Hello everyone, I just received the results from my 2nd prostate bx while on active surveillance. The Urologists office just called me to see if I wanted to come in earlier than my scheduled appointment on 3/31. After reading the results I had breathed a sigh of relief but since their call I began to wonder if I should go in earlier. My first bx (October 2021) had 3 cores positive for cancer (Gleason 3+3) and 2 cores atypical, the other 7 were benign. The one I had on Monday came back with 1 core positive for cancer (Gleason 3+4) and one atypical (probably cancer) and the other 10 were benign. I have BPH and my last PSA was 11.5 but I have a bladder obstruction that may have caused the rise. I was thinking I am good to go with active surveillance with regular PSA tests and MRI's (I've had 3, all PIRADS 2) and another bx down the road. From what I've read 3+4 is favorable. Thoughts? Thanks.
Active Surveillance/2nd Biopsy - Prostate Cancer N...
Active Surveillance/2nd Biopsy
Seems like excellent news. What is the % of 4 in 3+4?
(3+4) (Grade Group 2), involving approximately 15% of the core biopsy.
--Percent of grade 4 is 40%/
Others can comment, but that is high % of grade 4. What does the doctor say?
If I was you, I would start a treatment, You are still Grade 2. When they say #FAVORABLE#, THEY MAKE A COMPARASION WITH G(4+3=7) GRADE 3 which is UNFAVORABLE.
Which is my case. My RO put me right away on ADT and started VMAT-RT 3 Gy X 20 fx for a total of 60 Gy.
I’m getting a 2nd opinion from Johns Hopkins. If there were no side effects to treatment I would go ahead and treat but I never hear of anyone being treated without having bad side effects.
I am 75 y.o. going to 76 and the only S.E. was lost of libido, so not a great change.
in 2021 I spoke with a RO about cyberknife but opted for surveillance.
Forget the possible side effects , kill the pc now . It can only get worse . Surgery is a chance at a cure for you . What is the point of early detection without taking action ? You don’t ever want Stage #4 pc . But , I do also understand not wanting any of this . Good luck!
What were your bx results? Did you get another opinion or two? Were you on active surveillance or did you go straight to treatment after diagnosis? Thanks for your input.
PSA 13.7μg 2020-01-29, 6 out of 12 = G(4+3=7)Grade 3.
Review from Epstein 12 of 12 G(4+3=7)Grade3
Wow! Quite a difference in readings.
The whole left sides was misread.
You may want to get a second opinion from Epstein at Johns Hopkins:
pathology.jhu.edu/patient-c...
I’ve requested they be sent there. My urologist graduated med school at Johns Hopkins. Everything I see about 3+4 is favorable for active surveillance. I was also wondering about the involvement of 5 cores on the 1st bx and only 2 cores (1 cancerous) on the 2nd. They all came from the same place so it would seem there is less cancer.
Multiple cores from the same spot are counted as one. It depends on how much pattern 4 there is. If a core has a lot of cancer, and it is 40% pattern 4, continuing AS may not be in the cards.
thanks
Second opinion from JH is a very good plan. 40% grade 4 is pretty high; I'd start looking at treatment modalities and focus on side effects vs efficacy. I had HDRBrachytherapy for a similar tumor and other than dry orgasms I would say I don't have any side effects from the treatment.
I am not opposed to treatment but treating it when only 1 core out of 12 was positive for cancer just seems a little much. I await the 2nd opinion from JH. Thanks. Of course, if I could treat it and be done with it I would jump right on it, but it seems once you start treatment it's a lifelong commitment. 
Once you have PCa it is a lifelong commitment. But my commitment isn't any different than if I were on AS, maybe less at this point. I get PSA tested every 6 months (treated with HDRB 10/2020; 3 tumors: 6 (3+3), 7(3+4)20%, unknown; T1C). If my PSA stays in a low range (as of today's test .803 ng/ml) I'll switch to annual testing after 5 more readings. Lifelong remission is the goal and so far it looks like that's working. I chose treatment over AS because my genomic testing showed a 41% chance of it getting worse.
Thanks for the info. I appreciate it very much.
If I were you, I would start researching ways to get rid of it.
Thanks.
I was on AS for four years after I was first diagnosed with two cores of Gleason 6.
When I was first diagnosed with G6, the chance of being on AS for 10 years was a possibility.
When a core showed up with G7 , I could have stayed on AS, but I then knew the chance of being on AS at that point was probably limited to two or three years at best. The risk got a bit higher, and I knew I was looking at treatment sooner rather than later.
I opted for SBRT treatment because I personally felt I had hit the "sweet spot" for treatment -- still early enough to completely eliminate the contained cancer but not to the point of danger or exigent action.
So, you were treated and you are done with it or is it a lifelong commitment?
I'm unsure of what you actually mean. I was treated in November 2021. I now get PSA tests every six months to ensure PSA keeps dropping. Hopefully, my PSA will keep dropping, level off, and I will be in remission for the rest of my life. But, the follow ups, maintenance, and check ups are a "lifelong commitment" -- that's the case for everyone who has been diagnosed with prostate cancer.
Ok thanks. You give me hope.
I'm not qualified to advise you on whether to start treating the PC based on the severity of your Gleason scores, but I would advise you not to underestimate the side effects of the various treatment options based on a couple of these replies if that is a factor for you. In my estimation and experience there can be multiple side effects from radiation and ADT, and they can be substantial and long lasting. 🦊
I'll add my voice to the chorus saying you should aim for treatment sooner than later. Cancer doesn't just "go away," so the lower # of positive cores in your second biopsy just means the cores either missed the malignancies in your prostate (a common occurrence, read Patrick Walsh's book among others), or were misread by the pathologist (also common, and I second the recommendation for an Epstein reread).
From the perspective of one who was biopsied, and thus started treatment, too late to avoid metastasis, I can only say that if I could do it over again I'd obviously opt for treatment sooner, regardless of potential SEs. You are already signed up for life membership in the PCa club; delaying treatment to delay side effects (IMHO) only grants you some SE-free time now at the expense of possibly more severe treatments, and maybe a shorter lifespan, later.
Personally, I'm not a fan of AS. It only makes sense to delay treatment if you are absolutely certain that you can still catch your PCa in time for a complete cure later -- and as too many of us know, that's never a sure thing.
Thanks.
Consider NanoKnife IRE focal ablation. It's intended for localized PCa as an alternative to active surveillance. It uses high voltage electrical pulses to put nano holes in prostate cells in a very highly defined area. Cells die a natural death and are cleared away by the bodies normal processes.
Other focal ablation therapies like HiFU and cryotherapy's can damage surrounding tissues leading to incontinence and ED. I liken it to trying to boil/freeze the center of pot of water (prostate tissue) while leaving the surrounding water (nerves/bladder/rectum) at room temperature. IRE can do this.
The IRE technology has been around for 10+ years and the placement of the needles is very similar to doing a biopsy so surgeons don't have a difficult time learning to use it.
I had it done 9 months ago and it is an out-patient process with very rare side effects. I've had none.
There is a clinical trial going on now clinicaltrials.gov/ct2/show... to get approval to add prostate cancer to it's treatment capabilities.
This is an excellent article that summarizes info on NanoKnife IRE. ncbi.nlm.nih.gov/pmc/articl...
Feel free to ask me more about it.
Looks promising. Thank you.
You are 70. Absent other health issues there's a chance you will live until 90 or longer these days. It doesn't sound like you will be able to be on AS for 20 years. The cancer is growing and will continue. At 70 you can deal with treatment and side effects much better than you will at 80 or 85.
I was in a similar place at 60 a little less than two years ago. 3+4 but the percentage of 4 was the concern -- borderline, not the greatest AS candidate. I could go on AS but it would probably be within a year or so I'd need treatment. Even if it went longer, did I want to go through that -- and perhaps more intense treatment because cancer had spread -- at 65, 70, 75, or 80, with possibly other health issues? I work out, my body is in excellent condition and I have no other health issues.
Since treatment at some point was a forgone conclusion I wanted to do it now while in fit and healthy shape. Had LDR brachytherapy in January of 22, had virtually no urinary side effects or any other major issues. Back to the gym in days, doing well, and put it all past me, even though of course, as others have said, it's a lifetime of monitoring PSA. But that's fine and expected.
Thanks. I am leaning that way.
The 2022 American Urological Association guidelines to physicians for the treatment of prostate cancer state that active surveillance should be considered by some men with Gleason(3+4)=7.
But, that basically applies to cases with small amounts of Gleason 4 pattern in one or two cores. You biopsy report should state the percent of Gleason 4 pattern in that core. If it is less than 20 percent, AS may be feasible and safe for you to continue.
As far as prostate cancer growing, I was diagnosed in 2009, and have had zero progression of my pathology. But, I have had a lot of MRIs and biopsies to confirm my being a Gleason 6.
Thanks. I’ll see what the 2nd opinion says about the one core out of twelve that was a positive 3-4.
Hello everyone, just as I was looking at treatment options the second opinion of my biopsy results came back from Johns Hopkins with a lower grade assigned to the 3+4 core. Made my decision to stay on active surveillance much easier.
FWIW, I was diagnosed in 2005 at age 49 with one core of 3+3=6. Opted for AS over the misgivings of my urologist. Fast forward to 2024 - 18 years later. No treatment in the interim. Biopsy now shows one core with 3+3=6 and one core with 3+4=7. Guidelines have obviously changed in 18 years and now call for AS, RP or radiation for my situation. I'm sticking with AS for now.
It's very hard to get an answer to the question I have, which is what is the difference in treatment-free survival rate at five years for (1) intermediate-group AS compared to (2) low-risk AS compared to (3) those in both of these two groups who chose definitive treatment (RP or radiation).
As best I can tell, there is no significant difference. For now, I'm staying with AS.
so am I. Thanks for your reply.
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