Gleason 6 - PSA now 8 - time for surgery? - Localised cancer

User

Posted 09 Dec 2024 at 10:31

As I am currently on AS, I would like to know how many Gleason 6 diagnoses turn out to be higher grade cancer?

If they all do, then I might as well get on with surgery now!

There is too much unknown and chance in deciding what to do!

Yes, I was diagnosed with Gleason 6 (3+3) on 29/08/2024.

PSA 13/06/2024 was 6.6 and 25/11/2024 8.0. So it’s going up!

Next PSA early Feb.

I reckon that I am putting off the inevitable surgery and might as well get on with it whilst I am reasonably healthy and only 66!

What are you thoughts on this please?

User

Posted 09 Dec 2024 at 11:02

Hi Andy.

I was in a similar position to you, only my psa was 5-0 & diagnosed with Gleason 3+4. I never had tho option of AS so I opted for surgery, I like you thought at the age of 67 & still fairly fit ( still run 3 to 4 mile a day) that I may as well get the surgery done whilst still in good health. I was fortunate that the incontinence was not really a problem for me 95% continent on removal of catheter 7 days after surgery. I personally think the fitness & fact I used the gym regularly & did quite a few sit ups in the months before surgery was a big help. Of course you may decide to opt for one of the other treatments I.e. hormone & radiation treatment, brachytherapy, or other options available. Perhaps see what your psa is in February & decide with your family & urologist.

In my experience, although not medically trained a 3+3 is not a fast spreading disease but can obviously turn from a 3 into a 4 in the future.

All the best in whatever you decide.

Jeff.

User

Posted 09 Dec 2024 at 11:26

Hi again Andy.

I recall that due to prostatitis, you've been having regular PSA checks for years. On 08.11.2016 it was 5.3. So a rise to 8 over 8 years doesn't seem alarming. However, what is a bit of a concern is that your last three results show a steady rise.

You say you were diagnosed Gleason 6 (3+3) 29.08.2024. Is this the first biopsy you’ve ever had? Have you, prior to this year, had any previous MRIs? If not, I suppose it's possible that you may have been Gleason 6 (3+3) back in 2016?

I ask these questions, because I first had prostate problems, and elevated PSA in 2011. Since then, like you, I've had periodic PSA checks which all remained fairly stable. I had a couple of DREs but never had an MRI or biopsy until 2020. This makes me often wonder, when prostate cancer actually entered my life? 🙂

The decision to take radical treatment is a difficult one to make, as it often causes side effects

I've attached a link which discusses Gleason 6 (3+3). It states that about 30% of this grade cancer is up graded following closer post prostatectomy examination.

https://www.pcf.org/c/gleason-6-is-not-not-cancer/#:~:text=Another%20problem:%20approximately%2020%2D35,grade%20cancer%20in%20their%20prostate.

Personally, if I were in your position, I'd like to try and rule out other non cancerous prostate conditions, that may have caused the latest rise.

Have your clinicians recommended radical treatment or are they happy for you to continue on AS?

Good luck mate.

Edited by member 09 Dec 2024 at 12:02 | Reason: Additional text

User

Posted 10 Dec 2024 at 08:19

Hi Andy... i am in same situation (G6 diagnostic)... but i am 52 years... :( and my PSA in august are 35.88 ng/ml and in october 11.70 ng/ml... in June are 5.85 ng/ml... Next week i will make a MRI and we will see.

I made a consultation at the MSKCC in New York and this is what they told me...

I can only tell you the big picture with respect to best evidence and what would be standard practice at MSKCC. As I mentioned before, you have a low risk cancer, something very common in men your age (probably around 1 in 4 men). Worrying about small details on the radiology or pathology report, or subtle mathematical considerations about the PSA are not going to help rational decision-making about your cancer care and, moreover, is probably very bad for your mental health. As I mentioned, there are many doctors in the US who are actually trying to change the name of your prostate disease so that it wouldn’t be called cancer at all.

I will repeat these key points below. You need to keep telling yourself these

ISUP1 cannot metastasize or spread locally. Indeed, there is a growing movement to actually stop calling this cancer altogether and describe it as a premalignant condition that needs monitoring in case it turns malignant.

In the light of (1), would you be very scared if I told you you had a premalignant condition?

The amount of GG1 disease is completely irrelevant, it does not raise your risk of anything other than having some higher grade cancer hidden in there. Which is fine because that would be found if you had more biopsies as part of active surveillance.

About 1 in 4 men your age have prostate cancer.

If you came to Memorial Sloan Kettering Cancer Center, there is close to zero change that you would be treated with surgery or radiation. You would go on active surveillance with possibly an offer of focal therapy.

PSA velocity is not a value for prediction in a man with untreated prostate cancer. Your overall PSA level is moderate and there’s nothing to worry about again, this is according to best practice guidelines.

I thought I read that Pirads 5 has an injury?
Can you tell us if the MRI report indicates the size of the lesion or lesions?

B.R.
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User

Posted 12 Dec 2024 at 13:21

I saw a very well rated urological surgeon. He mentioned although I was Gleason 6 it’s generally accepted that in 44% of cases this is upgraded on post surgery histology. In my case as the cancer was in all four quadrants this was probably nearer 60%….and as predicted during surgery the cancer was more extensive than shown on 3T mpMRI or biopsy as returned as 3+4. With significant invasion of the bladder neck but confined and very close to breaking out in other areas. I’m so pleased I ignored my local team recommendation of AS and found the professor whocantbenamedonhere as moved swiftly for a retzius sparing RARP+neurosafe at Guys London Bridge. I was probably very close from going from T2c to T3 🥶 I’m now 5yrs post op and PSA still undetectable 😵‍💫🤪

Edited by member 12 Dec 2024 at 16:28 | Reason: Not specified

User

Posted 13 Dec 2024 at 09:14

Originally Posted by: Online Community Member

With significant invasion of the bladder neck but confined and very close to breaking out in other areas. I’m so pleased I ignored my local team recommendation of AS and found the professor whocantbenamedonhere as moved swiftly for a retzius sparing RARP+neurosafe at Guys London Bridge. I was probably very close from going from T2c to T3

I thought that any bladder neck invasion was at least a T3 staging?

https://librepathology.org/wiki/Prostate_cancer_staging

Edited by member 13 Dec 2024 at 10:27 | Reason: Add link

User

Posted 13 Dec 2024 at 13:43

That Wiki actually contradicts itself re bladder neck invasion!

My surgeon told me the prostate / bladder join is not a definitive boundary and requires some "guess work" to get the slice line correct. He said at this junction prostate and bladder cells co exist and it was very difficult to remove all the prostate tissue without damaging the bladder. Indeed he said this was the usual location for residual PSA producing cells.

In my own case he obviously took a bit much as re connecting my pipe work took 3 hours longer than planned and the resultant trauma resulted in a peritonitis that nearly killed me - All for a confirmed 3+3 that was also a T3A.

So would I chose AS next time? Definitely not! It suits me to know it's no longer in there rotting away!

PS my surgeon was a high volume Robotic pioneer who made it to the UK top 10 list. He said I was one of his 1% serious complications!

User

Posted 13 Dec 2024 at 15:46

You might be asking for everyone who had an upgrade to reply and come up with the wrong sample. However mine was upgraded after the op from 4+3 to 4+4.

With 2 discontinuous lesions 7mm and 12mm it sounds worth taking action. Although from your profile I don't know if you've had an MRI, a biopsy doesn't usually say how large they are.

Your psa history is a bit erratic as well and with your history could be ambiguous.

13/06/2024 6.6
11/05/2023 5.3
30/03/2023 6.3 (UTI at time of test)
15/08/2022 5.3
14/07/2021 4.8
16/06/2020 4.0
22/04/2019 4.6
13/04/2018 4.8
07/02/2017 4.7
08/11/2016 5.3

I think I'd be asking if a scan would be useful. The doctor might also be cautious about overtreating if it's treated without one. On balance I'd be thinking better safe than sorry but it's a tough call. All the best Peter

User

Posted 14 Dec 2024 at 13:36

Originally Posted by: Online Community Member

I thought that any bladder neck invasion was at least a T3 staging?

https://librepathology.org/wiki/Prostate_cancer_staging

I think what happened is NeuroSafe realtime frozen sections reported suspicious margins so more tissue was taken. Final histology (paraffin staining) thankfully came back negative on the suspicious samples. I think the take away is it was damn close to going T3….i suspect maybe weeks 😵‍💫

User

Posted 14 Dec 2024 at 22:23

22/08/2024 - MRI results - Left side of prostate has suspicious areas and is PI-RAD 5. Very highly likely to be cancerous. There are also other PI-RAD 2 areas on the right side. Contained within the prostate.

User

Posted 07 Feb 2025 at 17:33

I’m Gleason 6 currently on AS.

So my latest PSA03/02.2025 test is 6.5.

This has gone down from 8.0 on 25/11/2024.

I had a months course of antibiotics which ended at the end of December to treat dysuria possibly due to prostatitis / UTI etc. Maybe this brought my PSA level down. Or maybe not drinking alcohol since 01/01/2025 combined with daily exercise. Who knows!

The thing is, where does leave me with my treatment plan? Stay on AS or seek treatment?

I emailed my specialist cancer nurse and asked the following:

So what exactly does this mean?

Does this mean that there was an infection of the prostate and/or urinary tract that caused it previously to rise to 8.0 and the antibiotics worked?

Could the Gleason 6 biopsy results actually be incorrect and what the pathologist saw was actually cells mimicking prostate cancer? Especially with my long history of chronic prostatitis. Should I ask for a second opinion on the biopsy results?

What should I do next?

The PSA result is pretty inconclusive.

What does the consultant think I should do?

I need some professional input here.

Their reply to my email:

PSA levels fluctuate normally for many different reasons and rarely stay exactly the same. It is possible you may have had some infection/inflammation which pushed it higher when recorded as 8 and the antibiotics have helped but we can never be certain but the fact the PSA has fallen is reassuring because if you had more active disease it would not fall but continue to rise.

The biopsy results would not be incorrect as cells cannot mimic prostate cancer despite whether someone has prostatitis so we can be certain you have a confirmed diagnosis. If you wish for a second opinion regarding your diagnosis you would need your GP to refer you to your chosen centre.

I can see that as well as seeing the urology consultant you have also been seen by the Consultant Oncologist who also recommended managing you on a pathway of Active Surveillance and as I have explained in my previous emails active surveillance is about monitoring the PSA and looking for an upwards trend which would then trigger a review of management so currently as your PSA remains stable (as it has fallen) I would suggest we continue with 3 monthly monitoring.

If you are struggling with the surveillance pathway, which some men do, it is your choice as to whether you wish to pursue more active treatment and we will support this but our opinion is that this is currently a safe option for you.

So should I stay on AS or seek treatment?
If the PSA had gone up or remained on 8 I was thinking of seeking treatment.

The irony is that I feel really fit and healthy otherwise!

Edited by member 08 Feb 2025 at 08:34 | Reason: Incorrect date edited.

User

Posted 07 Feb 2025 at 17:54

Hello again mate.

I'd stay on active surveillance, but only you can choose.

Edited by member 07 Feb 2025 at 17:55 | Reason: Typo

User

Posted 07 Feb 2025 at 18:12

At 66, I would stick to AS and avoid the possible side effects of treatments. My surgeon said to me at 62 ,if we do nothing you will still be here in 10-15 years time, I have had lots of treatments still here but spread is now extensive. As Adrian said its your choice but if your medical team think AS is good they may be right.

Thanks Chris

Your second date has a typo.

User

Posted 07 Feb 2025 at 20:40

A very good friend of mine who died of something else, was in a similar position and his PSA varied between 7 and 9 for many years. He was told that radical treatment would be considered if it reached 10 but it never quite reached this figure. He was told he had PIN which is a sort of pre cancerous condition which leads to a cancer diagnosis in about 50% of cases.. As has been mentioned, some consultants don't consider 3+3 to be termed cancer but Gleason can be upgraded as we know from sliced Prostates in the lab or maybe a little area of 4 may be present but not found so far.

Were I in the poster's shoes, I would want to be very carefully monitored, and if 3 monthly PSA continues to show overall rise, have a high quality mpMRI and biopsy when appropriate. The thinking is to preserve function and avoid side effects of treatment for as long as possible and check the cancer is well contained. But individuals can take their own view on this and that is what they need to do, assuming Clinicians are prepared to treat.

Barry

User

Posted 08 Feb 2025 at 17:36

I agree I would want to stay on AS if possible and Definitely watch your quarterly PSA’s. I take issue with the cancer nurse on one account. I believe she is wrong though in regards to the PSA rising in only having active cancer that the PSA only continues to rise. My PSA bounced all over never over 4. 1.9 to something like 3, down to 2.7, down to 2.4, back up to 3.3, down, up. Now maybe if she is referring to more active cancer as she says that is often thought more active is referring to a cancer that has metastasized somewhere or is spreading outside the capsule. My Gleason was an 8 at DX, although downgraded to an unfavorable 7 but did have EPE. I would not want to wait for your PSA to just keep going up. Be your own advocate and get your PSA checks and if uncomfortable with the numbers push for the MpMRI snd another biopsy. Nothing wrong being on AS but be vigilant.

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Gleason 6 - PSA now 8 - time for surgery?

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