So two weeks ago, I finally nailed down my treatment. My earlier thread on this was titled “Treatment Thoughts”. Normally, I would just add to that tread but with the new format I decided to start a new tread. Hopefully, that’s alright. Here’s the brief recap:
PSA shot up in December to 13.6 April MRI had one Pirad 4 lesion and PSA dropped to 10.2. May biopsy was Gleeson 3+4 with one of eight needles coming back positive with 80% of the core but only 10% was grade 4. Want just SBRT but the Radiologist said I needed ADT because the high PSA placed me as Intermediate Risk Unfavorable. He did say if the Decipher Score came back low I could forego the ADT but unfortunately it came back as .85. Got a second opinion from a different radiologist and he said because of the Decipher score he considered me high risk and not only was ADT a certainty but he thought I should also have 21 sessions of EBRT of the pelvic floor as a precaution for microscopic spread. My PMSA scan was negative so I didn’t even imagine this was on the table.
Am I being careless with my health if I just do SBRT and ADT? I agreed to four months of Firmagon (got the first shots today)and if I tolerate it I would be willing to extend it another month or two.
Hi Lime:
I don’t think you’re being careless with the SBRT and ADT but you do have quite the dilemma. Of course I can’t tell you what to do but can advise you what I would do in your situation. As discussed in your previous thread, you did not get a second expert opinion on your biopsy slides; I suggest you do that with Epstein or JHU. This is a big decision and your peace of mind is worth a few bucks.
The second opinion can confirm:
- Is it definitely 3+4 rather than 3+3 or 4+3?
- How much pattern 4 is actually present?
- Is there cribriform pattern 4?
- Is there intraductal carcinoma (IDC-P)?
The last two would matter to me. If an expert review found significant cribriform/IDC-P or upgraded the cancer, I’d become considerably more sympathetic to the second RO’s aggressive approach.
However, if the second opinion confirmed the original pathology, then I would be more comfortable with the original decision, i.e. SBRT/ADT. I do think if you tolerate the ADT well then you might be better off with 6 months rather than 4 but that’s a marginal decision as well.
Good luck. Please update us as to how you progress.
Jim
A second opinion on pathology is a good idea. A eight needle biopsy could also miss some cancer which gives the Decipher of 0.85 more weight.
The time advantage of SBRT is pretty much lost when adding 21 sessions of EBRT and possibly increases side effect risk. You could always get another opinion.
It really depends on your confidence in the low intermediate assessment vs. high Decipher score. Tough decision based on the info you currently have.
I’ve decided upon SBRT and four to six months of Firmagon depending on how I tolerate it. Friday was one week on Firmagon and it’s already dropped my PSA from 13.0 to 8.49 and my testosterone from 493 to 33. Got the SpaceOar and the fiduciaries placed yesterday. I’d read on another forum(taking the guy at his word so may or may not be true) where someone replied to someone else asking about prophylactically treating lymph nodes and he stated the Mayo Clinic won’t do that for even high risk prostate cancers and prefers to deal with recurrence if and when it happens. That makes sense to me. My PMSA scan was negative and I just can’t treat additional areas and risk incurring additional side effects because they “might” have cancer. Since I was in Active Surveillance for eight years and this was a new lesion that wasn’t on my 2024 MRI I’m hoping we caught it early and I’m hoping the six months of Firmagon will deal with anything the scan didn’t pick up. I really appreciate everything you guys have done for me over the last eight years and especially this year. Thank you.
It would be nice if PCa was simple and there was one treatment that applied to all men. Alas, there are many shades of grey and opinions regarding a disease that is many times not a life threatening problem.
Usually decisions are made to the best of one’s ability based on limited information and personal preferences informed by doctor and others’ opinions.
The only thing to remember, no regrets regardless of what happens. No one will have enough information to make a perfect decision but no decision is not an option.
Lime, sounds like a plan! When does your treatment start? Please drop in and let us know how it goes. Best of luck to you.
Jim