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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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Here’s my whole story, up to date:
I’m 69 y/o with prebiopsy PSA of 7.8 and 3, 4 & 5 PIRAD lesions based on an Oct ‘23 mpMRI.
An MRI guided TRUS found 7/15 cores positive…five 3+3 (5-10%) & two 3+4 (10-20%).
Decipher Grid CG Model “Low Risk" @ 0.22.
Began AS in Nov ‘23, running 3-5k’s/wk and a whole plant food diet, until I reached my BMI goal of 22.5-23.0 in Feb ‘24.
I’m not a great fan of specialized diets, but now I eat a balanced diet to maintain my 162 lbs (5’ 11”); which I’ve done for the last 16 months.
I do believe one should target a BMI of 22-23 to help slow PCa progression.
The dietary changes I continue to maintain include: morning Matcha Tea, homemade Ezekiel bread, dark berry smoothie lunch and home grown broccoli sprouts every night with whatever I’m having for dinner (salmon, chicken or grass fed beef…all included)…snacks include unsalted nuts, dark chocolate and fruit.
Always include my afternoon glass of red wine, red peppers/carrots & hummus and some sort of spicy cheese and whole wheat crackers 😉
PSA dropped 25% after 4 mths and has stayed constant around 5.8 - 6.2 for the last 16 mths.
My current PSA density is ~0.135; a drop from the prebiopsy level of ~0.18.
My 12 mth mpMRI showed PIRAD 3 & 4 lesions were not visible and the PIRADS 5 lesion had shrunk and its T2 & DWI/ADC signals were reduced from “moderate” to “mild”.
In Mar ‘25 I modified my running regiment to 20k per week in Zone 2. My latest PSA (May ‘25) was lowest since diagnosis 5.8.
If one takes up running it’s critical to ensure one stays injury free!
I always wear Hoka Bondi 8’s (super cushioning) and only run on a rubberized track.
My change to Zone 2 running is also a move in the safety direction and a tremendous way to build endurance.
My current AS plan calls for annual mpMRI’s.
Currently, I only plan to have another biopsy if my annual mpMRI’s shows confirmed lesion progression, over my previous mpMRI’s.
My urologist says, in my case, “Why risk another biopsy unless there’s demonstrable cause?
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3 ReactionsThank you for your comments! I was diagnosed with Gleason 7(3+4, 4+3) with activity in two lymph nodes. The only options I was given were ADT plus either radiation or surgery. AS was never an option. all the best to you as you continue watching and monitoring!
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3 ReactionsWith the Lymph intrusion I dont think AS would be the first line of thought by most Dr's . Most would want to attack the cancer that has spread and get that under control ....so AS would not be appropriate in most circumstances I would guess ! James on Vancouver Island .
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3 ReactionsIt appears you have a great plan . Your Urologist sounds very competent as well. Its a good drop in PSA , but anywhere above 4.0 I feel a little uncomfortable . Keep a close eye on things like you are doing ! God Bless Sir ! James on Vancouver Island
@happydappy I was 3+4 with an 11.2 psa with low risk decipher. I believe that professionals need to be listened to, but everything needs to be taken with a grain of salt, including different information from professionals. I went to six Radiation oncologists, all of them were either trained at centers of excellence or were practicing at centers of excellence. All of them confirmed that Radiation or Prostate removal would result in good outcomes. One of them said active surveillance. One of them said short term antigen deprivation therapy. I researched all options and chose the Mridian radiation machine for a number of reasons. No ADT for me, which nccn.org suggests for a PSA greater than 11 but the radiation oncologist that treated me and I discussed it and we both felt the same.
We may not be doctors but our own personal education on prostate cancer is important and should be used to evaluate whether what comes out of a doctor‘s mouth is making sense and should be followed. Without including this in our own process of decision-making, we potentially fall victim to the biases, intentional or otherwise, that are built into the institutional and personal decision process that professional doctors make in evaluating each Prostate Cancer’s patients diagnosis. Dr. Walsh has confirmed some of these biases in his book.
I think what you said was very helpful, mostly. For the most part, I think when people take positions on Mayo connect, they are doing so in the belief that they are helping others. I don’t think that falls into the category of dereliction of responsibility as much as it is a belief level that they hope will benefit others. What we choose to do with the statements made, with the best intentions, is also up to the reader. For me, listening to other people’s statements and experiences as part of the evaluation process, which includes confirming accuracy of what we read, is helpful in many ways, including its potential to be inaccurate. None of us can assume that everything is accurate and sometimes we learn as much from the Data we can confirm as wrong, as we do from the positive.
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