Gleason 6, AS or immediate treatment?

Hello mate.

Welcome to the forum. I'm sorry that you've had to find us but glad you have.

We are not clinicians and views on suitability of AS vary a lot on here. I believe there is no doubt that the AS option is becoming and more frequently used.

https://www.cancer.gov/news-events/cancer-currents-blog/2022/prostate-cancer-active-surveillance-increasing 

The ProtecT Trial focused on a huge sample of men with low grade, low volume cancer and compared the outcomes of those electing surgery, RT/HT or Active Surveillance. After 10 years, it transpired that there was very little difference in the outcomes of the 3 treatments.

It appears that thousands of men are having radical treatment when it may never be required.

I was initially diagnosed with cancer that met the criteria for AS. I thought it was a no brainer to take that option. Unfortunately I was amongst the 30% who fail AS. My disease progressed and I ended up having surgery.

For those selecting AS my only strong advice would be make sure the surveillance is active and ensure that you are being monitored correctly, with follow up PSA checks MRIs etc.

You do need a certain mindset for AS. You've got to be able to live knowing that you have the disease, and knowing that it may progress. Personally I found the anxiety of AS a lot easier to deal with than the anxiety of recurrence after surgery.

Best of luck with whatever you decide.

Edited by member 21 May 2024 at 10:43  | Reason: Typo

As I said I'm not medically qualified. It would inappropriate for me to comment on the exact nature of your specific disease and the risks involved for you to opt for AS.

All I'm saying is, if my clinicians told me I was suitable for AS, it is the option I would take. The beauty of AS is you can always opt out and elect radical treatment if the need arises.

Prior to surgery: Gleason T2 6 pirads4 PSA:5.6

post surgery: Gleason 7 (3+4) T2c PSA <0.006

It’s quite a journey. I don’t have a single regret over having a retzius sparing RARP with neurosafe. Choosing a high volume surgeon and top rated hospital I found helped mitigate a lot of concerns. 

if I did it again I would have done it earlier as best to remove cancer as soon as possible in my view. Cancer can spread at any time…that’s the simple pathology of the disease although less likely in early stages. I whip it out when low grade rather than roll the dice waiting for potential prostate capsule breaches. Biopsy can also setup an environment for mets and hopefully in a few years tests and scans will reduce their need.

i looked at focal therapies extensively but wasn’t suitable as my disease was in all four quadrants of the prostate. PCa tends to be a multifocal and in my case this was reinforced by histology which picked up smaller medium grade cells which were missed on biopsy (fairly common). I was also mindful that focal therapies tend to just kick the can down the road in any case and would likely end up needing RARP as some point which would be more complex.

What have a learnt from this journey? Maybe us guys should be offered a baselining PSA test when around 40. Get a second opinion and find a verified high volume surgeon who is regarded as outstanding in their sphere and pioneers the field.

Edited by member 22 May 2024 at 14:23  | Reason: Not specified

Hello yes please ask him for this surgeons in spain.

Well, most here say that the surgery is quite bearable and with little post-surgery pain,
Some even say that it was worse to wear the urinary catheter for 2 weeks.
So far it is the most difficult decision of my life because I have a lot at stake.
In my case on paper, only unilateral lesion, so the balance must tip according to the reliability
we give to the MRI/biopsy

B.R.

Will ping him an email later today as he's probably in surgery now.

Yes, surgery wasnt anymore involved for me than having tonsils out. Catheter was annoying but you get used to it and the associated management. 

My mind was exploding after diagnosis so know how you feel.

I would find a surgeon who is at least high volume. The general accepted classification for high volume in the UK is >100 RARPs a year. I think my prof was 3-4x this number. 

Retzius sparing is apparantly a more complex approach but it tries to avoid disturbing the nerves which control urinary management. I think fundamentally it means faster continence post surgery. Longer term there isn't much difference I think with conventional (anterior) robotic surgery in terms of continence stats. 

NeuroSAFE is see as a no brainer as it basically means a rapid pathology is done to check if cancer cells are on the anterior of the prostate while the patient in open on the surgical table. In the UK is started to be rolled out on the NHS as add a superb level of near real time visibility and hopefully extra reassurances that no cancer is accidently less behind and nerves removed that could be spared.

A few of asked about best prostate cancer clinics in Europe...apparantly the Martini-Klinik Clinic in Germany is very well regarded if you can't locate a top surgeon closer to home.

Edited by member 22 May 2024 at 16:35  | Reason: Not specified

@quique no luck unfortunately with names of surgeons in Spain. 

if you decide to go abroad for treatment maybe drop me a line let me know.

I think the single port Da Vinci robot is now being used at London Guys Cancer Centre.

Cheers

simon

Edited by member 22 May 2024 at 21:11  | Reason: Not specified

Hello again, reviewing my MRI reports I have been able to read that my gleason 6 lesion reaches the prostatic margin... but there is no deformity of the surrounding fat or evidence of extraprostatic extension...
It is surprising that the urological clinical guidelines and inclusion criteria in AS do not take this into account as a critical element when making an accelerated decision about radical treatment or surveillance.

B.R.

Edited by member 04 Jun 2024 at 15:29  | Reason: Not specified

That demonstrates that the cancer is not developing very fast - personally I wouldn’t be concerned about that ATM. However, at sometime development will speed up and you’ll need to make a decision. Have they suggested HT to slow down the development?