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The Gray Area of Favorable Intermediate Risk 3+4=7
There has been much discussion on this thread about how to approach favorable intermediate risk 3+4=7 PCa. Many on here have been adamant that active surveillance (AS) is the best or even the only acceptable approach. Evidence in support of active surveillance has included a video from esteemed pathologist Dr. Epstein and the popular YouTube videos by urology oncologist Dr. Mark Schulz from his Prostate Cancer Research Institute. I want to post a rebuttal of caution to the claims on this thread.
Even Drs. Epstein and Schulz offer a myriad of caveats to choosing active surveillance. These caveats include genetics, family history, size and location of lesions, volume of grade 4, number of positive cores, cribriform, intraductal, and perineural invasion. But even these popular doctors could not give a definitive answer for choosing active surveillance.
Dr. Walsh offers a summary of research and recommendations for favorable intermediate risk 3+4=7 PCa in his commonly accepted definitive book Guide to Surviving Prostate Cancer. He notes that the good news is that men with favorable intermediate risk 3+4=7 PCa have an excellent prognosis. Walsh writes that a cure is attainable with a single treatment - surgery or radiation. On page 134 Walsh states,
“Most men with intermediate-risk prostate cancer should consider curative treatment with either surgery or treatment. In some very selective cases, in men who have a low PSA and very little Gleason 3+4=7 cancer, active surveillance can be considered.”
Walsh goes on to state that men who have one core of 3+4 with limited amounts of cancer might be candidates for AS. But he strongly recommends genomic testing to identify more aggressive cancers.
On page 266, Walsh cites Dr. Ross from Northwestern University where she stated,
“I think for men with favorable intermediate-risk disease and high volume low-risk disease, active surveillance could be considered, but patients need to be aware of a few things.”
Walsh goes on to argue that the best studies on active surveillance from Johns Hopkins and Memorial Sloan Kettering contain selection biases - the researchers selected only the best candidates who are more likely to demonstrate success with AS. But it was noted that even with these biased samples, the average time on AS before needing treatment was 6.5 years. Ross is quoted as saying,
“The outcomes of active surveillance for men with higher volume, low risk disease and favorable intermediate-risk prostate cancer are, to a large extent, unknown.”
It is noted by Walsh that even Dr. Epstein agrees that biopsies can miss cancer cells under representing the grade or extent of cancer. We’ve read of many on this forum who upon radical prostatectomy, had their grading increased and that was born out in the Johns Hopkins and Sloan Kettering studies.
I bring this topic to the attention of this group for several reasons. I am a favorable intermediate risk 3+4=7 prostate cancer patient who chose treatment rather than active surveillance. I’m a patient at a university center of cancer excellence and have consulted with a broad team of medical professionals and discussed the options with my family. I’m having a radical prostatectomy next week. It is disheartening to read non medical professionals on this thread pushing active surveillance for all or most favorable intermediate risk 3+4=7 prostate cancer patients when the research is unclear. This makes one question their treatment decisions. Making definitive recommendations for this gray area lacking research is tantamount to a dereliction of responsibility to our fellow prostate cancer members. While perhaps some read a lot or watch lots of videos, we are not medical professionals. Men and their families are struggling with making treatment decisions and are reading social media threads or watching videos for advice. If men with favorable intermediate PCa make an active surveillance decision without the consultation of their own medical professionals, I’m afraid that 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.
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I did Tulsa Pro for Gleason 7 (4+3). I really liked the MRI guidance that also monitors the temperature in real time so they know they get the targeted area to the proper temperature. I had it done at Mayo Rochester. The radiologist who did the procedure had high praise for the precision of Tulsa Pro. He has been ablating other cancers for many years and said none offered the same level of precision. Medicare paid for the procedure.
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4 Reactions“Many on here have been adamant that active surveillance (AS) is the best or even the only acceptable approach.”
Any non-biased (no dog in the fight) reviewer of this thread or most of the comments in this PCa support group would come to the completely opposite conclusion.
I was diagnosed with 3+4 PCa in October 2023 and Active Surveillance has definitely been the best decision, in my case, and it was recommended and continues to be confirmed by my urologist.
I rarely get any useful information that encourages my decision in this support group (but that’s ok)….I find most of that elsewhere.
That said, I do appreciate the comments of this “treatment leaning” group; as it’s always important to hear ALL perspectives.
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2 ReactionsYour statistics are very much like mine were. I chose focal therapy with the objective of trying to balance efficacy of treatment with quality of life/side effects. While there isn't a decision tree to help choose the modality of treatment, one of the key parameter/requirements should be accuracy/precision of treatment. I would rule out anything that isn't in-bore, MRI directed, in real time. I chose TULSA-PRO for those reasons, although I am of the understanding that cryotherapy is also possible under MRI real time direction. Beyond that it is critically important that the procedure be performed at a center of excellence, best done in a hospital setting, and by a doctor who is highly experience in targeting. You want precision (good margins), you want something other than a store front (center of excellence) and you want someone who really knows what they're doing and has significant experience in having done it. That's what maximizes your odds for a favorable outcome in my opinion.
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3 ReactionsGlad that AS was your choice and that it's going well for you.
The purpose of this thread was not to advocate for treatment over AS. But to rather point out that the medical community still doesn't have clear guidelines for choosing options for 3+4=7. And because of this, it's not wise for some to come here and say that for all men in this category, the only choice is AS. It can be a choice for some, but for others treatment is the best option. Each man's decision should be honored.
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3 ReactionsI’m sure I haven’t read every post in this support group; but I have never seen anyone say that ALL 3+4 men should choose AS. Maybe there are such comments, but they are definitely "one-offs".
I’m in other groups that concentrate almost exclusively on AS, and even there folks do not make such statements.
In any case, I’m in complete agreement with your last two sentences.
Thx for your note. I am definitely in the TULSA PRO camp. I could not get an initial appt until late August, so maybe other folks are catching on to a good alternative.
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1 ReactionI was diagnosed in March of 2024. I wasn't able to have the TULSA-PRO procedure until October of 2024. I believe you have time. The other piece of advice I took to heart from others like Dr. Scholz of PCRI was to take one's time in reaching a decision especially in our cases of favorable intermediate risk. He went on to say a 6 month delay had no negative impact on long term results. Back in the day when surgery was the standard of care, patients had to wait this long or longer to get access to a surgeon trained to do the procedure. Seems they had plenty of data supporting this claim of no negative impact.
Great, helpful comment. Thank you. I am waiting for the Decipher test results which could be another data point that waiting for the “right” procedure is ok. Thx!
Here is some useful information. Each PC is very different and have many different feature . Most 3+4 men cannot do 'nothing' . Your Dr has said this is a good option for you and its working , for now . Dont be disappointed if this changes as features change . AS is an option that usually and at times fit a 3+3 Gleason man . Sometimes this AS designation change at time . Remember cancer is dynamic in nature . Glad to hear your AS , is workign for you. Whats your PSA at this point. MRI's are sure where the lesion is ? That Lesson has to be monitored . Do you have more than one or two lesions? Any other health issues ? Yes absolutely leaving a VERY low grade 3+4 on AS is an option , but not without VERY close monitoring , due to the nature of PC . God Bless Sir ! James on Vancouver Island .
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1 ReactionYou make a good point on selection bias and confirmation bias on studies . You are right here . You make some very valuable points . 3+4 Gleason is USUALLY , treated .... for a reason . All material I have read is that 3+4 G PC is some rare cases can be handled with AS for some time ...but has to be closely monitored as this can go badly quickly !
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