Do I Continue Active Surveillance or Consider Intervention?

June 7, 2023 - Recent Blood test results
PSA 2.97 (total PSA level below 4 ng/ml, But 4.5-5.5: Normal for a man 70 and Older?)
PSA, Free 0.616
PSA, % Free 20.7 (Howard Health Blog suggest: Men with a total PSA in the same range and a free PSA below 10% need to have a biopsy? A percent-free PSA above 25% is considered normal?)
Do I Continue Active Surveillance? I am not sure what other options are there now, or will be available in future researches.
Thanks

The word active surveillance scares me. I was told when I found my prostate cancer I was good for 10 years before I had to worry about it. Three years later they went to my bones and metastasized. Now it’s in my ribs, my sternum, and my scapula and my back and shoulder lately, they would’ve taken the thing out or radiated it back in 2018 I wouldn’t be fighting this right now. Nobody told me you could go to your bones and do all that or I would’ve told him to take it out. Then one thing I learned from all this is get a second or third opinion , don’t wait for it to go to your bones because there’s no coming back from that. I’ve had radiation. I’ve had chemo and more radiation. It all could’ve been avoided. Good luck. My prayers are with you. Dave

All prostate cancers are different. And treatment does not guarantee cure as my cousin had his taken out five years ago and PSA went up to .5 and he just finished 39 external beam radiation treatments and doing ADT

I agree I was never given the options or told that if I did active surveillance and didn’t do nothing, they could go to my bones and metastasize. I figured if it gets worse will just take it out they take them out every day. That’s my biggest complaint, the doctor didn’t inform me of that possibly happening and I’m afraid other people are told that you need to get all the facts and it’s his job to tell us that stuff, I was let down by my doctor that’s my opinion

I understand your frustration. At the time of diagnosis what were your PSA readings, your age and did you have any biopsies?

We sound similar. 70, healthy eating and exercise. I had five lesions (PI-RADS 5, 4, 4, 3, 3), PSA at about 4, and biopsies at 3+4 but with a classification of Intermediate Unfavorable. I also had the Decipher genome test that put me at low risk for metastasis. The docs (I talked to three of them) recommended I choose between surgery or radiation. I decided on watchful waiting instead and hoped for development of the next miracle cure. It never came and a year later, my PSA jumped to 11 and a second MRI show the PI-RADS 5 pushing against the capsule. So, I opted for HDR brachytherapy. A month-and-a-half later I seem to be doing fine. While not a vacation on the beach, the biopsy and the two-step radiation procedure cause me zero pain and was all out-patient. It does slow you down for about a month. I'm only 55 days out from the second procedure, so can't tell you any long term effects from my delay.

You appear to be on the cusp of the treat/AS inflection point.

I found these articles to help me when I was at a similar crossroads, regarding age, PSA levels, and the use of the free PSA:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923265/ ("Age and prostate specific antigen level prior to diagnosis predict risk of death from prostate cancer" - review of several 100,000 men in VA database monitored over decades)

https://www.nejm.org/doi/full/10.1056/NEJMoa2214122 ("Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer" - UK study of 1600 men randomly assigned to AS, Radiation, or Surgery)

Also, talking with a medical oncologist (not a urologist) specializing in prostate cancer helped confirm my own decision. An in-depth 45 minute conversation with her was very helpful.

Applying the thinking I used at the time I had my biopsy, with your numbers, age, and cardiac status, I would have opted to continue AS. On the Plus side: relatively low, (and falling) PSA, Gleason (3+4) grade group 2 all sound reassuring for the next year. In my thinking, the free PSA percentage is only useful in predicting the probable presence of cancer. You already know the cancer is there, so you know how that bet played out

The key question in my mind would be, "How willing am I to undergo the side effects of radiation and possible hormone therapy?", compared to the likelihood I would die of the disease in the next 5-10 years. I would (personally) bet the cancer is not aggressive, and I'd rather live those years without the risk of bowel dysfunction and worsening penile erectile status. You may have different values on those questions than I did.

Thanks
At Diagnosis PSA 10.57 ng/mL; age 72 (4 years ago), biopsy 4 years ago. DRE: Negative. Urologist recommended Active Surveillance.

Current age 76, PSA below 3 ng/mL

Two treatment options: Radical Proctectomy ruled out (previous Heart Bypass surgery and age), Radiation. Immediate side effects, short term and long term both.

I am also 76 yrs old like you but except for my PCa diagnosis, am in quite good health. What has caught my eye in my pathology report was the finding of "perineural invasion present" just like your report. My gland has 3 lesions 2 of which are GL 6 and the third is a GL7. The GL7 tissue was sent out for a Decipher test which resulted in a Low Risk score of 0.37. Just had a second opinion with a medical oncologist at Medstar Georgetown Hospital who advised me to not worry about things since I was in his opinion Low Risk and should only consider Active Surveillance (AS). However, after reading all about perineural invasion (PNI), it was a big wakeup call for me. About 31% of those with PCa have PNI. To learn more on PNI and how it can influence your treatment go to these 2 articles: https://www.healthline.com/health/prostate-cancer/perineural-invasion-prostate-cancer AND also this one https://malecare.org/perineural-invasion-on-prostate-biopsy-does-it-mean-that-i-have-advanced-prostate-cancer/ . The second one looks dated as of 1998 but there may be newer info you can find on the internet. In summary, I intend to put AS on the back burner until I find out more about where PNI is located in my prostate (ie has it penetrated a nerve OR is tracking along side of it).To answer this I plan on writing a letter to the pathologist since she was the one who found the PNI. The main thing is to NOT allow the cancer to get outside of the prostate. What are your thoughts?

Anjalid30: I was 69 when my psa was 10.20. I am now 70 and had radiation treatment with the Mridian viewray machine. 5 treatments completed in February. 2 mm margins on the machine, I believe, made a huge difference on impacting healthy tissue vs 4-6 mm for all other types of radiation.

The advice to get the Decipher test was good advice. I did it as well. It gives some level of comfort and dr’s use it for further diagnosis.

I did not want to take the chance that the cancer would spread and force me into other treatments that could dramatically change my quality of life so I chose to get treated with radiation using viewray’s machine, over proton and other choices. I would make the same decision over again, even at 76 or beyond, because you just never really know how fast things can change and doctors cannot predict it well. I also did the Spaceoar gel which helped to protect the healthy tissue as well. I am sorry you have to go through this.