Canceling Radical Prostectomy In favor of AS

Thanks for sharing and welcome to the unsure zone of 3+4ish. Everyone is different. My dad was diagnosed with PCa at age 58. Got regular PSA tests and it started rising. Once it got around 4, had MRI which showed a large PI-RADS 4 lesion. Biopsy pulled one core of 3+3 and a few ACAP cores. This was at a center of excellence and had the slides read at another center and they confirmed pathology. Started on active surveillance. PSA rose a bit more. Had a followup MRI scheduled at about 11 months after the previous one. MRI showed a new PI-RADS 4 lesion. New biopsy pulled four 3+4 cores, lesion close to capsule, and with perineural invasion. Now we're talking treatment.

You're at centers of excellence and seem to be getting good advice. I think you can trust them. I know you want answers right away but this beast seems to be slow growing so six months doesn't seem long. But keep watching the beast because things can change as my case and others demonstrate.

I would just suggest that you have biopsy every 2 years the latest ! NEVER wait 5 years ! My husband went from 3+3 in 2 cores to 4+3 with aggressive cribriform and IDC in 5 years and Decipher 100 !

Wishing you the best of luck in whatever you decide.

Active surveillance sounds like a great idea . Not Sure you saw the video I posted, Dr. Epstein, who is really the specialist in Prostate cancer pathology had about a one hour talk Saturday, with A Q&A after. This talk was about active surveillance, and who was a candidate. Lots about Gleason 7. There is a lot of other good information in it as well.

So, in total 8/12 cores are positive?

For 3+3 and 3+4, always consider AS if there are no other significant risk factors.
> Johns Hopkins AS protocol calls for a confirmatory biopsy in 6 - 12 months: https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/active-surveillance-for-prostate-cancer

> Johns Hopkins AS protocol calls for repeat PSAs every 6 months. (Mine were every 4 - 7 months.)

> I did MRI/biopsy every 2-1/4 years. My first 3 biopsies were 3+3=6; my 4th biopsy (at about 9 years) was 3+4=7. (A second opinion raised that to a 4+3=7.)

> We also regularly tracked and calculated the lesser-followed numbers (% Free PSA, PSA Doubling Time, and PSA Density), as well as obtained OncotypeDx and Prolaris biomarker (genomic) tests.

Those 9 years on AS bought me the time needed to get referrals, and evaluate all treatment options, regimens, side-effects, outcomes, etc., such that when/if the time came that I needed to make a treatment decision, I was fully informed and prepared to pull the trigger.

Eventually, in late 2020 I had to make that decision and (at 65y) chose 28 sessions of proton radiation (April - May 2021), plus 6 months (two 3-month injections) of Eligard, and SpaceOAR Vue.

Today, 4 years since treatment, PSA levels vary between 0.35-0.55; most recent PSA was 0.478. Life is back to the way it was before this journey started.

Good luck!

65 year old male. 11 3+3 and 1 3+4(only 5% 4). No cribiform. No perinureal invasion. 22 ml prostate. Density = 0.18

Was going down the road to SBRT. Side effects of either SBRT or surgery sounded very troubling. Avoiding ED and incontenance very important to me. Then watched the AS video and Jeff on this forum mentioned why rushing to treatment and why not consider AS. Researched some more and joined the Ancan AS group that meets virtually every Wednesday.
Had second meeting with urologist and requested the Decipher test. Received results today (0.36) = low risk. What a blessing for sure.
Also sent out biopsy samples for second opinion with Dr Epstein.
If no changes from pathology second opinion…. going with AS. PSA every 6 mo. Biopsy again 1 year (Feb 2026) after initial one in Feb 2025. Repeat MRI Feb 2026

So glad I joined this forum and learned about AS, Decipher, Dr Epstein.

Not sure why my urologist didn’t suggest the decipher and active surveillance? I had multiple
opinions. I believe the 3+4=7 protocol that many physicians follow automatically goes to treatment?

8 out of 16 (they did standard 12 plus 4 in the leison identified in the MRI). All positive were on the left side.

Don't some claim that a lot of 3+3 cores, and/or PSA over 10 leads to suggestions of treatment rather than AS? I thought I heard that in Dr. Epstein's video that is posted by @jeffmarc in this thread. I have a friend who had one 3+4 core and a bunch of 3+3 cores. He was put in AS at first but then his PSA started creeping up over the next six months and that's when his doctor's all advised to treat which he did.

Correct. 3+4 (even with small amount of 4) some docs recommend treatment, but Penn also gave me AS as an option, though not as straight forward as Sloan Kettering. Sloan said they go by their pathologist evaluation of the biopsy slides and all of their evaluations came as 3+3. At Penn two cores came as 3+4 (with 4 less than 5%).

My urologist and oncology radiologist, at a university center of excellence, told me with 3+4=7 that AS was an option but other factors should be considered. According to Dr. Epstein on his video posted here, and Dr. Scholz on his PCRI YouTube videos, 3+4=7 doesn't automatically mean AS, has some gray areas in the research literature, and other factors should be considered like volume of cancer in cores, genetics, PSMA PET scan, family history, cell types (cribiform), nerve invasion, number of positive cores, etc.