PSA 74, Gleason 9

My husband, (age 64) was just diagnosed with Prostate Cancer. His biopsy results came back with a T2 aggressive, Gleason 9, PSA 74. The doctors said he needs to start hormone therapy asap and after two months he can either choose to have 45 regular radiation treatments, or 26 hypo fractionated treatments. There are two lymph nodes close to the prostate that they also want to radiate. We went to see two doctors and one said he wants to use the regular radiation treatment and the other wants to use hypo fractioned treatments. We don't know which one to choose. Both have their downfalls. We can't find enough research on the web about the differences in risk factors between them. Any help you can give us would be greatly appreciated.

jmg153 said...
My husband, (age 64) was just diagnosed with Prostate Cancer. His biopsy results came back with a T2 aggressive, Gleason 9, PSA 74. The doctors said he needs to start hormone therapy asap and after two months he can either choose to have 45 regular radiation treatments, or 26 hypo fractionated treatments. There are two lymph nodes close to the prostate that they also want to radiate. We went to see two doctors and one said he wants to use the regular radiation treatment and the other wants to use hypo fractioned treatments. We don't know which one to choose. Both have their downfalls. We can't find enough research on the web about the differences in risk factors between them. Any help you can give us would be greatly appreciated.

thankfully they didn't recommend surgery! you've come to the right place to learn the differences in treatment. good luck to you both.

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age - 64
12/09 - PSA 6.8
G7 - 3+4 - all 12 cores pos
HT, BT, IGRT
6/18 - 8-year post treatment PSA .1!
PSAs .2, .3, .2, .3, .2, .1, .2, .2, .1, .1, .1, .1, .1

"..You get braver as your options dwindle.." -- Fairwind

https://instagram.com/edraderphotography/

my thought exactly. depends on who you ask. but hey no recommendation for surgery!

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age - 64
12/09 - PSA 6.8
G7 - 3+4 - all 12 cores pos
HT, BT, IGRT
6/18 - 8-year post treatment PSA .1!
PSAs .2, .3, .2, .3, .2, .1, .2, .2, .1, .1, .1, .1, .1

"..You get braver as your options dwindle.." -- Fairwind

https://instagram.com/edraderphotography/

Sorry to hear your news, hang in there and try to not get too excited or stressed. This is not something that has to be tended to over the weekend.

I assume the T2 classification came from MRI scans? Was the biopsy MRI guided? There will be a lot of questions so try to get the pertinent data in your signature or added to this thread.

No idea on which radiation is best for this but the G9 high risk situation may limit options based on some limited studies I have seen. Sounds like you need a tiebreaker so you should consider an opinion from possibly a well known cancer center where multiple doctor types can take a look at your husband’s situation and all treatments are available so they can agree, disagree, or offer other options.

Good luck

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7/2018-66yo,PSA 4.1->5.1
8/2018-MRI, PI-RADS 5
8/2018-MRI Biopsy, 4+3
9/2018-CT/Bone clear
11/6/18-RALP @ St. Johns
11/2018-Post-Op Path G7 (4+3) 5% Tert Gr 5, pT3a pN0 Grade 3
Pos. Marg (SM+), EPE, <3mm, L=0.1mm?
11/2018-Decipher 0.47, Ave. Risk, 4.3%/4.8%
1/2019-Epstein-G9(4+5) Gr5
“Difficult to distinguish EPE vs intraprostatic incision, 3mm” Extent:pT2x
2/2019-PSA<0.10
4/2019-Begin ART

Radiation Oncologists get paid by the treatment..A treatment of 45 doses pays twice as much as a treatment of 26 doses...This is the main reason that the hypo fractionated treatment has been slow to catch on...Another factor, todays radiation equipment called LINACS are MUCH improved over what was being used just a few years ago.. Be sure he is being treated on a Varian Rapid-Arc or newer machine. This machine and its siblings are able to accurately aim the radiation beam precisely at its target and avoid most of the damage to healthy tissue. This is what makes the 26 fractions safe and effective..

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Age now 75 . Diagnosed G-9 6/2010. RALP, Radiation failed
Lupron, Zytiga, PSA <0.1 10/16 no change <0.1 5/17 PSA 1.6 Chemo or Provenge next..Sept '17, PSA now 9.2. ADT including Zytiga has failed. Will investigate treatment options. 11/17 PET/CT clear, but 4 new bone mets..Going to try Xtandi...3/2018 PSA now 54, chemo next. 5/10/18, PSA 200, Dosetaxel started..5/19 PSA300. R-223 ?

Another approach that should be considered by high risk men is a combination of external beam radiation (IMRT) and High Dose Rate brachytherapy. I used the combination very successfully as have some others on the forum.

Where are you located?

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PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 since February 2011. Located in Cumming Georgia north of Atlanta

jmg153 said...
My husband, (age 64) was just diagnosed with Prostate Cancer. His biopsy results came back with a T2 aggressive, Gleason 9, PSA 74. The doctors said he needs to start hormone therapy asap and after two months he can either choose to have 45 regular radiation treatments, or 26 hypo fractionated treatments. There are two lymph nodes close to the prostate that they also want to irradiate.

Considering the seriousness of this case, I also recommend that you both look into a 'triple play'. In other words, a combination of hormone therapy and two modes of radiation. My own case (see below) wasn't as advanced as your husband's, but that is what I ultimately decided on. I had SBRT (Stereotactic Body Radiation Therapy) as one of the modalities (in a clinical trial), but brachytherapy is more conventional. But one needs to find a RO or group that has serious experience in those areas.

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DOB 1940
Dec 2012: GP felt a nodule and hardened prostate; confirmed by urologist
PSA: 11.9 ng/ml
Biopsy (3/1/2013): Several Gleason 4+5 loci (prostate=45 ml)
Stage: T2c
Transferred to RO
Casodex 1 month; then Lupron 5/13 through 12/14 (18 months total)
Jul-Sep 2013: SBRT (CyberKnife; 3 x 6.5 Gy) followed by IMRT (25 x 1.8 Gy)
Lowest PSA thereafter: 0.1 (3/20/15)
Latest (09/18) PSA = 1.4 ng/ml

Please look at this article before you decide on hormone therapy. Really trying to be informative rather than upsetting. Earlier this year, my husband died at the age of 50 years old after only 1.5 year battle with prostate cancer that morphed into poorly differentiated neuroendocrine carcinoma.

He was diagnosed at 48 years young with prostate cancer, Gleason score 9 post radical prostecemy, with residual PSA 2 or less post surgery (26+ PSA pre-surgery). Dr. T (radiation onc) at CCF recommended EBRT and lupron. The lupron (androgen deprivation therapy) worked against my husband (and does so in 20% of cases per this study) - and exacerbated the cancer to a highly aggressive (poorly differentiated) neuroendocrine carcinoma in his liver and spine.

https://journals.lww.com/oncology-times/pages/articleviewer.aspx?year=2015&issue=02250&article=00003&type=Fulltext

I remember NewHere and her husband from her few posts here. He was so young and nothing seemed to work. Sad. From the article it sounds like they may be finding ways to identify and help men like him going forward.

But, a few comments about the numbers:

The paper said...
"Neuroendocrine prostate cancer is a high-risk, lethal subset of disease, often referred to as representing only two percent of all diagnosed prostate cancer. In fact, though, it [bold]probably occurs far more often[/bold] because the disease is not recognized as different from metastatic castration-resistant prostate cancer. That was the word from Himisha Beltran, MD, Assistant Professor of Medicine in the Division of Medical Oncology at Weill Cornell Medical College, speaking here at the Chemotherapy Foundation Symposium."

"Men rarely undergo biopsy of their tumors once those tumors have spread to bone or soft tissue regions of the body, Beltran noted. So while only a few prostate cancers are diagnosed originally as neuroendocrine prostate cancer, many cases that develop after adenocarcinoma has evolved into neuroendocrine prostate cancer go undetected. She estimated that as many as one quarter of patients who are dying of prostate cancer are dying from treatment-related neuroendocrine prostate cancer."

Note that the two percentages -- 2% and nearly one quarter ~20% -- are based on different populations -- 2% of all men diagnosed vs 20% of men dying of prostate cancer. A small percentage of men diagnosed go on to die of the disease so that 20% of men who subsequently die represents a small percentage of all men diagnosed. Actually, I wouldn't be surprised if the two percent figure turned out to be bigger.
The takeaway here is that if you are known to have neuroendocrine prostate cancer you should probably stay away from hormone therapy. But neuroendocrine prostate cancer is rare and hard to identify. Most cases are identified, if at all, by the progression of the disease in its later stages. If all you know is that you have prostate cancer then you should remember that the 2% of men who will respond poorly is baked into the statistics for the various treatment options. For a mix of men diagnosed with high-risk prostate cancer, a few percent of whom may respond poorly to treatment, radiation will cure some percentage and radiation plus ADT will cure some larger percentage. Unless they find an effective way to screen for neuroendocrine disease earlier in the process you have to go with the overall stats for all high-risk men in making treatment decisions, and overall ADT seems to improve the results with some forms of radiation treatments.

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65 Slow PSA rise 2007-2012: 1.4=>8
4 bxs 2010-2012: 1&2 neg, 3 pos 1/14 6(3+3) 3-4% (2^nd opn. 7(3+4)), 4 neg
DaVinci 6/14/12. "some" nerve sparing on left
Path: pT3a pN0 R1 GS9(4+5) Pos margins on rt
24 mo ADT3 7/12 - 7/14
Adj IMRT 66.6 Gy 10/17/12-12/13/12
8/2012-3/2015: Incont., Trimix, VED, PSA<0.015.
AUS & IPP installed 3/5/2015
Forum Moderator - Not a medical professional

Post Edited (PeterDisAbelard.) : 5/31/2019 8:54:14 AM (GMT-6)