Identification Statement: is a year old male diagnosed with a pathologic T stage N stage, Gleason score (3+3, 3+4, 4+3, 5+3, 5+4, 5+5) Group (I, IIA, IIB, III, or IV) adenocarcinoma of the prostate History of Present Illness: The patient was seen in consultation at the request of [requesting MD]. initially presented with an abnormal PSA. PSA was found to be (blank) on (date). He also presented with increased urinary frequency and urgency. His IPSS score was (blank). His SHIM score was (blank). In the past he has/has not had a TURP. On (date), Mr. underwent a prostate biopsy.
Pathology was consistent with adenocarcinoma of the prostate. Adenocarcinoma of the prostate was seen in (blank/blank) cores. Preoperative imaging consisted of a CT A/P on date and a bone scan on date that had/did not have any suspicious findings consisting of Patient went on to have a radical prostatectomy on (date). Pathology revealed an adenocarcinoma of the prostate, Gleason score (3+3, 3+4, 4+3, 5+3, 5+4, 5+5), (positive or negative) margins. There (was or was not) any seminal vesicle invasion. Extracapsular extension was (present or absent) Postoperatively he had some urinary incontinence.
His post-prostatectomy PSA is (blank). He lives (alone or with blank). He continues to have ongoing fatigue since his surgery. He spends (less than half, half, or more than half) of the time sitting in a chair. He now presents to us for an opinion regarding (adjuvant, salvage or definitive) radiation therapy. Postoperatively, he has/not had an imaging workup as listed below. Current Medications: Allergies: Past Medical History: Past Surgical History: Family History: Social History: Review Of Systems: Past Cancer Treatment (Surgical or Chemo/Hormonal or radiation therapy):
Safety/Pain Assessment: ECOG: Pain Rating: / 10 Risk of Patient Fall: LowReason for risk of fall: Vital Signs: Physical Exam: General: Patient appears his stated age. [He or she] is (alone or accompanied by). He is alert and oriented x 3. HEENT: EOMI, PERRLA. The oropharynx is clear. There are no lesions seen. NECK: The neck is supple. There is no evidence of thyromegaly. Lymphatics: There is no palpable cervical or supraclavicular lymphadenopathy noted. Lungs: Clear to auscultation bilaterally. There are no wheezes, rhonchi, or rales. Cardiovascular: Regular rate and rhythm.
No murmurs, rubs, or gallops. Abdominal: Soft, nontender, nondistended. Positive bowel sounds. There are no palpable masses. Rectal: Sphincter tone within normal limits. There are no palpable masses or nodularity noted in the prostate bed. There was no blood on the examination finger Extremities: No cyanosis, clubbing, or edema. Neurological: Cranial nerves II-XII intact. There are no focal sensory or motor losses noted in the upper or lower extremities bilaterally. Gait was within normal limits. Musculoskeletal: There is no spinal or CVA tenderness noted.
Labs: Pertinent Imaging Studies: [imaging modality][date]- [imaging modality][date] Histopathology: Diagnosis: male status post radical prostatectomy on (date) with a T stage N stage Gleason score, PSA (blank) Stage Group adenocarcinoma of the prostate who presents for consideration of salvage/adjuvant radiotherapy. Plan: We have discussed the role of radiotherapy in the management of his disease. Over 60 minutes were spent with the patient, over half of which was performed counseling the patient regarding the treatments and side effects of radiation therapy.
Based upon the pathology of his prostate cancer he would benefit from radiotherapy. The recommendation for adjuvant radiation therapy is based on randomized controlled trials by SWOG S8794 and EORTC 22911, both of which randomized patients with pathologic T3 disease or positive margins to adjuvant radiation vs observation. At 12 years, the SWOG study demonstrated that adjuvant radiation decreased the percentage of patients with metastases or death from 54% to 43%, improved metastases free survival from 12. 9 years to 14. 7 years (HR 0. 71 95% CI 0.
54-0. 94), and overall survival from 13. 3 years to 15. 2 years (HR 0. 72 95% CI 0. 55-0. 96). Per Stephenson, we estimate that the rate of success for salvage radiation therapy is ???? based on this patients pre radiation PSA of , Gleason score of , +/- margin status, estimated PSA doubling time of , We did/did not recommend concurrent hormonal therapy with his salvage/adjuvant radiation due to The side effects of radiation therapy were discussed, which include fatigue, increased urinary frequency and urgency, soft bowel movements and bowel urgency.
Long-term side effects include rectal bleeding, erectile dysfunction, urinary dysfunction, and risk of secondary malignancy. The patient will be simulated (date), and we will plan to start radiation therapy on date. I will convey my findings with [requesting MD] in order to coordinate the time with [him or her]. Treatment recommendations are based on: NCCN Guidelines____ ASTRO Recommendations____ Clinical Trial____ Other_____ I personally interviewed, examined and counseled the patient. I agree with the documentation and plan as above. E-Signature: CC: RWJUH Tumor Registry RWJUH Medical Recordsю