Gleason 3+4, How did you treat?

My PSA was 7.8 at 66 y/o and a mpMRI found 3, 4 & 5 PIRADS lesions. Had a TRUS biopsy in Oct '23 which found 7/15 cores positive…five 3+3 (5-10%) & two 3+4 (10-20%). My Decipher GRID indicated “Low Risk" @ 0.22. I began AS immediately and just turned 70 y/o in June.

My 12 mth mpMRI indicated that the two smaller lesions were no longer visible and my 28 mth mpMRI indicated all three original lesions were no longer visible. One small PIRADS 4 lesion (92% smaller than the original PIRADS 5 lesion) was found in the most recent mpMRI, but my urologist indicates there's a low risk (< 5%) of clinical significance, due to its central anterior gland location. My current urologist now believes the original mpMRI lesions were inflammation...

My most recent PSA was 6.5 and it has never increased over my prebiopsy level, which I have checked every three months.

As you have CAD, my AS protocol may not be suitable in your case, you certainly would want to check with your cardiologist before attempting any such activity. I crafted an AS program around the protocol defined in the the ERASE RCT. Just today I ran my normal Zone 2 5K followed by two quarter mile HIIT runs....I do this 3 times a week.
https://jamanetwork.com/journals/jamaoncology/fullarticle/2783273
All that said, I would definitely get a Decipher score. In my case, it was the key piece of confirmatory information regarding my AS decision, which is especially important when trying to decide what to do after a 3+4 diagnosis.

In any case, you have time to do extensive research (if that's your inclination) before making any treatment decision.

Thanks - good input. I would love to run but after my last spinal fusion my neurosurgeon said no more impact sports (or torquing). It drives me crazy because I live on a golf course and there is an active tennis/pickleball community and I can't partake in any of it. I can't believe that I hit the health trifecta - coronary, neuro, and now cancer!

The Decipher score is definitely a good idea, and others have suggested PET as well. I don't want to rush into anything because my schedule is pretty full (birthday this month, 50th anniversary next month, trying to get my northern house on the market, officiating my grandsons wedding in November, and of course the holidays). No good window for extended downtime, but I have to be realistic.

@keithl56
Don’t worry nothing really you need to do regarding the Decipher but a phone call to your Urologist or whoever performed your biopsy and request they do it.

@keithl56
I think that RT is much easier on body than surgery in cases when other serious health issues already exist, especially heart issues.

General anesthesia is hard on body and effects both heart and the brain. I suppose you must be on blood thinners now and you will have to stop them to have surgery and that would put you at risk of developing blood-clot : ((.

My husband had surgery and he recovered in record time but he does not have any health issues and is in great physical shape in general.

Many had much longer recovery than him. It is very individual indeed and depends on so many factors. I am not a doctor, I can only tell you my opinion and what I would have chosen for my husband if he had serious heart problems or previously had a stroke. It would most definitely be RT.

@keithl56
I had 3+4 with a psa of 10.2. I had no adt, did my research, got 6 opinions from doctors trained at, or currently at centers of excellence. Diagnosed in September of 2022. Treated, with spaceoar, in January of 2023. I eliminated removal as a choice, per the side effects possibilities and narrowed my choice down to proton or the MRIdian radiation machine. The Mridian and the Elekta Unity are the only two machines that have a built in MRI. John Hopkins has the Elekta Unity. The built in MRI means that the margins used are 3 mm, instead of 5+ mm for other radiation machines. The smaller the margins, the less healthy tissue exposure and the less side effects. I had 5 treatments. What they can see, in real time, they can treat.

@keithl56 For localized disease, data show that success rates comparing surgery vs radiation are statistically equivalent.
> https://www.nejm.org/doi/full/10.1056/NEJMoa2214122

As that paper concludes, “… the choice of therapy involves weighing trade-offs between benefits and harms associated with treatments for localized prostate cancer.”

So, it basically comes down to one’s quality of life priorities. For me, that clearly placed radiation at the top for primary treatment (and I chose proton radiation).

Also, if (heaven forbid!) I ever needed salvage treatment, primary radiation would leave me with the most options.
> For those who choose primary surgery, if there is recurrence the first salvage choice is radiation - the very thing they wanted to absolutely avoid at all costs.
> For those who choose primary radiation, if there is recurrence there are many salvage options - focal therapy (e.g., cryo), brachytherapy, and SBRT (because they’re all very targetable), and yes even re-radiation in some cases; salvage surgery is a last and distant option (if at all).

Much goes into this treatment decision beyond just “get it out”, with one’s personal quality of life priorities being a major factor.

@bens1

Good info for me to have for my JH consult.

@brianjarvis

I agree with your comments. My options may be limited since they found cancer in the right side while my primary is on the left, so focal therapies may not be possible. Given my comorbidities I am leaning toward quality of life versus quantity of life risks, although my wife seems to have a contrary approach.

@keithl56 For my primary treatments I was not a candidate for focal therapy for the same reason - they found lesions on both sides of my prostate. Not a big deal; simply move on to the other treatment options. (And for salvage treatments following primary radiation, treatment depends on the nature of the recurrence.)

With my localized disease, “quantity of life” has never seriously crossed my mind. For Stages 1-3, survival is nearly 100%. (For metastatic disease, the odds drop.) So, for me mortality was not even a consideration.

When I was initially diagnosed with prostate cancer in 2012, my wife was quite upset. She said she “couldn’t bear the thought of cancer being in me.” But, I’m the more pragmatic, logical (retired computer scientist) type, and was able to show her (based on the data), that there really wasn’t anything to worry about, many treatments were available, and that I would carefully evaluate and analyze all aspects of this disease and make a decision that was best for us. (I’ve had more adverse quality of life impacts from my back surgery and my two knee surgeries than I’ve experienced from my prostate cancer.)

Now 14 years later, she fully understands the rationale behind treating prostate cancer appropriately - not too hard; not too soft (the Goldilocks scenario) - and certainly not letting emotions drive treatment decisions.

I was 69 when my biopsy came back with two of twelve cores being 3+4 with some others being “iffy” (likely precancerous). My urologist and I agreed AS was a good option. Then my Decipher results came back as high risk and the AS option was no longer on the table. My urologist offered to set me up with both a surgeon and radiation oncologist to discuss my options, but I had already done my research and knew I wanted radiation. I had 39 sessions of VMAT (with fiducials and SpaceOAR, no ADT) and my PSA numbers have continued to drop in the 3 years since the treatment concluded. My RO has proclaimed me to be in remission. My side effects have been minimal (I had ED before treatment and it’s a bit worse now, though treatable) and my life is back to normal. Hopefully it will remain that way for many more years. Good luck.