose a TURP in 2013. The biopsy automatically done on the removed tissue was negative for PCa (new prostate size 30 g, down from 90 g). After the surgery I could put out small forest fires with my stream. Checkups at my uro/surgeon went from yearly to every 6 months. There were one or two negative biopsies for rising PSA after my TURP.
A new nodule on the right in 2017 and a PSA rise from 3.6 to 4.3 (so about
7.2 to 8.6 correcting for the finasteride) led to my last biopsy, which came back with 2 positive cores of 14 total: G10 (5+5) 50% RB and G9 (4+5) 3% RLM. Surprise!
After this G10 biopsy, I had two visits with my uro to discuss options. He was crystal clear that surgery and RT were equally valid treatments and offered to set me up with an RO. To make a short story shorter, after researching and reflection, I chose an RP with my guy. He had done my successful TURP, was Duke trained, and had about
25 years of high-volume,
open RP experience. I wasn't interested in exploring RT modalities. I had decided from my research that for my case I preferred an
open to a robotic procedure, and, by coincidence, my doc does only
Chest, abdomen, and pelvis CTs, bone scan, and X-rays pointed to prostate-confined disease. (There was a questionable spot on one rib, but an X-ray series and comparison with a 2009 chest CT led the radiologist and my doc to agree the lesion had remained the same size and was likely an old bruise.) Since one lesion was at the right base, my uro said he was fairly sure he could save the left nerve bundle, but wouldn't know about
the right side until the surgery.
My doc chose to do frozen sections* during the
open RP (all came back negative). Using the anatomical template he judged appropriate for my case, he removed 16 lymph nodes (5 L, 11R). He was able to spare both nerve bundles and said he encountered no problems and that my prostate "popped out" (although surgery took 4 hours).
Gist of my 2017 path report:Surgical margins, extraprostatic extension, bladder neck invasion, lymphovascular invasion, seminal vesicle invasion, and lymph node invasion: all negative; PNI+, nerves spared
pT2c pN0 pMX, G9 (4+5) acinar adenocarcinoma**
5% of prostate (4.5 x 5 x 4 cm, 64 g)
(So my prostate had grown back about
half of the tissue amount removed in 2013.) I'm dry and ED is OK with sildenafil (which I had started taking on and off for my BPH a couple of years before my PCa); erections still improving and do occur without sildenafil. Interestingly, the nodule my doc had felt at the apex on the DRE turned out not to be cancer (about 50% of nodules are malignant)!
Around the time of my RP I had decided to have a Decipher test done. My uro ordered the test, but tissue was not shipped to GenomeDx because BCBS of NC had declined coverage. They claimed I was no longer high-risk, having no major adverse features post-RP! This, of course, is bull, as we all know: once a G8-10, you remain high risk. I paid a small out-of-pocket fee for my Decipher test:Decipher Score 0.37, Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
My five-week post-RP PSA was <0.1. (I didn't know it at that time, but my doc's joint practice uses in-house Labcorp equipment for PSA that tests down to 0.5 going forward after the initial 0.1 test done at the nearby Labcorp facility.) I asked my doc if we could follow my PSA with Labcorp's uPSA, which has a LLD (lower limit of detection) of 0.006. He agreed; however, I am the only patient he follows with it (he says he gets plenty of BCR lead time with the 0.05 test).
11-28-17 (3 m ) 0.010
02-26-18 (6 m ) 0.009
05-30-18 (9 m ) 0.007
08-27-18 (1 yr.) 0.018 ?
09-26-18 (13 m) 0.013 retest
11-26-18 (15 m) 0.012
02-25-19 (18 m) 0.015
05-22-19 (21 m) 0.015
08-28-19 (2 yr. ) 0.016
12-18-19 (24 m) 0.015
I'm buoyed by two stats I came across in papers. Of men who encounter BCR, two-thirds of them do so in the first 2 years. Several studies have been done about
the prognostic value of the 3-month post-op PSA (one proposing above/below 0.03 and another 0.01 as prognosticators of BCR). Another study found that at 3 years post-op, <0.04 is a very good indicator that BCR is unlikely (although we know BCR can occur even 20+ years out in rare cases).
At my 2 year visit, my uro said he was fine going from 3-month testing to 6-month, but I could choose whatever schedule I feel psychologically comfortable with, 3, 4, or 6. I chose 4 for this year, and, if my PSA is stable, I'll go to 6-month testing in 8 months, at the 3 year mark.
If you aren't familiar with it, there is a seminal Decipher paper, Decipher correlation patterns post prostatectomy: initial experience from 2342 prospective patients
there shows the Decipher score distribution for met risk (low, average, high) across all Gleason grades and pT stagings. For my cohort, G8-10 and pT2, the distribution is: 30% low risk; 24% avg. risk; 46% high risk
Note the not insignificant numbers for high metastasis risk for men who submit G6 and 7 tissue from their RP. (This does not mean G6 itself can metastasize, but rather that their PCa has a genetic makeup that makes it prone to forming lesions that are >G6, as seen in men who need to abandon AS for treatment because of disease progression.)
A recent study*** found that for high-risk PCa, surgery had a edge in long-term oncological outcomes over RT: Survival Associated with Radical Prostatectomy vs Radiotherapy for High-Risk Prostate Cancer: A Contemporary, Nationwide Observational Analysis
This paper said...
Conclusions In patients with clinically high-risk PCa, primary RP is associated with an overall mortality-free survival benefit compared to primary RT+ADT, regardless of baseline characteristics.
However, another study concluded there was perhaps no difference:Comparison of Radical Prostatectomy Versus Radiation and Androgen Deprivation Therapy Strategies as Primary Treatment for High-risk Localized Prostate Cancer: A Systematic Review and Meta-analysis
This paper said...
In the treatment of high-risk prostate cancer, many observational studies reporting higher mortality for radiotherapy demonstrate potential for confounding. More recent studies with current standard of care radiation regimens using androgen deprivation therapy or brachytherapy boost demonstrate approaching equivalence of prostatectomy and radiation modalities. Prospective randomized trials are needed to confirm these findings.
It's been a happy and lucky result -- at least until now -- from a very scary biopsy. I've found little data in the literature, but from what I've pieced together, I estimate the chances of someone with my biopsy having my outcome (pT2 with no major adverse findings) are roughly 20%. Adding in a low-risk Decipher score brings this down to about
6%. Of course only time will tell just how lucky I was.
Djin (apologies for the long post)
* Frozen sections are controversial. Sometimes what look like positive margins are actually artifacts. J. Epstein at MSK thinks they are not needed, with some exceptions.
** The most recent (8th
) ed. of the TNM staging guide has done away with the a,b,c subdivision of pT2. It was found it has no clinical value: for prostate-confined PC
, there is no correlation between the number or
location of lesions within the prostate and oncological outcomes (BCR and PCa-related death). Studies done since this update have confirmed the reliability of this change. This is why recent path reports state pT2 with no letters.
*** Surgery vs RT comparison studies often rely on BCR rates for their stats; however, given that only about
40% of men with BCR go on to clinical recurrence, I prefer longer-term studies that look at overall survival. Also, across-the-board generalizations are less useful than stats for specific categories of risk as well as specific RT modalities, like SBRT, which is showing very good results at about
15 years out.