89 year old - Orchiectomy?

Most grateful Sandra. Sorry I didn't reply sooner - I thought replies would go straight through to my Yahoo account. Clare

I agree with what has been said. There are different hormone treatments and these can work in different ways. Some men react badly to one or more but worth discussing possibilities with consultant before plumping for orchidectomy. Apparently cancer identified outside the prostate and HT or orchidectomy would work systemically as would chemotherapy. It is possible to have a biopsy of the prostate after RT, I am one of a number that have had this but unlikely in your Dad's circumstances as can't think of what other radical treatment a biopsy could lead to.

It goes to show that sometimes PCa can develop many years after a man might feel he has been cured by his primary treatment. It makes the case for continued monitoring over the years, albeit on a less frequent basis.

Hi Dave,

Firstly, I don't know whether I have misunderstood part of what you said as regards to Gleason score but it is arrived at following biopsy by taking the largest number of cancer cells first and giving them a grade. The next most numerous number of cancer cells is graded and then added to the first graded number to give the Gleason score. The first and most numerous grade may be higher or lower than the second depending on whether examination shows a greater or lesser number of cells that have deviated further from being normal cells. Thus in a 4+3=7 Gleason there is a greater proportion of more greatly deviated cancer cells than in a 3+4=7 Gleason. This grading is done at the same time. The calculation is the same whether the TRUS or Transperineal type of biopsy is used. The latter involves more cores generally using a template for more accurate positioning.

Where another biopsy is done after RT, the results may come out the same as before RT (mine were the same at 3+4=7) although the overall amount of cancer found was reduced. But it could have had a higher or lower grading depending how the cancer had gone. It could have been a small area that was not fully treated or where some radioresistant cells had survived or a new tumour grown. So in my case at least, the usual Gleason score was used. Ideally, an MRI first helps identify where to direct the needles to take cores. Cores are assessed not only to establish grade but percentage of cancer. To the best of my knowledge once Prostate cancer cells have deviated to the point that they are assessed at 5 they have reached the maximum grading regardless of how much further they have mutated. As there are so many types of cancer and possible mutations, PSA will vary.

If cancer cells have escaped a previously radiated Prostate and established elsewhere removing the Prostate surgically might help debaulk to assist some form of HT or chemo but it is very difficult to do and can result in other issues. Further radiation to a previously irradiated Prostate is not usually done. I was told that salvage HIFU would not be done outside the study I was on if cancer had spread beyond the Prostate.

In the circumstances of Clare's Dad, it is therefore most unlikely that a biopsy would be given but sometimes consultants have particular reasons for doing things differently.

RT can damage the cells in such a way that cells that are actually only mutated to a 3 may look distorted enough to be a 5. It is also known that HT can make cells appear more or less mutated than would be warranted by the seriousness of the cancer.

I am trying to think who it was that had a very frightening time when his post-treatment biopsy came back with a much higher Gleason than had previously been noted. He was subsequently referred to a new onco who was amazed that the first med team hadn't known that the Gleason would be unreliable.

We also had a member whose hospital always notes on the samples if the prostate that is being biopsied is a post-HT one so that the results can be calibrated.

I am overtired so not quite sure but could it have been Topgun? You can probably find it by using the search function (ha ha ha ha ha)

Dave,

It is clear that hospitals and sometimes individual doctors can have a different approach, particularly where PCa progresses and patients respond in various ways to treatment. It comes to a stage where oncologists use their experience to judge what might be the best way forward within certain limits for a particular patient. Some are more prepared to 'think outside the box'. Taking my own case for example, I had regular PSA tests following radiation which showed a very slow but persistent rise at each successive test. I asked at a subsequent consultation what level the PSA would have to reach before further treatment would be considered. I was told 2 plus my nadir which was 0.05, so 2.05, (the point of biochemical failure as normally defined) but was told in a latter telephone conversation with another doctor that possibly a PSA of 10 before treatment. Many months passed and I expressed to a junior doctor in another telephone appointment my concern about the continued rise in my PSA. With a bit of prompting from me she said she would discuss it with her consultant. Although it was only about 1.66 at this point he felt that 'something was going on within the Prostate' and agreed to an MRI scan, (so a more proactive approach). He was right because the MRI showed a new tumour. I was subsequently referred to UCLH and had 4 scans and a transperineal biopsy and HIFU salvage therapy when my PSA reached 1.99. A month after the HIFU and with no HT to confuse the reading, my PSA had fallen to 0.42, so it got some if not all the cancer! Incidentally, UCLH wanted to put me on HT additionally because they said I also had a cancerous iliac node. However, I showed scans and biopsy to 3 other hospitals and none of them were convinced that this iliac node was cancerous so I have not started HT and will not do so unless there is a significant rise in PSA.

I have unanswered questions too but feel the foregoing illustrates how opinions and approaches can change and even scans be viewed differently. I will not elaborate further Dave as although this may be of interest to you, I don't think it will help Clare

Edited by member 28 Jan 2016 at 23:56  | Reason: Not specified

Cryotherapy is a possibility for salvage therapy after RT (and some have it as a primary treatment). I was told I would have been offered it if the location of the tumour in my prostate did not favour HIFU. Perhaps like HIFU, it is only generally offered (except in trials) if the cancer is not believed to be present outside the Prostate? Nanoknife IRE is a more recent development. This delivers short bursts of electricity through probes to blow holes in cancer cells and damage them irrecoverably . It has been trialed recently in the UK for PCa but is not presently available in the UK for PCa , although it is being used for some other cancers. So, discounting surgery for reasons previously mentioned and RT not being done again over previously used pathways to the Prostate, the above are alternative ways of attacking tumours directly other than systemically, although these treatments can be augmented by HT and Chemotherapy where considered appropriate.

Lyn is correct, HIFU (and Cryotherapy) are comparatively rare but are becoming increasingly used. I don't know if this is the case with Cryotherapy but certainly HIFU can be repeated again if necessary, which can be very useful. As it happens I have very recently received a long letter from UCLH sent to men participating in Focal Studies and will just give the gist of what may be of interest. It says that over a 1000 men have been treated with HIFU at UCLH since they performed their first treatment in October 2004. There were 2 clinical trials back then and there are some 15 active clinical trials now. ...."outcomes are inevitably variable, the vast majority of cases that are under our care have shown that compared to traditional treatment options this new pathway reduces side-effects and complications with good disease control."

HIFU is now available at a number of centres across the UK including North Hampshire Hospital; University Hospital Southampton; The Princess Alexandra Hospital and several others doing focal therapy using cryotherapy. Combined between these centres they are close to treating 2500 men with the the number growing each year. 2015 has seen work resulting in the Food and Drug Administration (FDA) in America approving the use of HIFU for treating Prostate tissue. This achievement due in part as a result of the work undertaken in the UK

Edited by member 30 Jan 2016 at 02:34  | Reason: Not specified

Dear Everyone

 Huge thanks to everyone’s thoughts. So interesting. Sorry I haven’t replied until now, I’ve been busy getting Dad sorted.

My husband and I and dad, all went back to the Urologist and asked a lot of questions. We saw the CT Scan and the Dr explained he wants to move fast as Dad’s tumour is fast growing and in his pelvis too. I think it’s also in the lymph (didn't quite take that in) and await a bone scan before we know if its in the bones.

 Dave /Lynn– you are right about the radiation. He can’t have that again.

 Barry/ Dave/Lynn- thank you for your thoughts about the biopsy.

Basically it’s a dangerous procedure. Dad being an ex dr seems to know he shouldn’t have one if poss.

 Barry – you are right about HIFU. They can’t do this as the cancer has progressed outside the Prostate sadly. This sounds a great option for anyone otherwise.

 So, we’ve opted for the Orchidectomy on Monday. All I can say is that we all feel - our gut instinct says - that it seems to be the best solution for Dad. Dad is really very sharp still and feels convinced by this too. The urologist said he’s doing lots of elderly men in Hampshire and with very successful results. The op will be under a local anaesthetic and I just hope the Urologist was right when he said there were few side effects. I do know full well that any procedure is going to knock dad at his age though. 

Re the HT - Dad being an ex-Dr doesn’t’ like taking pills – it's strange when he’s prescribed so many! He had such a terrible reaction to the Bicalutimide and I think that’s put him off the HT. I think the urologist felt that he was likely to react to the Degarilex too.

I did a crazy thing this week and wrote to the top prostate chap I’d seen on the TV months back – that show called ‘Harley Street’. I couldn’t believe it – he actually called me yesterday! probably because I had written that Dad had been a doctor - not sure. I had emailed him Dad’s scans and after questioning me why dad wasn’t going for the HT, he ended up saying he knew our Urologist, had complete faith in him and thought an Orchidectomy would be the right option for Dad.

 We shall see. I will let everyone know the results of the ochidectomy in case it is useful for the older members of the group to consider. It certainly sounds straightforward - lets hope it is.

So grateful for all your thoughts

Wishing you all the best of health.

Clare

Thank you Lynn for all your help - you seem to be a wealth of information. I hope we are doing the right thing. Clare

Many thanks. Will do. it's so important to learn from others. Thank goodness for the internet!