Decisions to be made after biopsy confirmation of prostate cancer.

When you meet your uroligist, bring up that you want to do a Decipher test to see how aggressive your cancer is. They will likely refer you to an radiation oncologist if you wish to pursue treatment. If they do, make sure that brachytherapy is discussed. If that is not offered, look for a place that does offer it, ideally a center of excellence.

You do not have an aggressive cancer. You could keep it under control with a drug like Nubeqa. It has very few side effects and works even if you have testosterone. You are an Gleason 4+3, the other lower numbers don’t matter.

You could have SBRT radiation to kill the cancer first. They might want to put you on ADT but it has a lot of side effects that could be tough to manage at 90. It would not be Mandatory with your Gleason score. It would be helpful to be in good physical shape before having this. If you do this, you could wait until your PSA starts rising before using any drugs.

Were any of the following things found in the biopsy like intraductal, cribriform, Seminal vesicle invasion, EPE or ECE.
 Those can make the cancer more aggressive.

Some things to think about, speak to your doctor about these issues.

For those who are 70+, radiation treatment seems to be the choice in lieu of surgery. I was approaching 69, when I had SBRT (one of the radiation treatments available). Your medical oncologist or radiation oncologist can advise what they think is best for you; I met an MO and an RO before I decided to proceed on SBRT.

With prostate cancer it's relatively easy to get a 2nd or 3rd opinion from a CCOE since you rarely have to travel. You only have to send your test results. Expertise and experience matter when treating prostate cancer. You might want to consider getting another medical opinion from a CCOE if you don't have confidence in whatever advice you receive from your doctors. Best wishes.

@georgemc
Take you time on decisions. When you talk to your urologist mentioned other test that can help determine the risk level of your cancer. A Gleason score is subjective to the pathologist reading it. A test called Decipher can do a genetic type test that can give a more accurate risk level. PSMA can see if spreat outside of prostate.

A decipher test can usually be done with existing biopsies and not have to do another. I mentioned this test as my Decipher was interpreted as intermediate. Decipher came back with low risk. That changed my treatment plan from radiation with hormone to radiation only. So an important test that I referr to a lot from my experience.

You mentioned age. We live a lot longer than we did 20 years ago. Most of the time and I repeat most of the time prostate cancer is slow growing and many doctors will tell you you are most likely to die from something else when you discover the cancer in your 70s. That is why you hear that mentioned.

But a lot of us live into our late 80s and early 90s. I did not want surgery at my age 76 with a low risk diagnosis nor was it offerred. A lot of men chose surgery with the mental attitude to get rid of it. Many of us chose radiation which has an excellent cure rate if cancer caught early and still in prostate.

Talk to your urologist about doing further tests like Decipher, PSMA, etc. to give you a better diagnosis than just a Decipher test. Then when you get them back use that to help you decide and also consder a second opinion if still in doubt or want a second opinion.

With your numbers:
PSA: 9.87
MRI: PIRADS 4.
> Did the MRI report mention the terms extracapsular extension, seminal vesicle invasion, or perineural invasion?
> Did you get a 2nd opinion on the MRI scan?

Biopsy: Gleason 4+3=7;
> What % were “4” and what % were “3”?
> Did the biopsy report mention the terms cribriform pattern or intraductal carcinoma?
> Did you get a 2nd opinion on the biopsy tissues?

If it were me, my next step would be to request a PSMA PET scan to confirm that the prostate cancer is still localized.

After the PSMA PET scan results come back, only then would I seriously begin to consider next steps (though I would be getting up to speed regarding appropriate options on my own in the interim).

I would also seek out and attend a local prostate cancer support group. (I attend two of them each month; face-to-face discussions with others who have been there provides a wealth of information that is useful to know.)

NCCN guidelines do consider life expectancy in treatment decisions, and quality of life due to treatment side- and after-effects are major considerations as well. (Your doctors will likely mention the options of “active surveillance” and “watchful waiting.” Be sure to understand the difference between the two.)

(I was 65y/o when I had 28 proton radiation treatments (4-1/2 years ago) for a 4+3=7; my oldest brother was 79y/o when he had 28 IMRT radiation treatments (earlier this year) for a 4+3=7. Both of our experiences were relatively benign.)

Note to all who replied/commented on my post. I am deeply appreciative of your inputs. They will help guide me in my meeting with the Urologist, and whatever follows. I was writing a response/reply earlier, but somehow lost it when a text message came in and bumped my writings somewhere into the ether, never to be seen again. In re-reading my post and the reports on my MRI and subsequent biopsy, I discovered that I somehow included erroneous info. The MRI noted two PI-RADS 3 lesions, not 4. Sorry for the mistake. The following is directed in response to some specific comments/suggestions from @brianjarvis.

There was no mention of the terms "extracapsular extension, seminal vesicle invasion or perineural invasion." The only related comment was "Seminal Vesicles: Normal." And no, I did not get a 2nd opinion on the MRI or biopsy specimens. There was no mention of the term "cribiform pattern," but specimen N below included the term "INTRADUCTAL CARCINOMA." Detailed results of the positive specimens in the biopsy are as follow:

5 of 14 specimens were positive.
E. Right Lateral Mid Needle Biopsy ADENOCARCINOMA, GLEASON SCORE 3 + 3 = 6 involving 50 % of the specimen (1 of 1 core(s) positive). Grade Group 1. Ends not involved by the tumor.

G. ROI, Right Apex Peripheral Zone Needle Biopsy ADENOCARCINOMA, GLEASON SCORE 4 + 3 = 7 involving 10 % of the specimen (1 of 2 core(s) positive). Gleason 4 comprises 80 percent of the cancer. Grade Group 3. Ends not involved by the tumor.

I. Left Mid Needle Biopsy ADENOCARCINOMA, GLEASON SCORE 4 + 3 = 7 involving 3 % of the specimen (1 of 1 core(s) positive). Gleason 4 comprises 80 percent of the cancer. Grade Group 3. Ends not involved by the tumor.

L. Left Lateral Mid Needle Biopsy ADENOCARCINOMA, GLEASON SCORE 3 + 4 = 7 involving 5 % of the specimen, discontinuous (1 of 1 core(s) positive). Gleason 4 comprises 5 percent of the cancer. Grade Group 2. Ends not involved by the tumor.

N. ROI, Left Mid Peripheral Zone Needle Biopsy ADENOCARCINOMA, GLEASON SCORE 4 + 3 = 7 involving 10 % of the specimen (2 of 3 core(s) positive). Gleason 4 comprises 70 percent of the cancer. Grade Group 3. Ends not involved by the tumor. INTRADUCTAL CARCINOMA.

If any additional thoughts come to mind, please don't hesitate to share. I am a "sponge," trying to soak u as much info as I can. A heartfelt THANK YOU to all.

@georgemc That’s good that most of those terms are not mentioned in the MRI or biopsy reports. Some of those terms are indicators of more advanced disease.
> You should ask your medical team about the significance of the “intraductal carcinoma” finding.

The term “adenocarcinoma” is simply the official word for cancer.

> Regarding specimens G and I: Gleason 4+3=7, with “4” comprising 80% of the cancer. That 80% is on the high end. You should ask your doctor if that % has any significance and does it warrant treatment being stepped-up?

> Regarding specimen L: Gleason 3+4=7, with “4” comprising 5% of the cancer. That 5% is on the low end. (Specimens G, I, and N are more concerning.)

> Regarding specimens N: Gleason 4+3=7, with “4” comprising 70% of the cancer. That 70% is on the mid/upper end. You should ask your doctor if that % has any significance and does it warrant treatment being stepped-up?
Intraductal carcinoma —> ask your doctor about this.

@georgemc
Intraductal can be a serious problem. According to USF doctors, it usually includes cribriform, But since they didn’t mention it, it probably doesn’t. You might wanna get a second opinion on your biopsy, There’s some great doctors that can tell you if there are differences in what you’ve been told and what actually is there.

Here is a couple of doctors that can give you really great. Second opinions on your biopsy..

Dr. Epstein biopsy
https://advanceduropathology.com
Dr. Zhou

Send an email to Ming.zhou@mountsinai.org to inquire about a second opinion and ask for his specific instructions for the process.

At the advanced prostate cancer ancan.org Meeting yesterday, they discussed intraductal a lot. It is an aggressive issue. it is a feature of aggressive prostate cancer that is associated with a higher risk of recurrence and progression.

The fact that your biopsy shows that the percentage of four is 70% and 80% Also points to an aggressive case. I suspect they found some fives, but it was very small percentage. That would be shown somewhere else in the biopsy report.

I would imagine they were talking about doing radiation, And that makes the most sense at your age. Surgery and radiation have the same long-term results but radiation is a lot easier on people. You don’t end up with the incontinence problems and usually don’t have ED problems right away

Because of the aggressive issues, they probably are going to talk about doing ADT, But that can be really hard on somebody that is 90, It can really diminish the quality of life. If that comes up, tell them you would rather be on Nubeqa (Darolutamide) Which has a lot fewer side effects, but works really well. That can control your cancer and stop it from growing and spreading. If they insist on ADT, tell them you want Orgovyx, It has fewer side effects and is a pill you take every day. When you stop taking it, your testosterone comes back quicker and you feel better sooner.

I’m not giving you medical advice. I’m just telling you about different options. This will give you things to talk to your doctor about and you have knowledge that you can use when you’re discussing your cancer treatment.