How I would consider all this if it were me…..

A PIRADS 4 indicates that “Clinically significant cancer is likely to be present,” and is not a diagnosis of cancer.

Did you request a 2nd opinion on the MRI scan and the biopsy slides? It’s often recommended to send them out for a 2nd opinion to an independent facility specializing in reading and interpreting scans/biopsies — not necessarily because you don’t trust the 1st one or don’t like that opinion. But, because much of the interpretation of images and scans is often as much an art as it is a science, as well as dependent on the skill and experience of the person reading them. It’s good to have an independent set of eyes reviewing the results.

Depending on your age, your PSA of 5.3 may only be slightly elevated. How old are you?

With all of the tests and information that you have, it’s not quite back to square one. In addition to your PSA, PIRADS, and Gleason, do you know what are your: % Free PSA, PSA Density, PSA Velocity, and PSA Doubling Time are? Those provide additional information as to the status of your disease.

Can you have your biopsy tissue sent out for biomarker (genomic) testing (like Decipher, Prolaris, OncotypeDx, etc.). That will provide even more information as to the status of your disease.

If those are all within good range, then things might not be as bad as the PIRADS 4 led you to believe.

For now, there’s probably no need or definitive justification for more invasive tests (or a PSMA PET scan). What you have so far and what you can get with those additional numbers I mentioned above should get you to the next step - a repeat PSA with a “Free PSA” test in a few months.

If those lead to the possibility of something more serious being there, then perhaps the repeat biopsy you’re considering.

If it were me, I’d do least invasive steps first. I wouldn’t want to turn my prostate into a pincushion with many biopsies in an attempt to find something.