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Urology/Prostate cancer : Gleason Score 7 ( 3+4 ) & PSA 4.24

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QUESTION: HEllo Doctor,

My father had undergone TURP surgery at the age of 74 after about 4 years various medicinal treatment of prostate enlargement. His PSA level pre-surgery was 4.92. Post surgery ( 2 months later ) PSA level was reported 1.62. However, the biopsy showed Prostate cancer with Gleason score 7 ( 3+4 ). Doctor advised active monitoring. After one year, now the PSA count is showing 4.42. Pl. let me whether he should go for any further diagnosis such as PET CT scan or Bone scan or we should continue to monitor PSA level. Pl. advice what should be our next step. He has been doing fine now. Thank you very much

ANSWER: Rupesh:

With the PSA going from 1.62 and a year later it's 4.42 which is almost 3 times higher.  This needs to be considered carefully.  His PSA doubling time is clearly less than 1 year and with a Gleason score of 7 (3+4) a careful discussion needs to happen to discuss further treatment.  If his health is good and he would accept treatment, definitive radiation therapy would be the most acceptable.  A bone scan prior to such a therapy would be helpful and recommended.  

Further observation and monitoring when the PSA is increasing rapidly and the cancer is relatively aggressive (All Gleason 7's are considered aggressive) may not be a good idea as the cancer may now be treatable and potentially curable.  If it spreads outside the prostate, then a cure is no longer possible.

Also consider getting a second urology opinion if his physicians are not interested in further treatment right now.  I am undertain why they did not have such a conversation back when he had the surgery that indicated a significant cancer in the prostate.

We don't typically recommend observation in Gleason 7 disease except in patients who have limited life expectancy or are not candidates for definitive therapy for some reason.

---------- FOLLOW-UP ----------

QUESTION: Thank you Dr. Stephen, Really appreciate you suggestions.

Wanted to provide few more inputs : The Biopsy report ( at the time of Surgery ) showed perineural invasion. Also, he had undergone two surgeries earlier ( Spine surgery for disk prolapse about 9 years ago and Laperoscopic surgery of Gall Bladder about 6 years back ). Currently, he is in good health and showing no symptoms of weakness etc.
My parents are averse to Radiation therapy as they had seen close relatives going through radiation therapy ( for other cancers ) and fallout thereafter. I am only worried whether his spirit will go down post RT.

Thank you very much
Very respectfully,
Rupesh

Answer
Rupesh:

There may be only a limited time available during which the cancer is still potentially curable.  After that, it may no longer be possible.

They should not make important life and death decisions based on emotions or what happened to someone else with a different cancer getting a different type and dosage of radiation years ago.  They should speak to the top experts in their region and get the facts before making such an important decision.  There is no reason for his "spirit" to go down after radiation therapy.  Isn't it better to take a chance on a cure than to sit back and do nothing hoping that something else kills you before the cancer eventually does?

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Stephen W. Leslie, MD

Expertise

Questions concerning erectile dysfunction, kidney stones and prostate disorders including prostate cancer. I have a special interest in kidney stone disease prevention.

Experience

Full time practicing urologist with 30 years experience. Associate Professor of Surgery and Chief of Urology at Creighton University Medical Center. Editor in Chief of eMedicine Urology internet textbook. Author of only NIH approved book written for patients by a urologist on the subject of kidney stones "The Kidney Stones Handbook". Inventor of the "Parachute" and "Escape" kidney stone baskets and the "Calculus" stone prevention analysis computer program.

Organizations
American Urological Association, Ohio State Medical Association, Sexual Medicine Society

Publications
Men's Health, Journal of Urology, Urology, Healthwatch Magazine, Emergency Medicine Monthly, eMedicine, "The Kidney Stones Handbook", and numerous articles in various newspapers. He is also the editor of the Urology Board Review by McGraw-Hill used by urologists to study for their Board Certification Examinations.

Education/Credentials
Graduate of New York Medical College with residencies completed at Metropolitan Hospital New York, Albany Medical Center and University of Wisconsin-Madison.

Awards and Honors
Thirlby Award of the American Urological Association. Rated as one the country's Best Urologists by the Independent Consumer's Research Institute

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