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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2004

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The verdict's in

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Dave - 30 Jan 2004 07:53 GMT
Got my results etc today:

PSA 10.8 (previously incorrectly posted 10.4)
Biopsy Jan 19 6 samples
T2a
PCa in 3 cores ( 1 at 7mm length) Gleason score 5 (2+3)
CAT scan and bone scan no abnormalities

Considering treatmnent options but leaning towards RP (pencilled in for
Mar 27)

Dave
c palmer - 30 Jan 2004 09:04 GMT
hi dave - looks like a good choice with the facts being presented.

radiation can also be used at this stage as well as you know.

the main thing is that YOU feel comfortable with your decision.

a couple of points in your favor of your decision is:

- the surgeon gets to be up close and personal with the pca and knows
exactly what you are dealing with.

- it is out of the body (the cancer)

- all the damage is done at one time, and healing begins right
afterwards

- you still have radiation as a back up option later if you were to need
it.

- painwise, it's not very bad at all.  the biggest problem you will have
is the waiting.

- keep researching. it will either make you question your decision or
make it more solid that ever.  

hope this helps you.

~ curtis

knowledge is power - growing old is mandatory - growing wise is optional
jimhoney - 30 Jan 2004 11:12 GMT
Dave,

I recommend a second opinion on the biopsy slides, especially because your
Gleason score is so low.

jimhoney

> Got my results etc today:
>
[quoted text clipped - 8 lines]
>
> Dave
dale.j. - 30 Jan 2004 11:36 GMT
> Got my results etc today:
>
[quoted text clipped - 8 lines]
>
> Dave

Dave

A 5 isent too bad, but sometimes during post op pathology they find it
at a higher number.  The doc actually felt something on the DRE?

Good luck on the treatment whatever that may be

Dale J.

Signature

Email:  dalej2@mac..com

Dave - 30 Jan 2004 12:18 GMT
.  The doc actually felt something on the DRE?

Yes, he could feel some enlargement of the gland.
dale.j. - 30 Jan 2004 12:40 GMT
> .  The doc actually felt something on the DRE?
>
> Yes, he could feel some enlargement of the gland.

Do you know what lab the biopsy samples were sent to?

If it's a big lab like Dannon where they do a lot then I wouldent think
another lab check would not be needed unless you have a high concern for
the quality work performed.  It's your call for sure and also consider
the cost of the second lab test unless your insurance covers it then
you'd be ok.  
The fact that they found IT won't change the outcome (you still need to
treat it someway) regardless of the score at least in my humble opinion,
unless of course the lab that did the reading of the slides are so
incompetient that they couldent tell the difference between a normal
cell and an abnormal cell.  THAT would be a big concern.

Dale J.

Signature

Email:  dalej2@mac..com

Alan Meyer - 30 Jan 2004 15:27 GMT
...
> Do you know what lab the biopsy samples were sent to?
>
[quoted text clipped - 3 lines]
> the cost of the second lab test unless your insurance covers it then
> you'd be ok.

I have to wonder about the quality of the big labs.  My HMO uses
Quest, which is a gigantic outfit.  Looking at their website, I see that
their 4th quarter revenues were $1.2 billion and their profits $108
million.  Talk about big bucks!

Quest graded my slides as 3+3, but the National Cancer Institute
graded them as 4+3, a very significant difference.  Quest said,
in effect, that grade 4 was not present even as the secondary
cell type in the biopsy.  NCI said it was not only present, but was
the dominant type.

So size doesn't impress me.  I still vote for individual pathologist
expertise over big company assembly line analysis.

> The fact that they found IT won't change the outcome (you still need to
> treat it someway) regardless of the score at least in my humble opinion,
> unless of course the lab that did the reading of the slides are so
> incompetient that they couldent tell the difference between a normal
> cell and an abnormal cell.  THAT would be a big concern.

I have wondered about that.  It seems that the same prescription is
given for all stages short of metastatic disease, i.e., RP or radiation.

What is the Gleason score used for in treatment planning?  Is it
used to decide whether to use hormone therapy or not?  Is it used
to decide whether adjunct radiation is required?  Does it affect how
quickly they begin treatment?

Hmmm.

  Alan
dale.j. - 30 Jan 2004 18:14 GMT

> I have to wonder about the quality of the big labs.  My HMO uses
> Quest, which is a gigantic outfit.  Looking at their website, I see that
> their 4th quarter revenues were $1.2 billion and their profits $108
> million.  Talk about big bucks!

I would be more concerned if they were in the red ink.

> Quest graded my slides as 3+3, but the National Cancer Institute
> graded them as 4+3,
>
> So size doesn't impress me.  I still vote for individual pathologist
> expertise over big company assembly line analysis.

What makes you so sure the guy/gal at the National Cancer Institute is
reading it right?  It's really a subjective analysis.  

> I have wondered about that.  It seems that the same prescription is
> given for all stages short of metastatic disease, i.e., RP or radiation.
[quoted text clipped - 3 lines]
> to decide whether adjunct radiation is required?  Does it affect how
> quickly they begin treatment?

Post RP pathology of the specimen will paint a much more clear picture
of what is or what was going on.

> Hmmm.
>
>    Alan

Signature

Email:  dalej2@mac..com

Alan Meyer - 30 Jan 2004 19:41 GMT
> > Quest graded my slides as 3+3, but the National Cancer Institute
> > graded them as 4+3,
[quoted text clipped - 4 lines]
>  What makes you so sure the guy/gal at the National Cancer Institute is
> reading it right?  It's really a subjective analysis.

You have a point.  I'm going on faith here that the National Cancer
Institute knows more about cancer than Quest labs.  I don't know
for certain that they're right.

I actually had 3 evaluations.  Quest, Greater Baltimore Medical Center,
and NCI.   The results were:

 Quest: 3+3
 GBMC: 3+4
 NCI: 4+3

In Patrick Walsh's book, he says that pathologists routine under-grade
pathology slides.  I'm assuming that he's right, and that the low grade
given by Quest is the more likely error than the high grade by NCI.
But I also met a lot of the people at NCI.  They struck me as more
than ordinarily knowledgeable.  I trust them.

   Alan
Steve Kramer - 30 Jan 2004 16:52 GMT
> .  The doc actually felt something on the DRE?
>
> Yes, he could feel some enlargement of the gland.

Enlargement of the gland is a minor indicator of something wrong.  You
already knew that.  It does not point to PCa.  At least not nearly as much
as finding a hard spot on the gland.

Signature

Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000
PSA  .1  .1  .1  .3  .4  .8
EBRT 05-07/2002 @ 47
PSA  .3 .2  .2  .2 .3
Erection 05/12/2003 @ 48
HTbegins 07/21/2003 @ 48
PSA  .1
Lupron 7/03, 8/03, 12/03

Steve Kramer - 30 Jan 2004 11:50 GMT
52 years old with 2+3 Gleason ....  I'd say RP also.  Do they have robotic
LRP there in AU yet?

Signature

Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000
PSA  .1  .1  .1  .3  .4  .8
EBRT 05-07/2002 @ 47
PSA  .3 .2  .2  .2 .3
Erection 05/12/2003 @ 48
HTbegins 07/21/2003 @ 48
PSA  .1
Lupron 7/03, 8/03, 12/03

> Got my results etc today:
>
[quoted text clipped - 8 lines]
>
> Dave
Dave - 30 Jan 2004 12:17 GMT
I'm not sure on that, although the procedure, in any case, is pretty
new.  I'm fairly comfortable with this guy, he's well experienced, does
about 50 RP a year, and is well recommended.

> 52 years old with 2+3 Gleason ....  I'd say RP also.  Do they have robotic
> LRP there in AU yet?
JohnG - 30 Jan 2004 16:08 GMT
> I'm not sure on that, although the procedure, in any case, is pretty
> new.  I'm fairly comfortable with this guy, he's well experienced, does
> about 50 RP a year, and is well recommended.

Welcome to the club, Dave, and to an exciting time in your life.   Not
that so much excitement is always welcome.  

Your Gleason numbers, etc., look promising.  

I am not sure that 50 a year is considered to be a lot.   I'm trying to
remember what was recommended in the book my urologist gave me -- maybe
it recommended finding someone who did about 100 a year, that that was
the number needed to keep their skill level up.   Or maybe it was 50,
and the one who did mine did about 100 a year (though I think he does
more than that).   Even if I could remember the numbers correctly, it
wouldn't necessarily say whether your surgeon is good or not.   All I
can do is point out that some practitioners have opinions about how many
of these a surgeon needs to do in order to keep their skill levels up.

Regarding your Gleason score, you might ask just where the slides were
read.  

The urologist who did my biopsy had the slides read at Urocore.   He was
the one who gave me the book to read, and when I threw the question at
him the question from the book about how many RPs he did in a year, I
wasn't entirely satisfied with his answer.   I got a 2nd opinion
elsewhere and had my surgery done by one of the good ones who learned
the procedure under Walsh.    This 2nd surgeon was impressed, though,
that my urologist had had the slides read at Urocore.  He said he'd have
his own pathologist double-check but given that my slides had been read
by the guy at Urocore, didn't expect to come up with different
readings.   And he didn't.

(I don't recall the author of the book I got from my urologist, but I'm
pretty sure it wasn't Walsh.)    

JohnG
Steve Kramer - 30 Jan 2004 16:51 GMT
I have no problem with RRP and the surgeons that do it.  But RLRP is to RRP
what a day is to a week when it come to recovery.

Signature

Prostate Cancer Survivor (so far), not a doctor
PSA 16 10/17/2000 @ 46
Biopsy 11/01/2000 G7 (3+4), T2c
RRP 12/15/2000
PSA  .1  .1  .1  .3  .4  .8
EBRT 05-07/2002 @ 47
PSA  .3 .2  .2  .2 .3
Erection 05/12/2003 @ 48
HTbegins 07/21/2003 @ 48
PSA  .1
Lupron 7/03, 8/03, 12/03

> I'm not sure on that, although the procedure, in any case, is pretty
> new.  I'm fairly comfortable with this guy, he's well experienced, does
> about 50 RP a year, and is well recommended.
>
> > 52 years old with 2+3 Gleason ....  I'd say RP also.  Do they have robotic
> > LRP there in AU yet?
Tee Doubleyou - 30 Jan 2004 18:06 GMT
>I'm not sure on that, although the procedure, in any case, is pretty
>new.  I'm fairly comfortable with this guy, he's well experienced, does
>about 50 RP a year, and is well recommended.

The number of 50 RPR  per year is rather small. I would start looking
for a more experienced surgeon. This is extremely important if you
care about being continent and potent son after the procedure.
Any surgeon or even senior resident can remove prostate but to spare
nerves is a totaly something else and requires a real skill.
Tee
Wakeley Purple - 31 Jan 2004 03:44 GMT
...
> The number of 50 RPR  per year is rather small. I would start looking
> for a more experienced surgeon. This is extremely important if you
> care about being continent and potent son after the procedure.
> Any surgeon or even senior resident can remove prostate but to spare
> nerves is a totaly something else and requires a real skill.
> Tee

It's also important to check the doc's record of success. My surgeon said he
did only ~25/year. However, he specializes in oncology, was highly
recommended by other physicians, and has an excellent rate of success
(including me).

However, I agree in general the more experience the better.

Signature

Wake

Age 58
PSA 3.8
Biopsy positive 5% in 1 of 10 cores
Gleason 3+3
T1c
RRP 1/12/04
Pathology agrees with biopsy
Negative margins

Alan Meyer - 31 Jan 2004 17:54 GMT
> ...
> It's also important to check the doc's record of success. My surgeon said he
> did only ~25/year. However, he specializes in oncology, was highly
> recommended by other physicians, and has an excellent rate of success
> (including me).

Wake,

What's the procedure for finding out a doctor's rate of success?

Do you just ask him?  I'm hoping there's a more objective way than that.

   Alan
Wakeley Purple - 01 Feb 2004 04:01 GMT
> Wake,
>
[quoted text clipped - 3 lines]
>
>     Alan

Good point. I don't know how you get factual reports since all that stuff is
protected by patient privacy, etc. I decided to trust what he told me, but
I also depended on the comments made by several doctors and others who said
essentially "he's the one I'd go to".

My wife was the real researcher. Having worked for 27 years at the hospital
I had surgery in, she asked the people who work with him and know his work
from the inside.

There's a limit to objectivity. I agree it's important to find somebody
that's in the high end of the skill distribution, but beyond that I think
the unpredictable variables of the nature of the disease, patient's
condition, unpredictability of metastatis, etc. overshadow the differences
between skilled docs. I think that's what can make it "a crap shoot" as
others have coined it. I tend to trust my gut feelings after doing some
basic research. That hasn't always been successful for me, but it feels
right and I'm comfortable with it.

The thing that really clinched it for me, though, was the report that my
surgeon sings to himself during surgery. 8)

Signature

Wake

Age 58
PSA 3.8
Biopsy positive 5% in 1 of 10 cores
Gleason 3+3
T1c
RRP 1/12/04
Pathology agrees with biopsy
Negative margins

SexyHeSays - 30 Jan 2004 12:25 GMT
Hi Dave-

I have to "ditto" everything Curtis told you!

Having recently 'been there" with a Gleason of 3+3, I suggest the possibility
you seek out another opinion on your slides, though, your Gleason is awfully
low!

Rus
Massachusetts

>From: PALMER_ENT@webtv.net  (c palmer)

>hi dave - looks like a good choice with the facts being presented.
>radiation can also be used at this stage as well as you know.
[quoted text clipped - 17 lines]
> keep researching. it will either make you question your decision or
>make it more solid that ever.  
MH - 30 Jan 2004 13:13 GMT
Hi, Dave....

Guess you are an *official* member of the club now.....

You certainly have time between now and March to study and weigh your
options.
Just choose whatever you feel is right for YOU..... it's different for each
of us.
Then, look forward.... never look back.

You're gonna be fine, guy!!

MikeH

> Got my results etc today:
>
[quoted text clipped - 8 lines]
>
> Dave
Outlivecancer - 31 Jan 2004 03:56 GMT
Hi,
welcome to the club,good that you got it early and young.A couple thoughts;
in Walsh's book it was not just the doc's experience but the facilities,mine
did a thousand RPs a year.Also robots might be good don't know about nerve
sparing,my doc had the feel to get a clear surgical margin.Two monthes seems
like a wait I had too much anxiety and a 4+3 to wait,
pounded on my doc and got 3 weeks including giving and typing 2qt.s blood and
other tests.Anyhoo I am wishing you good luck you got it early with choices.
Alan Meyer - 31 Jan 2004 17:58 GMT
> ... Two monthes seems
> like a wait I had too much anxiety and a 4+3 to wait,
> pounded on my doc and got 3 weeks including giving and typing 2qt.s blood and
> other tests. ...

Good for you!

I hate it when a doctor says, "You've got this thing inside you that will
eventually kill you, but don't worry, it's growing slowly....  Hmmm, let me
see what time I've got available ... Nope, golf on Wednesday ...
Nope, my inlaws are visiting next month ... Ah yes - I can take you two
months from now."

   Alan
 
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