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Gleason 3+4 A.S. or treatment?
Prostate Cancer | Last Active: Jan 13 12:14pm | Replies (33)Comment receiving replies
Thank you all for the replies! Rather than individual replies, I'll try to address all of of them in this post.
( A note about me, I'm a retired Engineering/Operations guy, so I tend to over analyze everything... bear with me!)
First off, regarding AS vs RALP vs Radiation:
When I was first diagnosed, it was a local Uro who saw my high core count, all 3+3, and immediately wanted to do surgery. I live about an hour north of Seattle, so I decided to get into Fred Hutch/UW for second opinions. The Uro Oncologist that I am seeing there laid out all of the options including AS, RALP, and radiation. She sent my tissue and imaging out to be evaluated by the UW labs, and that resulted in a slight upgrade to 3+4 in one core, and ID of another small lesion on the other side of the prostate. Her recommendation at the time was to wait for the confirmatory Biopsy in 9 months and proceed with AS until then. At the time, my PSA was about 6.5 Since then my PSA rose to 7.2, then came back to 5.5.
In the meantime, I had a meeting with a radiologist at Fred Hutch. (I'll touch on that further down) .
In October of 2025, Urologist did the confirmatory, 12 std cores, and 6 targeted to the two lesions. That results of that biopsy tracks pretty closely with the original, except for the extra core (now 2) of 3+4 still less than 5%. At that time, she said due to my low PSA, Low decipher, Low Artera and slow progression, I could continue on AS if desired, but that treatment was also not an unreasonable path.
(Note: Fred Hutch/UW is one of the centers that is part of the PASS study. The goal of the study is to try to get longer term data on AS in Intermediate risk patients. I am on the Favorable/Unfavorable bubble, so they asked me to participate as part of the AS protocol. I am enrolled in the study, but it doesn't affect my decisions regarding treatment at all.)
Radiation: when I originally talked to the radiation Oncologist at UW, I had done a fair amount of research on radiation treatments. At the first meeting I asked about Proton because I really liked the idea of generating the radiation pulse in the prostate with a proton Bragg peak. The Radiation oncologist said that was an option, but his recommendation was SBRT due to the ability to get it done in 5 sessions. Due to my travel distance to Fred Hutch, that is pretty attractive. As to why I was considered a good candidate for that, I don't know that answer definitively, but I suspect its due to organ confined cancer, 58CC prostate volume, and reasonable existing urinary function. I recently had a second meeting with him after the confirmatory Biopsy, and he still thinks SBRT 5 sessions is a good fit, but we have to watch the urinary symptoms. (I am scheduled to get a sonogram next month to measure my bladder full and empty to see how well I void. at that time I will discuss Flomax, Ditropan, and other alternatives)
Trans Perineal Biopsy. My first biopsy was a standard TRUS. it was supposed to be an MRI fusion, but my local Oncologist did it, and it was only 12 cores. (7 positive). I'm not really sure he did the MRI fusion bit since he was done in about 12 minutes. It was a non-event for me after taking a 10mg Diazapam... I think I was more rattled at that point after being told I probably had cancer. I think you all know that experience.
The second biopsy was a Trans-Perineal. The Dr I have at UW no longer does TRUS biopsies due to the infection risk and increasingly antibiotic resistant bacteria. I was awake for the TP Biopsy, and after all the lidocaine was in, the needle part of it was reasonable. It took about 30 minutes for the Dr to get all 18 cores, so she was in my butt with the sonogram probe for a long time. The samples are taken with a similar spring loaded device, so you get the same click with each sample. Not painful, but a bit jarring. The biggest issue for me was having the pain of having the sonogram probe in my butt for that long, plus all the gyrations she made getting the needle into the right spots. I came away from it with the worst hemerroid flareup I've ever had. It took a month of sitz baths twice a day to get it under control again. I was also bruised from scrotum to anus for a few weeks. Even with that, I'd still do it again over a TRUS due to the infection risk.
So, as I said in my original post, I'm really leaning towards SBRT. I have a lot of confidence in my care team, and I think they are all being very open and honest without pushing any particular options. At this point, I'm 69, and in pretty good shape, so I would rather get it treated and move on. I really do appreciate all of your feedback and experiences.
Replies to "Thank you all for the replies! Rather than individual replies, I'll try to address all of..."
@higgins56 Good detail. As a retired computer scientist (aerospace industry) myself, I also analyze every situation. This prostate cancer provides the perfect scenario for analysis. Mine followed a similar path at points, but with different decisions at those points.
Similarly when I was initially diagnosed (in April 2012), it was a 3+3 in half of the cores; the other half were benign. My urologist wanted to schedule surgery immediately. My first comments to my urologist were (that I recorded in my journal), “I don’t know anything about prostate cancer so, I’ve got a zillion questions to ask before you cut anything out of me, or bombard me with radiation, or inject toxic chemicals into me……”
From that point on, it was about self-advocacy and shared decision-making.
Based on my review and analysis of the literature, it was my decision to go on active surveillance (AS). With no sound argument to the contrary, they cooperated with me.
Regarding your upgrade to a 3+4 at U/W, remember that a Gleason score is just one pathologist’s educated, experienced opinion of what he/she sees under a microscope; a 2nd opinion is just that as well. There’s no way to know which one is “right,” the 1st or the 2nd one. (I attended a webinar out of Johns Hopkins a couple of years ago where the urologist mentioned if they can get two urologists to agree on a Gleason score 2 out of 3 times, that’s considered great success.)
Regarding your PSA rise and fall. Remember that PSA is impacted by testosterone levels, and since testosterone levels are diurnal, PSA levels can vary with that. PSA can vary from morning to afternoon so, keep that in mind as well. (I get my PSA tested at about the same time of day each time.)
I was on AS for almost 9 years and at the start had made a commitment that should (1) my Gleason ever reach 7, or (2) my PSA ever reach 10, or (3) a biomarker test ever return unfavorable results, that I would then seek active treatment. Again, it was always my decision.)
Though, I chose not to be part of any clinical trial, I did choose to have my proton radiation treatment results submitted into a registry (https://clinicaltrials.gov/study/NCT02040467). Hopefully, it will help someone make a decision one day.
I also had the option of SBRT (when I was eventually treated in April 2021), but the increased risk of urinary bother following treatment (due to the higher dose each session) was not appealing to me so, I chose the 28 fractions of proton instead. Additionally, being retired made the 40-minute drive to the proton center rather easy to fit into my daily routine. (The Bragg-Peak characteristics of proton was a factor in my decision as well.)
As for why you were considered a good candidate for SBRT - you were probably a good candidate for any of the treatment options depending on what specialist you asked. (The old saying of “if all you have is a hammer, everything starts to look like a nail” comes to mind.) Each being expert in their specialty, each would have recommended theirs.
In this 2023 Mid-Year PCRI conference, Dr. Rossi mentions SBRT with some caution. (He’s talking about proton SBRT, but says it applies to photon SBRT as well): https://www.youtube.com/live/WTqPnSRYtW4
—> Starting about timestamp 4:30:45
All 4 of my prostate biopsies during the more than 8 years that I was on AS (2012-2020) were done transrectally. Never had any infections or unexpected after-effects. The Diazapam and Lidocaine (lots of it) worked for me as well; non-events. For my fourth (& final) transrectal biopsy before receiving active treatment, I invited my wife to be in the room where the MRI-guided procedure was being done. I wanted her to see that it wasn’t as painful as she was imagining. She said ok; the urologist said ok. So she sat in the corner of the room (towards my head) during the entire procedure; an experience I think she’ll never forget!
I appreciated the open and honest advice and recommendations from all the specialists that I met with. But ultimately - it being my decision - at 65y, I chose 28 sessions of proton radiation (@ 2.5 Grays each), along with SpaceOAR Vue (the iodized version of SpaceOAR Hydrogel).
As for “getting treated and moving on….,” following treatment I had PSA tests every 3 months for 2 years, then every 4 months for 2 years, now we’re doing PSA tests every 6 months for 2 years……. I don’t think there will ever be a “just moving on.”
(Similar to your oncologist’s caution regarding any changes to the diagnosis —>) Prior to starting my 28 proton treatments, we had a 2nd opinion on those last biopsy tissues, which came back a 4+3. Not knowing which was right - the 3+4 or the 4+3 (since they were both educated, experienced opinions) - I chose to be treated using the higher Gleason score. So we simply added 6 months (two 3-month injections) of Eligard to the treatment regimen prior to starting.
Good luck with your decisions.
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@higgins56
My brother had 4+3 and had the SBRT treatment three years ago when he was 77. He had some minor urinary issues that Flomax resolved. It works quite well, and you have such a limited case without any spreading you probably will have long-term resolution.
I guess the AS option is still open since your amount of four is so small.
And your latest biopsy with seven chorus positive. You don’t mention whether they were all 3+3. You could get a second opinion biopsy from an expert that has done them for many people for a couple of decades. They do charge $500 but you can speak on the phone with the doctor for as much time as you need once you get the results.
Here’s two highly respected doctors that do it, They will work with your medical group to get samples.
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.