Gleason 6 (3+3) treatments

@brianjarvis

Your comments are “spot on” regarding the results of the study you referenced.

The observation that upgrading was observed 24% of the time, is better interpreted to individual cases by considering the factors that predict upgrades AND downgrades.

My takeaway from that study is the following:

If your Gleason Score is accompanied with the following predictive factors, there is a higher probability that your PCa is in the “24% upgrade category” AND visa-versa.

1) Higher PSA
2) Older Age
3) Larger tumor lesions per mpMRI
4) Higher percentage of cancer in the biopsy cores
5) PCa involvement of lymph nodes per PMSA PET

One of the primary conclusions of the study was that physicians should use these “predictors” to guide their treatment recommendations.

Therefore, it’s not a good decision to jump to the conclusion that one needs to “cut it out of me” just because 24% of biopsy results get an upgraded Gleason score.

An individual that has 4 out 5 of the predictive factors may want to move more quickly to a treatment decision. However, if one has the inverse of 4 out of 5 of the predictive factors; they have even a higher probability of NOT being in the “24% upgrade category”.

Like most things in life…details matter…and it’s in the understanding of the complicated details of ones particular PCa situation that wise treatment decisions are found.

Hello All.
I was diagnosed with 3=3=6 on four samples of the twelve taken during an ultrasound biopsy. I am currently awaiting referrals to specialists. I am looking for a new urologist as I have lost confidence in the one who did the biopsy due to a lack of communication and getting results sent to me and my physician.
PSA History. May 2022 (5.45), Nov 2022 (4.38), May 2023 (7.05), Nov 2023 (8.21), May 2024 (12.0).
Frequent peeing, poor pressure, and an urgent need to pee occasionally with very little volume; also have some abdominal discomfort that rarely relents now. The question I have is whether or not I am needlessly worrying about the 3+3=6 on the four samples if these rarely evolve to higher grades or Gleason scores.

Hi. Welcome to the forum. We’re here to help.

I’m a prostate cancer patient so please don’t construe my responses as medical advice, just comments based on my own experience.

I was originally diagnosed with low risk Gleason 6 prostate cancer in 2020 based on a 24 sample ultrasound guided biopsy. I received brachytherapy radiation therapy with the promise that the cancer wouldn’t come back. The only problem was that the biopsy missed high risk aggressive cancer and the treatment failed. Cancer returned with a vengeance in 2023 and now I’m fighting high risk aggressive Gleason 9 Stage 3 locally metastatic cancer.

Your symptoms are concerning as they are more consistent with more advanced disease, not low risk Gleason 6. Please understand that I’m not making a diagnosis. I’m just commenting that your symptoms are similar to what I had when advanced cancer showed up.

Have you had an MRI and received a PI-RADS score? It’s possible that an MRI can give greater insight into what’s going on. I recognize now that my 2020 biopsy showed more significant disease than the biopsy revealed. I didn’t know that at the time or I would’ve sought a second opinion and likely repeated the biopsy.

You mentioned looking for a different urologist and that sounds like a good decision to me. Getting care at a center of excellence is also a good idea. When I was first diagnosed in 2020 I received care at a local second rate medical provider. When cancer returned, I sought here at a nationally recognized center of excellence and the difference in just blows my mind.

Here is a link to list of National Cancer Institute recognize sites. Obviously Mayo is on that list and they’d be on the top of my list for consideration. https://www.cancer.gov/research/infrastructure/cancer-centers

Good luck on your journey. We’re here for you.

@joe1
You just don't know. That is why almost all will suggest a second opinion. That I think is critical for descion making. The 3+3=6 is based on that alone a low risk but your symptoms don't enforce that.

When they do a biopsy they can miss prostrate cancer cells. It is almost impossible to do every single cell in prostrate. It is why when you have targeted treatments and not all the prostrate the cancer can still be present after treatments.

Even though I had low risk per Decipher, negative PSMS, and negative bone scan, my R/O did proton radiation on my entire prostrate explaining the above to me. I concurred.

Me personally and that is all we can give as not medical professionals is I would definetly get a second opinion and asked for a new biopsie. Choose an experience medical institution and urologist. Based on where you live many on MCC can guide you to close institutions and medical professionals. I live in Jacksonville area and use Mayo Clinic for diagnosis and UFHPTI where I had the proton radiation done over a year ago now.

You may have missed my post . I had an MRI which showed a T2 Score & PI - RADS 5 .
I followed this with an MRI Fusion Biopsy . Typically a fusion biopsy calls for 2 to 4 core samples . My Urologist , a former Head of Surgery & Head of Urology at a major hospital in Toronto , Canada , took 5 cores . He maintained " HE HIT THE TARGET AREA " .
My pathology results came back negative . Being proactive and not believing the pathology results - I proceeded to have a 2nd MRI this time with contrast and a 2nd MRI Fusion Biopsy . This time with 16 cores - of which 6 were from the same "Target Area ". This biopsy was performed by a Urologist from Princess Margaret Hospital in Toronto . Ranked in the top 5 Teaching & Research Cancer Centeres in the world .
This time the pathology results came back : 6 cores in the " Target Area " positive Gleason 3 + 3 = 6 The remainder were negative .
Once again not being satisfied with the conflicting pathology results I had a 2nd opinion of my 2nd Biopsy slides . Wait for it ; " It came back with all 6 cores in the target area upgraded to Gleason 3 + 4 = 7 -- All other cores remained negative ."
I am considering a 3rd opinion of my 2ns Biopsy PLUS a 2nd opinion of my 1st negative biopsy .
At this juncture . Who do you believe ?

I suspect that the 2nd opinion is more trustworthy. My surgeon told me that implicitly trusted the pathologist that worked on the biopsies samples he took. As I understand it, grading Gleason score is an art because of cell variability. It not all clean, cut , and dried. Check out this link to see what some of the variability can look like. https://www.cjcrcn.org/data/pic/9260_0.png

My first biopsy in 2020 had a Gleason score of 6. My care teams (I had to switch due to logistics) both felt that either the biopsy missed significant cancer, was graded incorrectly, or most suffered from botched sampling and mis-grading.

Do whatever you need to do to have the most confidence possible to move forward. Be your own advocate. You can do this!

So... I am at Mayo now. Something I learned. Doctors at smaller hospitals get paid more for doing surgeries. Places like Mayo... they are salaried. They get paid the same, surgery or no surgery. I was concerned my urologist in my hometown was pushing surgery because he was wanting to do procedures for more money and a chance to move to a larger hospital. So I wanted to get a second opinion from a larger more established facility.

With that said, from what I understand a 6 (3+3) monitoring is a legitimate option. The side effects of surgery or radiation are real and no joke.

Good for you. Mayo was my first choice but I was unable to make that work. My experience has been that centers of excellence like Mayo and Northwestern Medicine in Chicago where I receive my care set a standard for care that community hospitals cannot match.

You’re in good hands and going to do great!

Mayo at the time at Phoenix did not take Medicare. They now take Medicare but not Medicare advantage. I have a blocked carotid. So I went to Mayo. Actually 100% in the right and at the time 65% in the left. The Mayo cardiologist said lets wait until your over 70%. blocked for surgery. He said you can find a vein stripper that will do it but its best if we wait. He said I get paid either way they get paid for the surgery.

Hi, ctb2024. It sounds like I have a similar story. From a small town, South Georgia, with the rising PSA. Urologist Did a biopsy with a score of Gleason 3+3, Frequent need to urinate with a very weak flow. Urologist prescribed flomax, but it did not improve. Suggested either radiation or robotic prostate surgery, and referred me to a larger institution. I chose Mayo. I had initial Teleconference and the doctor Discussed options. He suggedted active surveillance with follow up testing and MRI at Jacksonville Mayo to check for any signs of tumors, etc. That came back clear but they found my bladder was extremely distended due to being unable to empty it. That was their main concern as IT could lead to serious kidney problems. Had a HoLep procedure Where they basically run a laser and camera up and hollow out part of your prostate as it was impeding the urine flow. All the material removed came back benign and I can go like I did when I was a teenager. I’ve been back twice at six month intervals for PSA testing. It’s remaining level and they are suggesting 6 month PSA and annual MRIs going forward.