Part II: Different strokes for different AS patients: The case of the two octogenarians
By Howard Wolinsky
Mileage may vary, as they say. So does Active Surveillance.
My version of AS isn’t the same as yours.
Take the case of the two octogenarians: Howard Furer and Allan Greenberg.
Furer, a retired marketing executive, who will turn 83 in August, has been on AS for 14 years.
He had Gleason score 3+3 in one core 12 cores taken with tumor size less than 0.5 millimeters, less than 5% of the length of the core biopsy. He’s only had two biopsies. He had a negative biopsy six years earlier.
“My PSA had been in the normal range until it jumped to 6.6 in February 2008, prompting me to get a biopsy. My urologist prescribed dutasteride, and a PSA test every six months. My PSA has been in the normal range ever since,” he said.
I’ve had two multi-parametric MRIs in my almost 12 years on AS. I was among the first prostate cancer patients to undergo an MRI to check their prostates.
When I started, they did a biopsy first and then an MRI--ass backward from what is done today. Today, MRI is used to find potential lesions that then can be biopsied.
Furer said he has never had an MRI in his version of AS because he had metal hip replacements--though these days it is possible to have an MRI with artificial hips.
He gets a PSA every six months. (I have a version of the PSA, known as the Prostate Health Index, once a year.)
As you can see, there are no universal protocols for AS.
Furer is sticking with AS. “I am still on AS and always will be!” he said, even as he heads in the direction of his 90s.
Allan Greenberg, who turns 82 later this month, a retired college professor in the Boston area, is pondering whether he wants to stay on AS and maintain the rituals of regular testing.
He was diagnosed at age 69 and went on AS after consulting with a urologist, a radiation oncologist, and then a medical oncologist at Dana Farber Cancer Institute.
I think it was a smart way to go to get opinions from multiple specialists.
(I only consulted with two urologists, who disagreed on how to manage my case. I went with the one who called me the “poster boy for AS.”)
Greenberg has PSA tests twice a year.
He’s had only two biopsies.
(I've had six, following a protocol from Johns Hopkins of annual biopsies, but I have not had one in six years.
(How often do you rotate your tires? Probably more often than I do.)
Greenberg said, “The urologist wanted me to have another [biopsy], but at my hesitancy, he agreed that if I did twice a year PSA's that would suffice. At the same time, he did want me to have the MRI last year.”
Like me, and unlike the other Howard, Greenberg has had two MRIs and is planning another soon.
“I had an MRI as part of an experimental project about eight years ago, and then not again until last year. I am scheduled for another later this summer after they found some lesions and noted that I was a PI-RADS 4. After speaking with my urologist, and with the medical oncologist with him I had first met shortly after the original diagnosis, the decision was made to see where we were after the coming MR,” he said.
Furer plans to stick with AS. Greenberg isn’t so sure. In the mainbar, I describe how
(I am in a hybrid version of AS, backing away from MRIs and biopsies unless my PSA rises significantly.)
Greenberg said, “No matter what they find [in the next MRI], I am rather unsure that I will commit to any kind of treatment. My priority is quality of life with my wife and my son and daughter-in-law, and I don't anticipate living more than another 10 years, and so expect to outlive my PC,” he said.
What is your AS “protocol”? Why not share it with us in the comments or write your own article.
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My AS story.......first my details;
61 yrs old
PSA tracking-2013-2.5.....currently 4.75
MRI-03-2022 found two areas that had lesions, one was PRIRADS #4 other was PRIRADS # 5
Biopsy 04-2022...12 cores taken.....7 were Gleason 3+3 =6........3 each were found in each lesion and 1 other.
NOW......my urologist suggested Proton Therapy. The Proton Therapy suggested AS. DaVinci surgeon suggested surgery. (of course). Another urologist suggested surgery . All that is left is an upcoming appointment with a SBRT Doctor at John Hopkins.
I think the most good indirect information I have received is reading "The Active Surveillor"..Thank you.
This is just a "sidebar", I also have some lung concerns, minor at this time, but could become serious. Something I was told by my Pulmonologist (after several CT's) that some of the damage to my lungs "could have" been caused by a general anesthesia when I had my biopsy. Saying that, he suggested that I "limit" getting a general anesthesia......biopsy, surgery etc.
Saying all that, surgery for by prostate isn't a consideration now. (Actually, never was) That adds to helping me to go the AS route, but still talking to anybody who can help educate me. (Knowledge is power)
So I will get my MRI and do my PSA as needed and go from there, and when and if the time come I will have to make another choose!!!
Thank you Howard for all the information you provide, it has really helped me along with many others am sure!! My hats off to you!!
JFrevele
Retired USMC
In general, the 10 year survival for prostate cancer, whether treated or not, is similar.
Older men are at greater risk for higher-grade cancer. Yet we are still recommending PSA monitoring which has a 78% false positive rate. Furthermore, high-grade prostate cancers may not produce much PSA.
Then we still recommend the risky prostate biopsy which samples blindly and randomly only 0.1% of the prostate or, we recommend the MRI where there is a problem with errors-of-interpretation amongst radiologists. AS is not only embarrassingly unscientific but, it has yet to show irrefutable and reproducible evidence that it saves significant numbers of lives. We already know from previous studies that neither PSA testing nor prostate cancer surgery save significant numbers of lives. PSA testing is the definition of insanity.