Gleason 3+4 A.S. or treatment?

@wwsmith . My decipher and Artera scores were both low, so probably no ADT for me. I do appreciate your feedback!

Mike

@higgins56 You may already know this but if you are headed down the SBRT road you need to do a PROSTOX test to make sure that you are at low risk from radiation side effects. If PROSTOX says that you are at high risk then you would need to switch to low dose IMRT treatments.

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.

@wwsmith . My decipher and Artera scores were both low, so probably no ADT for me. I do appreciate your feedback!

Mike

@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.

@higgins56 do extensive research before undergoing any treatment at all. The Protect T Trial indicates active surveillance is EQUAL to RP and radiation in the ultimate outcome (only 3 in 100 die from prostate cancer, no matter the form of treatment). Most need some form of treatment eventually, but many do not. Research, research, research, then decide.

@jeffmarc

first biopsy: 7 of 12 cores positive, one 3+4, the rest 3+3
second biopsy: 12 of 18 cores positive, two 3+4, the rest 3+3, less than 5% g4

@ezupcic
If the cancer was isolated to the prostate, The Gleason score is not too high, Then SBRT is a good decision. My brother had it done at 77 with the Gleason score of 4+3.

ATRUS biopsy is transrectal not transperennial. Has a higher risk of infection.

You can have the same ultrasound guided Biopsy that is transperennial. I read a couple of days ago that’s the only thing Mayo does now.

As to when to stop AS, There’s a lot of factors involved. Are you only Gleason 3+3? If 3+4 is it a very small percentage of four? You could probably get a better feel for what the answer is by watching these videos.

Here is a video with Dr. Laurence Klotz, one of the experts on active surveillance. He can give you answers as to why you would or would not be a good candidate for active surveillance.