Pi-Rad 5, PSA 8.4, (last year, 5.3)

The PIRADS score tells you nothing about how aggressive the cancer is. It just means they looked at the MRI image(s) and spotted something which has a high probability of being cancer. 

Until they do the biopsy they won't know if it is cancer and if so what Gleason grade it is. The image probably does show them whether it is contained in the prostate. After my MRI and before the biopsy the nurse said, "if it is cancer, it has spread beyond the prostate" (extra prostatic extension).

I suspect that they aren't telling you much, because until the biopsy there is not much they can tell you, and it isn't good to give you half the story.

I think you need to know all the details before you start thinking about treatment choices. If it turns out you can be cured with 5 doses of radiotherapy and no HT (appropriate for some cases), having a major operation sounds like overkill.

If you have lesion identified as PIRADS 4 it has a 50% chance of being clinically significant cancer if it is PIRADS 5 it has a 90% chance of being clinically significant cancer. So this might lead to a grim diagnosis, i.e cancer, but it is too early to talk about a grim prognosis.

You and the medics need all the test results, and it needs to be discussed by the MDT before a firm diagnosis exists. Then you can think about your prognosis. If you have metastatic cancer (which you have no evidence of until you have a bone scan) then the prognosis is grim (five to ten years in most cases). If you have extra prostatic extension, which is more likely with a large tumour, and a pirads 5 lesion is usually large so if it is tumour it is a large tumour, then you have a higher risk that some cancer cells have migrated. I would not say that was a grim prognosis because radiotherapy to the pelvis has a high chance of killing all the cancer.

If you have cancer with extra prostatic extension identified at diagnosis, most surgeons would not want to treat you, recurrence is quite likely in that case. If it is identified during surgery they will do their best to remove it and you may get lucky.

Thank you Madam. That would be a significant relief to score a Gleason 6, allowing active surveillance, presumably, at least for a while. 

When I first found out about the PI-RAD'S 5, I expected the worst scenario, including spread outside the capsule. The way pirads5 is presented - it looks very grim. 

Thank you. Crossing my fingers for a biopsy that will yield a finding that the cancer has been contained within the capsule. In that case, I think more options might be available depending on the Gleason score and other factors. 

Nah, it's like one of them murder mysteries where it turns out he's got a twin brother. 😉

Indeed the human body is a wonderful thing to behold. (Which used to be one of my chat up lines)

Joking apart I suppose it's the ultimate cure to train the body to self heal.

I also often wonder whether our particular disease has inflicted men throughout history. Whether cavemen suffered from it. Perhaps I've got too much time on my hands.

Edited by member 22 Dec 2023 at 12:50  | Reason: Not specified

I think there's some truth on both sides because there is some evidence that drinking green tea, for example, is somewhat protective for ailments like prostate cancer going by multi generational studies with populations who drink a lot of green tea such as in Japan, and at the same time it is true and undeniable that the allure of money from pharmaceutical companies may diminish the ethics of many medical doctors but we have to look at the whole issue from a global perspective and try to work out what is best.

What is regrettable, once you have been diagnosed with prostate cancer, especially if it spreads beyond the capsule,  is that only palliative care can be given and there are no proven cures.

A friend of mine, in his 60s, was recently operated on for prostate cancer (Gleason 4+5, PSA 18), and had his prostate removed but after removal the surgeons told him that they found some cancerous cell evidence had gone beyond the prostate and that there was a 30% chance that the cancer would return. This was after having this prostate removed. He's philosophical about this. 

The good news, if you can call it that, is that the older you get the slower prostate cancer progresses. 

Thank you, Sir, good luck. 

That's not true - I think you have confused 'spread beyond the capsule' with 'metastatic spread'

Palliative care is what is given at the end stages of life - usually considered to be the last 3-6 months when all active treatment has been stopped and only treatments to keep the person comfortable / mobile are being given

Noted with thanks, Madam, and apologies for jumping the gun on this one as well. 

Having said that, the idea that only performing the minimum amount of treatment based on age, quality of life and life expectancy is nothing new and has been around since the dawn of modern medicine. Someone in their 80's is far more likely to be offered palliative care than a radical medical procedure.

Given that PCa is a slow growing cancer, and that it is generally accepted that most men will die WITH PCa and not because of it - non-treatment is definitely an option in the older generation in order to maintain QUALITY of life in their final few years.

Now, you mentioned that this doctor was American and that adds another slant to it. Having lived in the US for 14 years, you develop an understanding of how the American health system works and the huge power, both financially and politically of the drug and medical care companies. The system works of action and procedures - not on let's wait and see. You are much more likely, regardless of age etc, to be offered a full set of procedures aimed at cure in the US than probably anywhere else simply because, for those that can pay and/or have the insurance, the medical resources are virtually unlimited.

The idea of getting a second and third opinion is also a stateside process - you might manage it under the NHS but you will probably be waiting a very long time.

You don't mention your age and where you live - both will influence what treatments are offered.

I'm having a biopsy tomorrow and if the result indicates that cancer has spread outside the capsule and potentially later becomes metastatic (almost a certainty ) making surgical procedure such as prostatectomy impossible or ill advised I'm wondering if anyone has ever considered to opt not to be treated with hormone therapy and radiation in the following months and years because especially with hormone therapy it does not appeal to me at all with the side effects and everything else. 

The side effects of hormone therapy including diabetes, impotence and other things are of great concern I feel but it seems many people or most prostate cancer patients accept the hormone therapy and chemical therapy if their Gleason score is in that number range (9/10) where surgery is not advised or possible. It is stressful just to think about all of this.

Thank you. 

Thank you, Sir. I'll keep that in mind. 

Just for the purpose of clarity, HT does not cause impotence - it causes a loss of libido. In other words, many men can still get an erection but have no desire to use it. The impotence is caused either by radiation damage to the nerve bundles (often 5 - 10 years after the RT was actually delivered) or by penile atrophy, which is irreversible.

Also, prostate cancer can be fully contained within the gland but still be metastatic.