Gleason7(3+4) - treatment options recommendation

@johnnyz
While 7 of 15 cores is good to know it’s even more important to know what the Gleason Scores were on those seven cores. Were they all 3+3? Were some of them 3+4 or 4+3. Or any of them 4+4 or 4+5.

Any of those group of scores could mean you need different treatment. Was the cribriform Large or small? My brother had small cribriform And just had five sessions of SBRT radiation and he’s doing fine three years later. If it’s large cribriform But you only had one 3+4 and it was only 10% of four then you could actually hold off and do active surveillance. I know a guy who’s gone well over a year with large cribriform But only a 3+4 and many doctors have told them there’s no urgency and he’s just stayed on active surveillance.

If it’s a 4+5 or 4+4 then you want to get a PSMA PET scan to see if there’s any spread outside the prostate. In that case, surgery is not an option usually you want to do radiation.

How high was your PSA at diagnosis? The higher it is the more urgent treatment is.

I need a lot more information to really Assist you.

Are you a patient that could have focal therapy? A lot of that is based on how much it is spread and how aggressive it is.

Were any of these things found in the biopsy intraductal, ductal, large cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive.

@johnnyz
While 7 of 15 cores is good to know it’s even more important to know what the Gleason Scores were on those seven cores. Were they all 3+3? Were some of them 3+4 or 4+3. Or any of them 4+4 or 4+5.

Any of those group of scores could mean you need different treatment. Was the cribriform Large or small? My brother had small cribriform And just had five sessions of SBRT radiation and he’s doing fine three years later. If it’s large cribriform But you only had one 3+4 and it was only 10% of four then you could actually hold off and do active surveillance. I know a guy who’s gone well over a year with large cribriform But only a 3+4 and many doctors have told them there’s no urgency and he’s just stayed on active surveillance.

If it’s a 4+5 or 4+4 then you want to get a PSMA PET scan to see if there’s any spread outside the prostate. In that case, surgery is not an option usually you want to do radiation.

How high was your PSA at diagnosis? The higher it is the more urgent treatment is.

I need a lot more information to really Assist you.

Are you a patient that could have focal therapy? A lot of that is based on how much it is spread and how aggressive it is.

Were any of these things found in the biopsy intraductal, ductal, large cribriform, Seminal vesicle invasion, EPE or ECE. (Extraprostatic extensions extra capsular extensions). They can make the cancer much more aggressive.

@johnnyz -- I leaned toward surgery for a variety of family and personal preference reasons that I wouldn't try to justify since they weren't based on scientific data, but rather emotional and family bias/preferences. That said, one aspect of surgery I did like was I believed (and still do) that a prostectomy is a very difficult surgery and that the skill and experience level of the surgeon (while not a guarantee) is very crucial to improving the odds of getting the best possible outcome. I was on original medicare so I had the opportunity to "shop for a surgeon", which helped me feel I had a little control in determining my outcome. To that end I made an effort to try to find the best surgeon available to me, and then I asked him what he thought my specific chances for incontinence and ED were, and whether he'd be able to spare my nerves. I ended up traveling out of town for my surgery, but I think it was worth the cost and effort. The surgeon I found told me at 1 year I had a 90% chance of being continent and 70% of not having ED. He also told me he was very confident he'd be able to spare my nerves, based on the biopsy and MRI test results. After surgery he told me everything went exactly as planned and he was able to spare my nerves. I was never incontinent (other than the normal accidents figuring out the new normal) and at 15 months my ED was gone and I was fully back to normal. I think getting an experienced and successful surgeon, while certainly not a guarantee, is worth the effort if that's an option available to you. However, I'm not a medical professional and this is just my layman's comment. Best wishes.

@pesquallie

I guess my first urologist wasn’t up on the latest research. Can you provide a reference to this research as I would like to provide it to my initial urologist.

@pioneer
Below are some recent articles I have read that support testosterone replacement therapy. Below is an overview. Sorry that I can not show the actual web sites, but you can google any of them to see the details.

Testosterone replacement therapy following definitive treatment for prostate cancer: a scoping review of safety and efficacy | International Journal of Impotence Research
Conclusion: TRT does not increase the advancement of prostate cancer and may actually decrease cancer growth. 11/26/25 summary of 12 studies.

Testosterone and prostate cancer: What's the connection? - Mayo Clinic
Conclusion: Studies have shown that testosterone replacement therapy doesn't seem to increase the risk of prostate cancer returning. 10/29/25

youtube.com/watch?v=Pb3ENO3oSso&t=1381s – Kristen Geiger and Alex Scholtz, “TRT After Prostate Treatment”. Recommend TRT for treated patients.

Testosterone Supplementation After Prostate Cancer Treatment
YouTube - ISSM International Society for Sexual Medicine - Dr. Mohit Khera (Baylor College of Medicine) and Dr. Gerald Brock (Western U. London) explain the evolving view on testosterone and prostate cancer, noting a shift from seeing testosterone as harmful to recognizing potential therapeutic or preventive roles. Low testosterone is linked to higher risk of high-grade cancer, recurrence, and poorer erectile recovery. 3/28/25

Testosterone Recovery Uncertain after Androgen Deprivation Therapy for Prostate Cancer | Memorial Sloan Kettering Cancer Center

Study Solves Testosterone’s Paradoxical Effects in Prostate Cancer | Duke Health
How testosterone went from prostate cancer villain to potential ally
Can You Take Testosterone If You Have Prostate Cancer?

@jeffmarc Hi Jeff, my PSA is/was 10.8 at biopsy, Cribriform architecture is evident but <10%, and pattern 4 <5%. No IDC, bilateral cancer on both sides. Stage 2 unfavourable, but surgeon biopsy review suggested stage 1...No evidence of seminal invasion, EPE or ECE. Surgeon said NO to SBRT. Surgeon also leaned to pushing for Robotics RP

@johnnyz I should have included that my Gleason score was 3+3 last year, and after this biopsy it has shifted to 3+4=7 and intermediate unsatisfactory

@johnnyz
Did you have a Decipher test? If so what was the outcome of the test? If you did not have one I would suggest talking to your doctors about getting one.

It really help you and your doctors to see what the applicable treatment options are for you.

Thanks for the reply and interest. Nowadays, I have regained urinary continence to ~98%. I still have little unexplained dribble leaks that see me wear a thin Depends "Shield". My biggest sadness...it is truly a sadness...is that even though my urologist said he "preserved the neurovascular bundles" which of course contribute to urinary continence and sexual capabilities, I haven't even had a twitch/hint of an erection since my April 2025 surgery. My urologist just kept "stringing me out": in the beginning it was "most men regain the ability to get erections between 3-6 months post-surgery." At my sixth month appointment I asked: "So....why don't I have erections yet?" He answered: "well...it 'can' take 'some' men between 6 - 12 months before sexual function is restored." He kept speaking in the affirmative like "it will happen." At my 12th month appointment I said: "So....I am at 12 months and still no erections." Then he said: 'it can take 'some men' up to 'two full years' before their sexual functioning has returned." Again, he spoke in the affirmative...he never said at that point: "sorry buddy...you're dead down there for the rest of your life." Then I mentioned all of the men on this blog who write about having ED for five years, ten years, and "never" regaining it ever. My urologist said: "yes, that does happen a lot of the time." I asked "so what does it mean for "ME" specifically?" He shrugged his shoulders saying "all men are different...some DO recover within 3-6 months, and some never do." He added that our age has a lot to do with it. I reminded him that as a man who had just turned 70 prior to my surgery, that I was fully capable...instantly...when the moment presented itself to me...I was as virile as I was when I was 35 - 40 years old. Now I carry around a limp wet noodle. Quite literally before I jumped on this blog, just 5 minutes before, I was sorting photos from a dating site that I joined a few days ago. I mentioned "sadness" above...I can't imagine coming to a point when any of these women let me know they are ready for sex, and I have have to tell them: "Um...I had prostate cancer surgery, and I am now incapable of performing for you." I haven't cried since my parents' funerals, but I think I would literally cry when I had to tell a woman that I can't satisfy her sexually with intercourse. I have pondered Trimix, but even as a guy who was in healthcare and around needles all of my life, I can't fathom sticking even the smallest bore needle in my penis to get an erection..."chills" down my spine. So...
Other than that, everything is normal and fine in my life. It took me 4-6 months before I started feeling like I "turned the corner" on the surgical recovery, and had regained my strength. But...it destroyed my well-maintained progress and status in the gym. I lost SO MUCH strength and capability...it was like starting over after not working out those 4-6 months. Good luck to you.