high risk (4+4) diagnosis with moderate PSA (4.2)

skl8r

hey y'all, I'm a month in to this journey (since biopsy), and just found this forum while searching for info on a particular patented treatment (that's not pertinent to my question) …

so, what is typical treatment for a high risk (4+4) grade group 4 diagnosis with moderate PSA (4.2)

I'm just past getting a good PSMA-PET report (still local) and just starting to talk to oncologists and surgeons about treatment options. my urologist told me that a gleeson 8 with 4.2 PSA is uncommon. I was a bit flustered at the moment - as I'm you can relate to - and didn't ask about what that comment meant. he did express confidence that we have a good window to cure this!

so anyone? in your experience, what's the significance of my numbers?

(by the way, is there a FAQ here?)

Clevelandguy

Hi,

4+4 is on the aggressive side and surgery or some forum of radiation are the two main treatment paths. The choice based on your specifics is up to you and what your doctor team recommends to put your cancer into remission. Cribriform should be looked into as it can be radiation resistant. If cribriform is present then I would think surgery would be a better option in my humble non medical opinion.

Dave 3+4

Marlon

Your age is a factor in treatment choice. In my case at 67, the doctor said both options would give a good outcome. Older, and radiation would be recommended. Younger, and surgery would be preferred. I chose surgery because I wanted the cancer out, not just damaged. And I'm glad I did because post surgery pathology said the cancer was more aggressive than they thought. Which goes to show that they don't know for sure what's going on until they get in there. If it comes back, radiation is still an option. There are side effects either way. The book by Dr Patrick Walsh, "Surviving Prostate Cancer" was invaluable to me to explain the details.

Wheel

It would help if you could share your age and details of your biopsy report. I was one core Gleason 8, two favorable Gleason 7, and two Gleason 6. Minimal involvement in cores, but also cribriform pattern. PET was clear to not have gone outside capsule, but turned out wrong as it was discovered during surgery. Fortunately surgeon was able to obtain negative margins and final pathology of the prostate was a favorable Gleason 7. My PSA remained under 4 throughout time to diagnosis, but my Decipher test was high intermediate. The decipher test is what you need next before final determination of how you are going to proceed. Also seek consultation with both surgical and radiation oncologist’s to understand what is offered with side effects. I will say once you are able to share a little more about the details of your diagnosis, members can offer their recommendations more suited to your specific case.

skl8r

I have been nibbling away at Dr Walsh's book, "Surviving Prostate Cancer". there's not much of anything about my particular situation to explain a moderate PSA with high Gleason though, which is why I'm asking here.

more about me… I am 67. out of twelve cores, there was one 3+4, one 4+3 and one 4+4. all on the right.

my test history is slightly elevated PSA (then waiting to see urologist), a positive DRE, MRI with peripheral zone pi-rads 5 and pi-rads 2 (BPH) in transitional zone and no extraprostatic extension of tumor, then biopsy with 3 of 12 cores positive (3+4, 4+3 and 4+4), and PSMA-PET scan that was clear outside the prostate.

I've not had a genetic test yet, Decipher and/or Arterra AI are what I favor, but neither has been ordered yet… still "interviewing" doctors.

I am filling up my schedule with Dr consults and am getting into a large cancer center that has proton, and multi-disciplinary teams.

I'm moving right along - it's just over two months since the lesion was first felt in the dreaded DRE.

Marlon

skl8r, I neglected to say that my PSA was 4.2 at age 67 as well. I thought that wasn't too bad because for my age range 4.0 is high normal. Turns out I was wrong and the DRE detected nodules. PSA is just one tool and it's not in itself an indicator of cancer, but of prostate tissue. A low number might support the finding that it has not spread much, but it doesn't define anything about the at this point since you've had the biopsy to confirm you have cancer. Just my experience.

skl8r

Marlon - that's good to know, thanks!

"might support the finding that it has not spread much"

I suppose the Doc might not see that too often, but your comment answers my question spot on.

Josephg

https://csn.cancer.org/discussion/329411/high-risk-4-4-diagnosis-with-moderate-psa-4-2

Regarding your Physician's comment on Gleason score and PSA number, we generally think that the higher the PSA, then the more prostate cancer (PCa) volume. While this is generally true, it has also been found that the more aggressive types of PCa tend to produce less PSA than less aggressive types of PCa for the same tumor volume. And, that appears to be your case.

Similarly, I had a 4+3 Gleason score and virtually 100% tumor involvement throughout my prostate, yet my PSA number was only 5.2.

Wheel

I would recommend getting your urologist to order your Decipher now. There are studies that having a low PSA with cancer can be an indication of a more aggressive cancer. The Decipher test is something that will be needed and can help guide your decision and your Doctor’s recommendations in your initial consultation’s. As for your one Gleason 8 core, a study that was published, and an article written in The Journal of Urology was titled Most Gleason 8 Biopsies are downgraded at Prostatectomy - Does 4+4 =7?. The study indicated that if only one core is a Gleason 8, with other indicators you might turn out with Gleason 7. That was ultimately my case. The study in men lacking other high progression risk found 60% were downgraded from high to intermediate. Then in another article in Urology Oncology found That if only one core was a Gleason 8 , <50% maximal core involvement and a Gleason pattern 3 was present in any other core, i.e. (4+3), (3+4), (3+3), a higher proportion of prostatectomy specimens were downgraded to GS less than < equal=7 at radical prostatectomy. Again in my case this turned out to be. With those stats and at my age at diagnosis 70, with not getting any younger, at time in good health and the window closing in a few years for surgery if I even stayed in good health I opted for surgery. I also had cribriform pattern which is known in many cases to be radiation resistant. One thing if you investigate surgery options, there are significant differences in surgical approaches by surgeons such as single port robotic or multi port, and Puboprostatic ligament sparing. I did not even spend the night after surgery in the hospital. Once my catheter came out I was immediately continent, and within two weeks of surgery traveling. I also had nerve sparing and happy with results although need viagra now. I still have Radiation as a backup if it returns, while if straight to Radiation, a prostatectomy as a backup is extremely more difficult and only done by certain surgeons .

Wheel

I will add one additional comment regarding a Gleason 8 core diagnosis. You receive your Gleason score for treatment protocols based on your highest core, so all your cores could be 6’s of 7’s, but if just one core is an 8, you have Gleason 8. During my consultation’s it was always pointed out I have Gleason 8 and therefore protocols start with the Gleason 8 and involve radiation included ADT for minimum 18 months. Also in one of my surgical consultations, the Surgeon emphasized I had Gleason 8 and he recommended that although he was happy to do the surgery he felt likely I would need further radiation and hormone treatment sooner due to Gleason 8 and wanted me to consult with a Radiation Oncologist. I had planned too, but you don’t typically hear the Surgeon referring to Radiation unless you are too old or ill health. His reasoning was he felt if I was going need the Radiation ultimately why go through treatment and side effects twice. Now my second surgical consultation was much more positive about the surgery prospects and not really concerned about down the road radiation needs. He seemed to acknowledge many Gleason 8’s were downgraded and with negative margin obtained at a surgery his concern for BCR in near future was much less.

centralPA

Hey, sorry you find yourself here.

Curious..you wrote "more about me… I am 67. out of twelve cores, there was one 3+4, one 4+3 and one 4+4. all on the right."

From your post, you had an MRI before the biopsy, with some lesions detected, correct? Normally they will do the 12 samples on a grid and then go after the lesions with additional samples. Did that happen with you? Were the positive cores all in the main lesion?

Also, what percentage of your cores that were positive, were positive? Just a little bit, or most of each core?

jc5549

I just tagged you on a post I did that has great information for all stages of disease.
jc

skl8r

https://csn.cancer.org/discussion/comment/1722939#Comment_1722939

I had the 12 sample grid, all positive were in the (one and only) lesion. talked to a rad oncologist this morning - now I know that my gland is well enlarged, which my urologist had not explained. lesion is about the size of a dime. this morning Dr said the things about PSA 4.2 and Gleason 8 is not of particular interest, that's not so low as would indicate a very aggressive cancer. (like a 1.0 would.)

his recommendation for photon therapy is brachy + rad following ADT. adt could last a couple years. TBD of course since we're all different.

skl8r

very good info, thank you! I would definitely want fascia sparing robotic surgery if I choose that route. but. I haven't talked with a surgeon yet. and I have an appointment at the big cancer institute, which has proton rad as an available option. I theoretically like its very precise aiming.

skl8r

https://csn.cancer.org/discussion/comment/1722925#Comment_1722925

I had a consult with a rad oncologist today who says he very rarely sees cribriform. mine wasn't reported that way by biopsy. thank goodness

Old Salt

I quite agree that the focus should be on treatment modalities for Gleason 8 cases. The relatively low PSA value is 'interesting', but that's all, IMHO.

Proton vs photon: actually, photon therapy is more precise. Not according to me, but according to published studies. Protons do seem to be getting a lotta love though on forums such as this one.