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Gleason 3+4 A.S. or treatment?

Posted by higgins56 @higgins56, Jan 8 2:31pm

First off, thanks to everyone who participates in this forum. PC is a journey that is different for all of us. Information exchange is really helpful.
My journey so far..
Diagnosed at 66 (2023) with rising PSA.
MRI in May 2024 Pirads 4 with a lesion on the left side
TRUS biopsy in Jul 2024, 7 of 12 cores positive, all 3+3
PSMA PET in 2024 says confined to prostate
Moved from local Uro to Fred Hutch/UW for second opinions
UW re-evaluated tissue and scans, upgraded to 3+4 and another lesion on other side of prostate. (If you are in a rural area, go to a center of excellence!) started AS in Sept 2024
Oct 2025 Confirmatory Trans perineal Biopsy (fun!)
10 of 18 cores 3+3, 2 cores 3+4, less than 5% GP4 now on both sides.
My PSA is monitored at 3mo intervals pretty steady at 5.5, peaked at 7.2 then back to 5.5. Decipher low.
Oncologist says still OK for AS with 3 mo PSA, but also treatment wouldn't be unreasonable..
Radiation guy says I am a candidate for SBRT without ADT, but I have urinary urgency issues that could preclude that if they get worse.
What to do..?? I just turned 69. I'm leaning towards SBRT, because I don't want surgery, and I am worried about losing the SBRT option if my urinary frequency and urgency continues to degrade. I cant do Flomax due to headaches. ( It made my migraines unbearable) As much as I'm glad to not have a worse diagnosis, being in the unfavorable intermediate group is a blessing, and a curse. Any input from folks with a similar diagnosis would be appreciated.
Thanks!

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brianjarvis | @brianjarvis | Jan 11 2:12pm
In reply to @lyricw "@brianjarvis Very nice treatment summary. GGI treated with RARP has about 96% BCR free at 5..." + (show)
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@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

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@lyricw One of the understandings I had with my doctors was that quality-of-life and successful treatment were equal priority for me. That set the basis for us working together and agreeing on an appropriate treatment plan.
> All primary treatments seem to have good BCR-free numbers. Once I saw that, I put that consideration aside.
> With a GG1 and no other risk factors, I didn’t treat; I chose active surveillance (and avoided any serious side-effects.)
> At GG2, I would treat. However with a 7(3+4), I would consider the % of the “4” cell structure in that decision (as well as any other risk factors).

From my evaluation of treatment options (success rates being statistically equivalent), for me proton ranked better than IMRT; SBRT ranked 3rd, and RP was a distant last place.

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heavyphil | @heavyphil | Jan 12 7:45am
In reply to @soli "My biopsy confirmed by a different pathologist earlier this year was Gleason 3+4 on one out..." + (show)
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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.

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@soli What a fantastic post, soli…so many men STILL don’t realize that not all Gleason scores are alike - even if the numbers are!
The degree of aggressiveness is a big red, flashing beacon begging you to take your treatment to the next level. Thanks again,
Phil

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kjacko | @kjacko | Jan 13 12:14pm

I was in the 3+4 group when I was diagnosed. I wanted the cancer gone so I decided on surgery. My post surgery pathology report came back at 4+5, so I was really glad I took the surgery road. I had zero incontinence issues, which was wonderful since I had urgency all the time prior to the surgery due to an enlarged prostate. As I have told others similar to you, do everything you can to make sure you Gleason score is accurate. BTW, I was 71 when I had my RP a little over two years ago. Doing fine since, my PSA is still < 0.01.(knock on wood). Hoping for the same this April🤞🙏. Best of luck to you.

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