Did my Cancer get worse on my latest biopsy, or just more accurate?

Posted by oldoz @oldoz, Feb 6 4:40pm

After a Transperineal MRI fused Biopsy Test 5 weeks ago at Mayo:
19 cores biopsy done in January 2025 (Mayo)
5 - (4+3) Gleason 7 - Grade Group 3. - PIRADS 4 region
8 - (3+4) Gleason 7 - Grade Group 2 - PIRADS 5 region
2 - (3+3) Gleason 6 - Grade Group 2
4 - benign
Intermediate Aggressive on the report.

An increase from 12 core done about 20 months by local Urologist:
4 - (3+4)
1 - (3+3)
1 - undermined (?)
6 - benign
(Done prior to having an MRI - did it because of my rising PSA)

Did the Cancer likely get worse, or did the earlier samples likely miss some of the cancer because they were random samples?
The other issue is the local doc had me on Active Surveillance, but then wanted to do a TURP, and then a traditional Prostatectomy, after he had me get an MRI 6 months ago, and also because the meds were no longer helping with urinary flow/retention. I went to Mayo (recommended from others on this site) for a 2nd opinion on the cancer, and because a HoLEP sounded better to me than a TURP.

The Mayo doctor ordered the Transperineal Biopsies and a Urodynamic Flow Test. On followup he told me a TURP or a HoLEP would not help my urinary retention problems, because they were caused by my bladder, not my Prostate. He didn’t think a prostatectomy was likely going to help my urinary retention much either. He said my bladder collects urine well, stores it well, but fails to contract much to empty it (atonic bladder). He said I was using external muscles and pressure to empty my bladder. He said at some point I will have to be doing self catheterizations multiple times a day (I didn’t like hearing that).

The Mayo Doctor gave me possible options from continuing on Active Surveillance, ADT, Radiation, and a Robotic Prostatectomy. If I decided to do surgery he can likely only do Nerve Sparing on one side, because of the cancer being so close to the prostate capsule. He also said my 5.2 psi is well over 10 because of the long term usage of the Finasteride. He suggested I discontinue the Myrbetriq and Finasteride, but to continue the Tamsulosin, to see if that changes my urinary function at all.

This is at least how I though he was explaining everything to me, and reading the reports.

I am tentatively scheduled for a Robotic Prostatectomy in 6 weeks, primarily because I’m concerned about spread outside the Prostate, and the need to do this while I’m still in good health. Also it’s a long drive to Mayo, which makes long-term radiation difficult.

Any thoughts from the group are appreciated!

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jeffMar | @jeffmarc | Feb 6 5:31pm

No exact answer, you hit the main possibilities the Cancer may be worse, or the earlier samples missed some of the cancer because there were random samples?

I have seen biopsy reports where they say exactly the location of each group of samples. You might ask for that information.

You might request a decipher score. That test will tell whether or not your cancer is aggressive, and will metastasize soon. That way, you will know if your cancer grew or was just different spots. If it’s aggressive, it’s probably that it grew.

Since you have a 4+3 your cancer is a little aggressive, It doesn’t matter if they missed the spot it matters that you need to do something. AS is not in your best interest with 4+3. I had surgery and before surgery my biopsy showed my Gleason was 3+4 after surgery they found 4+3 in my prostate. I was hearing about somebody who had gone from 3+4 to 9 in the prostate, recently.

Check with Mayo, Many doctors will allow you to get your radiation somewhere else, but they set the parameters. You could just have it done closer to home. I’m not sure how Mayo handle this.

There are other treatments, besides radiation and surgery. Some are Cyberknife SBRT , HIFU , NanoKnife , Cryotherapy and TULSA-PRO. Many people here are very pleased with Tulsa-pro. If your cancer is confined to the prostate, you have other options.

survivor5280 | @survivor5280 | Feb 6 5:31pm

That's quite a lot of data to process!

Since biopsies are random samples, you could likely have two back-to-back within a couple of months that would give different results. The 20 month difference also could play a part in it, that's a long time for the cancer to spread.

You have enough 4+3 that I can understand why you would be moved from active surveillance to treatment, 3+4 puts you right on the bubble but my understanding is that if you have multiple 3+4 samples or any 4+3 that you should be considering treatment. You might look at getting a Decipher done just to be certain.

I've also been on finasteride for over 20 years, and had a very small prostate but did not have any urinary issues either before or after the prostatectomy - although after I do notice the flow doesn't seem quite as strong, but I am only 9 days out from it and my system is still adjusting to it's new normal.

Depending on your age, the prostatectomy sounds like a reasonable course. Radiation is an option but doesn't leave you a back-up option after - which many doctors seem to be ok with if you are older. Since I'm only 54, the radiation would have been more detrimental to me over the long term so removal was my best option.

There's also the possibility that two pathologists read your biopsies differently and that either you were worse off the first time or better off the second, but I think that's probably a bit hopeful however you can always ask for another review of the samples to be certain.

In all cases, it sounds like you are already seeking multiple opinions and being a good advocate for your own health, if you have multiple doctors from multiple specialties (urology, medical oncology, radiation oncology) give you a consensus then you know what your next move should be. Obviously we're just a bunch of strangers online, they are your first and best defense.

gently | @gently | Feb 6 7:40pm

Cheers for the Mayo doctor. Second opinions are crucial. What about third.
Have you looked at the 5 treatment MRI guided radiation treatment. It offers the best (lowest) margins and can be more nerve sparing. https://www.uclahealth.org/cancer/cancer-services/radonc/cutting-edge-devices/viewray

It's easier to look around once you have a plan.

monteshark | @monteshark | Feb 8 10:20am

I spoke to a representative from the “Sperling Prostate Center”. I’m going in for my first biopsy. According to her many times the biopsy targets the lesion but doesn’t hit the center giving a lower Gleason score or even benign because it hit the out edge. The cancer may vary slightly throughout the lesion. I don’t know any of this to be true or false only what the representative told me. So a later biopsy may show a higher Gleason level