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Re: What would you do given the following...............

Hi Tom F,

I, for one, absolutely agree that you can wait until November for your next biopsy. What I would recommend, though, is that you look into having your next biopsy be a targeted one, done with the aid of a CDU or MRI scan. While a standard TRUS biopsy is just a "hit or miss" procedure in that the Dr. cannot see your tumor(s), the scans I mention allow the Dr. to insert the needle directly into the tumor(s). The result is that you get a more accurate assessment of what is going on inside your prostate. To illustrate this, I cut and pasted this information on CDU/targeted biopsies from the Prostate Institute of America run by Dr. Bahn in Ventura, CA: "A target biopsy usually takes a fewer number of biopsy cores, but diagnoses 2-3 times more cancer than a systemic biopsy. It also comes with a higher Gleason grade and a higher stage of disease. It is not uncommon to see a systemic biopsy actually underestimate and under-stage a cancer". While it is not mentioned in the above quote, both the CDU and MRI scan are also capable of detecting perineural invasion, extraprostatic extension, seminal vesicle and lymph node invasion.

I think that most men and their doctors would agree that the single most important factor in practicing AS is your Gleason score. Although statistics vary on the subject, I have read that some 25 to 35% of patients who were found to be a Gleason 6 after their biopsy were actually discovered to have a higher Gleason score once their prostates were removed after surgery. While there is no way of knowing what your "true" Gleason score is without having your prostate removed, a CDU or MRI targeted biopsy is as close as you're going to get to knowing. In fact, if you visit askdrmyers.wordpress.com/ the highly respected Dr. Myers, who is a proponent of AS, says as much. More specifically, you can find his words to that effect in his video entitled "Active Surveillance Revisited" which is dated February 29th, 2012.

On Yana, a very recent post by Joe H on April 12th illustrates this greater insight into your Gleason score. He was initially diagnosed a Gleason 6, and on a subsequent MRI guided biopsy, he was found to have a Gleason 8 tumor.

One last point. When you go to make an appointment for a CDU or MRI targeted biopsy, you need to let them know that you do indeed want a biopsy as part of the scan. Personally, I had flown out to see Dr. Bahn and found that, based upon the scan, he felt the biopsy was unnecessary at that time. However, I insisted on it, and the biopsy revealed a small tumor that the scan missed, which is right up against the edge of the capsule near the left neurovascular bundle. (It should be noted that the scans do tend to miss small tumors which are felt to be insignificant, while picking up those larger tumors that are thought to be possibly aggressive). This small unseen tumor was revealed because I asked for him to biopsy not only the visible tumor, but also those areas that are a common pathway out of the gland; so I advise you to ask the Dr. to biopsy these areas as well. I say this because, even though the tumor was small, the nature of its location makes it anything but insignificant. In fact, Dr. Bahn was less supportive about my AS strategy after the finding than before. Still, I remain on AS at this time largely because the CDU scan/targeted biopsy confirmed that I was a Gleason 6.

Good luck,
Alan M in the USA

Re: What would you do given the following...............

Thanks Alan,
That was a pretty thorough response & clearly points out the best way to zero in on cancer in the gland, is with the CDU imaged suspect areas targeted for the needle biopsy procedure. I may actually go that route if this next sample biospy shows any progression of additional cancer areas in the prostate, but will wait until the fall to have it done as you agreed makes sense. Also, I was quite disappointed to find out the best active surveillance program I am enrolled in uses the random biospy technique as a on-going check for monitoring progression of the disease in the gland. Would have though a teaching institute such as the University of Washington in Seattle would have a better way to definitively assess the amount of disease in the total gland. As prevalent as prostate cancer is, I don't understand why more comprehensive procedures are not the follow up protocol after an initial cancer diagnosis.

Take Care

Re: What would you do given the following...............

How old are you Tom? That's a very important factor in my opinion. These prostate biopsies are nothing to look forward to. My Gleason was a 6 and my PSA a low 3.2 but my velocity was high such as yourself and they indeed found I had a Gleason 7 after I had my prostate removed and fully tested. I was told that this was often the case. Being younger ( 58 ) my Urologist said that in retrospect I made the right choice to have it yanked as the cancer was turning more aggressive and dangerous. I didn't want to continually keep going through the biopsy process when I kind of knew that I would eventually have it looked after anyways. It's a tough personal decision.

Re: What would you do given the following...............

I don't know or recommend, but here is what Rick K. did here in Michigan and is noteworthy: diagnosed in 1995-6 era psa 11.0 2 positive cores (back then 2+3=5) so today Gleason 6's (don't know further detailed pathology). He decided to do primary therapy doing drug combo Lupron+casodex+proscar (ADT3) or (CAB) for 13 months per Dr. Leibowitz concept, then quit and stay on proscar. He just recently got rebiopsied for the 3rd time after and no cancer is found (yet), still can do any treatment if wanted. He has normalcy as a man, he claimed. Of course it takes bravery to do this, but his results are fabulous, so for quality of life and future hold off for new options????? Not saying cured and he won't claim that either, but great results (yeah).

Re: What would you do given the following...............

G'day Tom,

I don't think you can draw any PSA velocity significance from 0.43 to 2.7 to 0.93. But the free PSA of 25% is a good sign, as is the 15% of Gleasons 6 in 1 core out of 14. Tom, I had a look at your Experiences story for a bit more background, such as your age.

If it was me, I would be having 3 monthly PSAs until June, 2013, and not having another biopsy until then, unless the PSA results give a pressing reason to do otherwise.

And rather than the June, 2013 biopsy being the very unpleasant transrectal nail-gun procedure, I would be having a 20 core biopsy through the perineum under general anaesthetic by a urologist experienced in this type of biopsy. This will also ensure much better sampling of your prostate. If this results in only one, two or even three cores of low percentage Gleasons 6, I would stay on AS with 3 or 4 monthly PSAs and, with a favourable PSA history, not schedule another biopsy for about four years, sort of like 2017.

As for AS programs at the local cancer centre, I think they are more likely to be of benefit to them and their research work, rather than to your needs and desires. If you are not happy about doing a follow-up biopsy so soon, maybe leave the program and manage your own AS program with protocols that suit you.

All the best from Brian in Australia.

Re: What would you do given the following...............Brian

Sounds like solid advice to me given the current numbers etc., thanks for your input!

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