Gleason 3+4 A.S. or treatment?

@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.

@bens1 I would have preferred MRI-Guided SBRT too, but it was not available (for me) in the cancer center where I was treated -- their Elekta Unity prioritizes those who need more accuracy and could not have the gold seeds fiducial markers implanted on their prostate. What I had was MRI-Guided Radiation Planning, then mini-CT scan before each SBRT treatment. (I was told their procedures compare the CT images with the MRI images, and make the necessary adjustments before each radiation session.) On the third of 5 treatments, I was asked if I experienced burning urination; I did not. I did have frequent urination at night until a month ago, then back to normal. I am now 8-1/2 months post-"SBRT with six months in Orgovyx." My next follow up consultation with the RO is on January 27 -- nine months & a week post-treatment. So far, it looks good, and I hope it continues that way.

@ezupcic Somebody on this forum had a prostate size of about 100 and did Tulsa Pro. The benefit for him was he treated the cancer and his enlarged prostate at the same time. Tulsa Pro can actually be used as a standalone just for BPH. My Prostate was only 45cc and I ablated 30 percent with Tulsa. No doubt I am peeing much better these days!

@brianjarvis
Brian: Thank you for sharing! I have watched pretty much every video on the PCRI website relating to AS and intermediate risk prostate cancer. I have also read pretty much everything I can get my hands on from NIH and other research institutes regarding this disease. ( My wife is a very patient woman!)
You experience in 2012 tracks perfectly with the state of PC diagnosis at that time. There was a pretty strong bias to treat regardless of the level of the disease. My original Local Uro was nearing retirement when I first saw him, and his reaction was similar...cut it out! you comment on pathology is spot on. My local pathology lab also got a different reading than the UW lab on the biopsy samples. ( a man with one watch always knows the time, a man with two is never sure)
Another person on this thread mentioned the ProtecT study. It has interesting data, but being an older study, it seems to suffer from a bias towards lower risk cancer. If I recall, > 70% of the participants were GG1. The challenge with Intermediate risk PC, is it seems to be a very broad grey area. This has been my biggest frustration ( And my wifes as well.. LOL) it includes GG1 with limited cores, and GG2&3 with more extensive disease. If I look at the NCCN guidelines for PC, my current data puts me squarely in the Unfavorable Intermediate category. AS is not even listed as an option for treatment in that case.
When I started seeing the staff at FredHutch/UW, they asked me if I wanted to be part of the Canary Pass study. ( I cant post a link, just google Canary Pass or Canary Pass calculator) This is a multi institute study of AS on a broader cohort of participants. One of its goals is to try to include a broader spectrum of potential AS participants to include those that were traditionally excluded from earlier AS protocols. Canary Pass is trying to take select patients from that category, and follow them long term to develop a better treatment profile. They have developed a pair of online risk calculator that tries to predict the risk of progression at either the next biopsy, of the next 4 years.
When I enter my data, It tells be I have 43% risk of progression at the next biopsy. I also tells me that 93% of the participants in the study have lower risk than me. This tells me that even Canary Pass has a bias towards lower risk disease. (Maybe that's why they were so happy to have me in the study! LOL)
In the end, we all have to make a personal decision based on everything we know at the time. I know this disease is pretty unlikely to be fatal. I describe it as just being messy and somewhat inconvenient. I know i'll never be able to completely be free of it. Like everyone else here, I'm just trying to make the best data driven decision I can. I haven't made up my mind on treatment yet . That's why I reached out on this forum. I do really appreciate you sharing your story.

@ezupcic
Somebody else replied about HIFU. I guess it depends on the size of the prostate and other issues as to whether or not treatment is available. This is focal therapy and here is a comment about it from PCRI.

At the 11/1/2025 PCRI conference the following was said by Matthew R. Cooperberg, MD, MPH

What about focal therapy?
* The energy modality matters much less than the accuracy of the imaging - which is not there yet.
* Overall focal therapy is associated with minor side effects, but high rates of recurrence both in- and out-of-field.
* Focal therapy is not really a replacement for surgery or radiation; it is better considered an adjunct to active surveillance

For SBRT there is no such limit. They can work with any size prostate. If the cancer is spread outside the prostate, they frequently do not like to do surgery so radiation is the best solution. There are cases where IMRT plus brachytherapy can be more effective than SBRT.

Hello,
I have offered my story here on several occasions. Hopefully I can be brief in near "bullet point" statements:
1. The Gleason score, no matter what it is, is only the "tip" of a large, lurking iceberg.
2. I was a low-risk moderate Gleason 3+4=7 with only 6-10% "4" cells. My doctor said I was basically a 3+3=6 with a very small number of "4" cells, and that "we caught it early."
3. My doctor was adamant: "You HAVE cancer, it is not going away, it can only get worse with Active Surveillance which I never do...I am taking your prostate" (he basically told me I have no choice...I was going to have surgery). Glad he did because it added several to many years of life because...
4. Only upon surgical removal of your prostate, seminal vesicles, and vas deferens can the true extent and pathology of your cancer be known. My pathology was as follows:
5. Extraprostatic Extension ("EPE") meaning the tumor broke-through and extended outside the membrane capsule that surrounds the prostate; therefore, I had surgical margins...cancerous tissue left behind because with EPE they no longer know exactly where to cut to "get it all." Left seminal vesicle invasion with no tumor or nodules, just cells...but still "not good at all." Cribriform glands where your prostate tissue fixed to microscope slides and stained, looks like Swiss cheese with holes in it. This is another ominous sign like seminal vesicle invasion.
6. NONE of that can be seen or determined on a mere biopsy that yields that "tip of the iceberg" Gleason Score.
It is such a strange disease. Someone might be an ominous Gleason 5+4=9, and still have prostate-confined disease without EPE, Cribriform glands, seminal vesicle invasion, etc. But someone like me with 12 cores, three of which were negative, three of which were 3+3=6, and six that were 3+4=7, again with only 6-10% "4" cells, had all of this added and unknown pathology. It humbled my doctor who apologetically said "it seems your cancer is more advanced and aggressive than I would have thought (by the Gleason score itself)." Needless to say, I am glad to say that I had the radical prostatectomy, despite its own inconveniences, with the fact that my pT3b class of cancer has a 25-50% of recurrence "within" five years. So, my advice: You HAVE prostate cancer. Do not wait another two years for it to get worse under Active Surveillance, especially since you have no idea of how aggressive it is. BUT...MAKE SURE that your physician sends some of your prostate tissue to Veracyte Laboratories in San Diego, CA for their proprietary "Decipher Test." It tests for 22 prostate-cancer-specific genes that will give you a score from 0.1 to 1.0. You want the lowest score possible. It "risk stratifies you" for longevity (mortality) at 5, 10, and 15 years based on which cancer genes you have. My Decipher Score was dead-middle at 0.5, but even with that, my 5, 10, and 15 year longevity or mortality probabilities were low, between 4-7%, meaning I had a 93-96% chance of being alive in 5 to 15 years. Good luck in your journey.

@brianjarvis Very nice treatment summary. GGI treated with RARP has about 96% BCR free at 5 years & Proton to GG1 about >97% BCR free at 5 years. GG2 & GG3 show less success rates. Do you think it is reasonable to bypass AS & proceed to Proton or RT or RARP?
Thank you

My biopsy confirmed by a different pathologist earlier this year was Gleason 3+4 on one out of 18 cores. I learned that the 3+4 intermediate risk group as a whole was extremently hetrogenous with some in the group similar in biological risk category to Gleason 6, while others were very high risk similar to Gleason 8 , 9 or 10. Before making any decision on what type of treatment I would seek (or before determining if a treatment was necessary right now), I had a GPS genomic test done. Unfortunately, my GPS score was 47, showing the very aggressive and high risk biology of my cancer. If my GPS score was below 20, my risk would have been very similar to Gleason 6, and I would have definitely considred active sureveillance, intead of treatment. But given a GPS score of 47, I evaluated surgery vs radiation and settled on surgery, primarity to say "good bye and good riddance" to my very enlarged prosate which has caused me all kinds of urinary issues for many years, even - and specially after - a TURP surgery. You are definitely a candidate for active surveillance given the low risk biology of your cancer - so - unlike me - you have two viable choices: AS or definitive treatment. Choosing between the two options is a very personal decison weighing in the pros and cons of many factors including your values and life priorities. In my case, if my GPS score was low, I probably would have chosen active surveillance to postpone the initiatiaion of treatment sideffects as much as possible, knowing full well that I will get treatment if and when the PSA reaches a certain threshold. That is also taking into consideration the reality that with a cancer behaving like 3+3, there is a finite possibility that I may never have needed treatement.

I was 63 when diagnosed with similar circumstances (2 tumors gleason 7 with cribriform / 4 tumors gleason 6). Decipher score: .72 (high). Disease confined to prostate. I am treated at a center of excellence, my oncologist/surgeon (Joseph Wagner - a renowned robotic surgeon) advised that radiation or surgery were 'equipoise'. This was confirmed by Smilow (Yale) and Memorial Sloan Kettering. Jeff's advice matches closely what my research and consultations confirmed. I am in the midst of treatment: I opted for 5 SBRT treatments now complete 3 weeks ago/ orgovyx (ADT) another 6 weeks started last week of November. Some fatigue, poor voice for some reason, not much of a libido/but not zero, and doing Pretty Good/Not Bad. I feel about 75% of normal and have not stopped or resisted any activity. It may be of value to have a decipher test (it was important to my physicians re: cribriform). Hope this helps and Very Best Of Luck as you find the right decision for You.

@soli

I apologize , I posted my earlier response before completing spell check. Here is spell-cheked version of my earlier response.

My biopsy confirmed by a different pathologist earlier this year was Gleason 3+4 on one out of 18 cores. I learned that the 3+4 intermediate risk group as a whole was extremely heterogenous with some in the group similar in biological risk category to Gleason 6, while others were very high-risk similar to Gleason 8, 9 or 10. Before making any decision on what type of treatment I would seek (or before determining if a treatment was necessary right now), I had a GPS genomic test done. Unfortunately, my GPS score was 47, showing the very aggressive and high risk biology of my cancer. If my GPS score was below 20, my risk would have been very similar to Gleason 6, and I would have definitely considered active surveillance, instead of treatment. But given a GPS score of 47, I evaluated surgery vs radiation and settled on surgery, primarily to say "good bye and good riddance" to my very enlarged prostate which has caused me all kinds of urinary issues for many years, even - and specially after - a TURP surgery. You are definitely a candidate for active surveillance given the low-risk biology of your cancer - so - unlike me - you have two viable choices: active surveillance or definitive treatment. Choosing between the two options is a very personal decision weighing in the pros and cons of many factors including your values and life priorities. In my case, if my GPS score was low, I probably would have chosen active surveillance to postpone the initiation of treatment side effects as much as possible, knowing full well that I will get treatment if and when the PSA reaches a certain threshold. That is also taking into consideration the reality that with a cancer behaving like 3+3, there is a finite possibility that I may never need treatment.