46 year old, two lesions. Pirad4 Pirad3

Sounds like we have much the same diagnosis, difference being I'm 71 yrs old. I’m sorry you have to deal with this so young. I had the same MRI results, the subsequent biopsy showed two tumors confined to the prostate and a good prospect for HIFU. Genetic testing showed mine not to be aggressive and no genetic markers showing I'd be prone to cancers. At my age, just monitoring its progress might be okay, but since I qualify for HIFU, that’s the course I’m pursuing. I've been on Orogvyx because my prostate volume was too high for the procedure and after 6 weeks, it’s shrunk enough to proceed. I’m now just waiting to get on the surgical schedule.

Everyone is different so you have to do your best research and decide the course you feel is right. Read the book referenced by others and try not to become overwhelmed. Best wishes for a successful course with a long happy life.

If I already had the biopsy, am I too late for Decipher Test? Why don’t Urologists ask for that automatically?

@pmclarksr I have heard that the biopsy material can last for a long time but best to contact decipherbio.com or call them at 1.888.792.1601. It took a couple of weeks for them to process mine and I requested my Decipher test a couple of weeks after the biopsy. I also requested my own copy from Decipherbio.com, separately from the doctor, as I had asked him to order the test as it was not on his suggestion list but was on the list for two radiation oncologists I spoke with.

Good morning. Sorry to hear about the equivocal Prostate MRI results but remember that you have not been diagnosed with cancer at this time.

My 2 cents both as a patient who had an RP and as a retired physician.

Surgery (RP) by an experienced, highly skilled Urologist has a low complication rate. The upside is the cancer has been immediately removed and the pathologist can evaluate the tissue and give an exact diagnosis of the extent and type/aggressiveness of the cancer. The surgeon can "look around" and see if there appears to be any local spread during surgery. The downside is dry orgasm (but your ejaculate will diminish with radiation/brachytherapy as well), the short recovery time from surgery, the small but definable potential complications from surgery and possible incontinence. From studies, the vast majority of young men regain total continence. In the event you have local recurrence down the road you still have the potential option of curative radiation to the pelvis.

Radiation involves multiple weeks of daily short treatments. Cure rate is similar to RP. The PSA is a little more difficult to follow because it slowly goes down and doesn't become undetectable like surgery. There are potential short and long term complications with radiation, although with newer machines and protocols they are less than in years past. If you have a future recurrence, surgery is difficult sue to radiation induced scarring.

Brachytherapy is similar to radiation option but obviously doesn't involve weeks of treatments since seeds are implanted at one sitting.

All good options. Take your time. The important point is to go to a highly skilled professional no matter the choice.

Thanks, it amazes me what these urologists don’t do. I was never given a consult for mpMRI nor a PSMA PET scan, nor a bone scan to rule out spread outside the capsule, and I’ve never before heard of the Decipher analysis on the specimen sample ( I only had 1 of 12 come back malignant).

Thank you, retireddoc. I know I have to wait for the Biopsy results, but the writing’s on the wall. My age, PSA, Free PSA and Pirad4, and pirad 3, results. I’ve already spoken to my family about the possibility just to prepare them. I know I have to come up with a plan for treatment, so after they give me the results locally, I’m going to send them out to Mayo for a second opinion. This issue is really F’n with my head, Im still a father, provider, and to think I may not be around in a few years kills me inside, and I top with all of this, I also have to work. And the possibility of having months of recovery, incontinence at work, and just the stigma of being that GUY with “C” also screws with my head. I know, but we’re all complex beings. . Thank you for your time.

Again, I'm so sorry. This is a shock, and it's natural to feel pessimistic and a bit hopeless in your first few months.

By all means, make reasonable preparations, but don't assume the worst. From what you wrote earlier, I understand you're still at stage 1, which has something like a 99% *cure* rate when caught that early.

But let's say you're unlucky and fall into the 1%. Not being "cured" isn't a death sentence; it simply means that you now have a long-term, chronic condition to manage, just like people with HIV or Parkinson's have. It might mean life changes, and maybe less energy for work and childcare, but it's doable.

Even those of us already in advanced stages of prostate cancer may be able to keep going indefinitely with modern treatments. You'll find many of us here who've been living good lives with stage 4 prostate cancer (the most-advanced kind) for years. You've contracted a bad disease, but at a good time in the history of cancer treatment. More here (I don't remember if I shared this already):
https://www.scientificamerican.com/article/treating-prostate-cancer-at-any-stage/

You are right in the middle of this, so it is hard to have an objective perspective. I know; I've been there. From what you have said, even if you have prostate cancer (certainly not a given at this time) there is no evidence of spread outside the gland. The likelihood of metastatic disease at this time is low. Either RP or Radiation has a good chance of being curative. If you have surgery, recovery time is in weeks, not months. You are very likely to be completely continent within weeks at your age if you choose surgery.

Again, good luck.