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DiscussionThe Gray Area of Favorable Intermediate Risk 3+4=7
Prostate Cancer | Last Active: Jun 15 12:46pm | Replies (35)Comment receiving replies

For me there were no “gray areas” when making that 3+4 decision. I’m not one who gets analysis paralysis. Being a retired computer scientist, given sufficient data I can make any decision. (However, in my 2nd life as an elected official - ultimately Mayor of my City - making a decision was a bit more nuanced, not because of my own “gray areas” but, because I had ~45,000 constituents who each mostly had “gray areas.”)
I was on active surveillance for about 9 years with localized, low-level, 3+3=6 disease. When my Gleason hit 3+4=7, and my Prolaris test indicated that I had “exceeded the threshold for active surveillance” was when I sought treatment
With a 3+4=7, I would use all those other factors those experts mentioned in making my treatment decision vs active surveillance:
> PSA
> genetics (germline)
> genomic (biomarker)
> family history
> size and location of lesions
> volume of grade 4,
> number of positive cores,
> cribriform,
> intraductal
> (not so sure about PNI)
> and others not listed there.
As for concern about upgrading/downgrading of prostate cancer, there are many studies about this. The one that I often reference is one out of the UK in 2019 showing that initial grade and pathological grade matched 59% of the time, was downgraded just 16% of the time, and was upgraded just 25% of the time —> https://bmcurol.biomedcentral.com/articles/10.1186/s12894-019-0526-9
So, I wouldn’t let that concern affect my treatment decision. Letting one’s fears impact treatment decisions almost always leads to bad outcomes, just as do uninformed decisions: The mistake that is often made - that often results in treatment-related regret - is not being fully informed and rushing the treatment decision without having established expectations —> https://jamanetwork.com/journals/jamaoncology/article-abstract/2786406
It am not at all disheartened to read non-medical professionals advocating for active surveillance for most favorable intermediate risk 3+4=7 prostate cancer patients when the research is unclear. Most decisions in life are made with uncertain and unclear guidance. Few things in life are definitive; (except for death and taxes??). Given the uncertainty factor in every life decision, I would first choose the one that did the least harm, and permitted me a multitude of options should that first decision not have the desired result. Medicine and treatments these days are at a stage where there are actually “do-overs” with prostate cancer treatments (unless one makes a treatment decision that eliminates “do-overs”.)
Making a treatment decision is not rocket science; one need not have a PhD or be a medical professional to understand the diagnosis, nuances of the disease, treatment options and making a treatment decision. Once one factors emotions out of the picture, the view becomes much clearer and the decision much easier.
And as you allude, asking medical professionals - even Epstein, Schulz, Walsh, and Ross (and even my own urologist, radiation oncologist, and medical oncologist) - does little good; those with PhDs don’t always agree; and what they say isn’t always gospel. So, getting to the treatment decision goes well beyond having a medical degree or certification.
For me, the most difficult part of making a treatment decision was figuring out what my expectations were from treatments. I was confident from all the data that I had read that “just cutting it out” was no more successful than not cutting it out in treating the disease. So, all of those other factors have played a role in my treatment decision.
What came out of my personal introspection —> I wanted to balance quality of life with survival (of course!) along with the possibility of treatment in the future if needed (as medical treatments and science progress). This was about utilizing the best modern treatment techniques to get the best outcome while still surviving and maintaining my quality of life. That was the foundation (i.e., mission statement) for me making my treatment decision.
This need not be a “struggle” for men and their families when making a treatment decision. It’s just another data collection and analysis challenge that life throws at us once in a while. (Like buying a new house or a new car or doing one’s own taxes - it’s not a struggle, it’s just awfully time-consuming, and takes understanding oneself and one’s capabilities.)
The consultation of our own medical professionals is a necessary part of the decision and data collection process. But just as you indicated, is by no means definitive. They’re providing advice and recommendations; but the final decision is ours.
For me, I didn’t view it from the standpoint of “several years down the road, there are going to be some very sorry patients because their cancer spread or got worse making treatment more difficult.” But rather, by getting the appropriate treatment for my stage of disease today, and then by tracking it closely and regularly going forward, I’ll catch any negative change early enough that I’ll still have treatment options
Now (at 70y/o) after 9 years on active surveillance and 4 years after proton radiation treatments (with 6+ months of Eligard), I’m taking my 3 young grandkids swimming today. Life is good. (And I am confident that I made the right treatment decision.)
Replies to "For me there were no “gray areas” when making that 3+4 decision. I’m not one who..."
Thanks for sharing your experiences and thoughts. It seems you and I both had the benefit of starting out with 3+3=6 diagnosis leading to a fairly easy active surveillance recommendation and decision. And both of us eventually moved to 3+4=7, you after 9 years and me after just 10 months, demonstrating that we are all unique.
My medical team spoke a lot about risks and probabilities for an individual patient - risk of spread, risk of re-occurrence, risk of treatment side effects, etc.
Glad you are able to be comfortable with your decisions and enjoy those grandbabies!