The Gray Area of Favorable Intermediate Risk 3+4=7

Nobody should be pushing anything, only sharing their own experience. Hopefully people don't make medical decisions based on comments from strangers. I was on the bubble and went with treatment and I'm glad I did because the pathology of the removed prostate showed I was worse off than the biopsy and scans indicated.

I think you voiced a very reasonable perspective that deserves a place in this forum so it can be included by those considering AS. It's always good to consider both sides of any decision of this magnitude in ones life. Thanks.

Happydappy: you are spot on. I was a 3+4=7 & after case discussion with my urologist went with radiation treatment. In my early stage of PC I took in a lot of mixed information. So much that I decided to write a book on my experience. I am working on the book now. I will be interested in learning more about other people’s cases.

I’m with you buddy…To me, the number ‘4’ precludes watching anything. Others may want to wait but in my mind, aplastic/malignant cells rarely slow down their growth and getting them before they jump ugly is the better way to go.
Phil

@happydappy
My biopsy was 3+3 and I was told AS should be good enough but I insisted on RARP. Post surgery biopsy said 3+4 (less than 10%)!! Nobody could guarantee the rate of growth in AS. I am glad I had RARP and it is out of my body. I cannot imagine the stress of having to deal with AS. They(docs) all said only the final biopsy (pathology) after surgery can give more information!

Amen, and best of luck with your surgery!

For me there were no “gray areas” when making that 3+4 decision. I’m not one who gets analysis paralysis. Being a retired computer scientist, given sufficient data I can make any decision. (However, in my 2nd life as an elected official - ultimately Mayor of my City - making a decision was a bit more nuanced, not because of my own “gray areas” but, because I had ~45,000 constituents who each mostly had “gray areas.”)

I was on active surveillance for about 9 years with localized, low-level, 3+3=6 disease. When my Gleason hit 3+4=7, and my Prolaris test indicated that I had “exceeded the threshold for active surveillance” was when I sought treatment

With a 3+4=7, I would use all those other factors those experts mentioned in making my treatment decision vs active surveillance:
> PSA
> genetics (germline)
> genomic (biomarker)
> family history
> size and location of lesions
> volume of grade 4,
> number of positive cores,
> cribriform,
> intraductal
> (not so sure about PNI)
> and others not listed there.

As for concern about upgrading/downgrading of prostate cancer, there are many studies about this. The one that I often reference is one out of the UK in 2019 showing that initial grade and pathological grade matched 59% of the time, was downgraded just 16% of the time, and was upgraded just 25% of the time —> https://bmcurol.biomedcentral.com/articles/10.1186/s12894-019-0526-9

So, I wouldn’t let that concern affect my treatment decision. Letting one’s fears impact treatment decisions almost always leads to bad outcomes, just as do uninformed decisions: The mistake that is often made - that often results in treatment-related regret - is not being fully informed and rushing the treatment decision without having established expectations —> https://jamanetwork.com/journals/jamaoncology/article-abstract/2786406

It am not at all disheartened to read non-medical professionals advocating for active surveillance for most favorable intermediate risk 3+4=7 prostate cancer patients when the research is unclear. Most decisions in life are made with uncertain and unclear guidance. Few things in life are definitive; (except for death and taxes??). Given the uncertainty factor in every life decision, I would first choose the one that did the least harm, and permitted me a multitude of options should that first decision not have the desired result. Medicine and treatments these days are at a stage where there are actually “do-overs” with prostate cancer treatments (unless one makes a treatment decision that eliminates “do-overs”.)

Making a treatment decision is not rocket science; one need not have a PhD or be a medical professional to understand the diagnosis, nuances of the disease, treatment options and making a treatment decision. Once one factors emotions out of the picture, the view becomes much clearer and the decision much easier.

And as you allude, asking medical professionals - even Epstein, Schulz, Walsh, and Ross (and even my own urologist, radiation oncologist, and medical oncologist) - does little good; those with PhDs don’t always agree; and what they say isn’t always gospel. So, getting to the treatment decision goes well beyond having a medical degree or certification.

For me, the most difficult part of making a treatment decision was figuring out what my expectations were from treatments. I was confident from all the data that I had read that “just cutting it out” was no more successful than not cutting it out in treating the disease. So, all of those other factors have played a role in my treatment decision.

What came out of my personal introspection —> I wanted to balance quality of life with survival (of course!) along with the possibility of treatment in the future if needed (as medical treatments and science progress). This was about utilizing the best modern treatment techniques to get the best outcome while still surviving and maintaining my quality of life. That was the foundation (i.e., mission statement) for me making my treatment decision.

This need not be a “struggle” for men and their families when making a treatment decision. It’s just another data collection and analysis challenge that life throws at us once in a while. (Like buying a new house or a new car or doing one’s own taxes - it’s not a struggle, it’s just awfully time-consuming, and takes understanding oneself and one’s capabilities.)

The consultation of our own medical professionals is a necessary part of the decision and data collection process. But just as you indicated, is by no means definitive. They’re providing advice and recommendations; but the final decision is ours.

For me, I didn’t view it from the standpoint of “several years down the road, there are going to be some very sorry patients because their cancer spread or got worse making treatment more difficult.” But rather, by getting the appropriate treatment for my stage of disease today, and then by tracking it closely and regularly going forward, I’ll catch any negative change early enough that I’ll still have treatment options

Now (at 70y/o) after 9 years on active surveillance and 4 years after proton radiation treatments (with 6+ months of Eligard), I’m taking my 3 young grandkids swimming today. Life is good. (And I am confident that I made the right treatment decision.)

Thanks for sharing your experiences and thoughts. It seems you and I both had the benefit of starting out with 3+3=6 diagnosis leading to a fairly easy active surveillance recommendation and decision. And both of us eventually moved to 3+4=7, you after 9 years and me after just 10 months, demonstrating that we are all unique.

My medical team spoke a lot about risks and probabilities for an individual patient - risk of spread, risk of re-occurrence, risk of treatment side effects, etc.

Glad you are able to be comfortable with your decisions and enjoy those grandbabies!

Responding to the original statement offering: I too was a Gleason 3+4 = 7 "at the time of 12-core samples biopsy." I had 3 normal/negative cores, 3 cores rated 6, and 6 cores rated 3 + 4 = 7 with only 10% being "4." I also had perineurial invasion. My physician lulled me into a confident and secure mindset. However...
The problem with "biopsy" pathology reports is the most they can offer in addition to Gleason score is whether there is that "perineurial invasion". When I wanted to discuss my options including "active surveillance", my Urologist gave me an odd facial expression and flatly said: "I'm taking your prostate...there is no benefit to actively surveilling you if you already have even 10% "4" cells. Watching you for two years will just mean that we gave the cancer more time to grow and advance in staging, perhaps even spreading to your seminal vesicles and lymph nodes." Well...
I had the single-incision, DaVinci robotic-assisted radical prostatectomy surgery April 18, 2025. The "surgical pathology" report was more ominous: I had "Extra-Prostatic-Extension (EPE)", and it had just spread into my left seminal vesicle (surgeon took both seminal vesicles and both vas deferens as well), and...I was one of the unlucky 10-20% that had "surgical margins", meaning of course, that my Urologists "didn't get all of the prostate/cancer" ...some was left behind. That makes me a p3Tb, with a less optimistic, long-term survival. NONE of that was seen or could be known from the biopsy itself. In other words, you don't really know how serious your cancer is until your prostate is removed, and a full pathology exam and report are done.
The fact that I had EPE, seminal vesicle invasion, and "surgical margins" was a huge game changer. At the time we reviewed my biopsy report, I joked with my physician: "As long as I am here for my son's 40th birthday in fourteen years." He laughed and said "of course you will be...and well beyond!" When I saw him two weeks post-surgery for catheter removal and discussion of the surgical pathology report, he was more serious saying: "We'll need to talk about radiation at your 3-month follow-up."
A lot will depend on what my PSA is a three months. Hopefully, < 0.01 ng/ml. If so, then we still may do radiation because we both know that my Urologist left cancerous prostate tissue in my body, and it will start to grow and spread. The nature of p3Tb is that despite radical prostatectomy, it just tends to come back. Survival rates are more like 5-10 years instead of 15-20.
Caveat: My father lived to 99 years 10 months old "with" prostate cancer that was never operated on with a prostatectomy. He suffered a lot with perpetual UTI's and hospitalizations, but never had the prostatectomy. My maternal grandfather lived with his prostate cancer until age 96 years. He never had the prostatectomy. My maternal uncle lived with his prostate cancer until suffering a non-associated massive stroke at age 86. You're thinking: "ahhh...familial tendencies...genetic propensity." Answer: No. I had genetic testing done. I have no cancer genes in my body of any kind. I am the perfect example of the 70 year male who falls into what is now the: "One in five men will have prostate cancer sometime in their life" category.
I agree with the original comments above: we are strangers on a public blog-like website sharing our stories and a bit of cautionary advice. We should not believe everything we read, but...perhaps my offering here will lead to more discussion with your physician about the futility of "active surveillance" if you already have even as low as 10% "4" graded cells. You don't really know how extensive your disease is until the prostate is removed. I went from confidence for a long, typical survival and life thinking I will "die of something else other than prostate cancer" as is often quoted, to now wondering if I'll live more than just five more years with or without radiation.

Yes, so far my experience has been relatively benign. Having monitored my PSA annually since I was 45y (in 2000), left me comfortable with tracking my PSA regularly during active surveillance, after treatment, and even these days every 4 months.
Risk of spread approaches nil for a “true” 3+3 (https://youtu.be/NV8QHzbgamI?si=H3BXS6BxFl3jI5rw), for those that aren’t “true” 3+3s, continuous monitoring of all of those datapoints mentioned earlier (and possibly more) minimizes that risk.

Even if active surveillance is just for a few months (or a few years), as long as it was done by the numbers and accounting for known risk factors, it was done right.

Good luck!