Early-stage prostate cancer: Treat or wait?

Marc B. Garnick, M.D.

Editor in Chief, HarvardProstateKnowledge.org

Editor in Chief Marc B. Garnick, M.D., discusses issues and controversies about early-stage prostate cancer

Thanks to more widespread prostate-specific antigen (PSA) testing, today nine out of 10 men diagnosed with prostate cancer have tumors that are detected at the earliest stage, when they are still confined to the prostate gland and are so small they can be detected only through a biopsy.

Maybe you are one of these men. If so, it is likely that you are feeling overwhelmed by your diagnosis and all the treatment options for early-stage prostate cancer, and are wondering what to do next. (See “What constitutes early-stage prostate cancer?” below.) You may even be feeling as though your life depends on making a treatment decision as quickly as possible. So it may surprise you to know that one respectable study indicates that you can take up to one year to evaluate the options before choosing a treatment, and it will not affect your long-term likelihood of remaining cancer-free (see “Time to decide,” below).

Time to decide

Researchers at Memorial Sloan-Kettering Cancer Center analyzed medical records of 3,149 men with early-stage prostate cancer who underwent a radical prostatectomy within a year of diagnosis. The time the men took to make a treatment decision did not affect likelihood of relapse (measured by a rising PSA level, known medically as a biochemical recurrence). This held true even for men at high risk for relapse, based on their clinical profile.

Source: Boorjian SA, Bianco FJ, Scardino PT, Eastham JA. Does the Time from Biopsy to Surgery Affect Biochemical Recurrence after Radical Prostatectomy? BJU International, 2005;96:773–6. PMID: 16153197.

Yet all too often when I meet with patients who are diagnosed with early-stage prostate cancer, I find that they want to rush into treatment without fully considering the ramifications of their decisions. What I often hear from patients who have just received a prostate cancer diagnosis are statements like “I want this out!” or “I just want to get on with my life.”

The emotional impact of cancer can be devastating — there’s no question of that. But you owe it to yourself to do whatever you need in order to remain calm and take things one step at a time. There is no one-size-fits-all treatment for early-stage prostate cancer. Even the experts do not agree about which men with such cancers should be treated, which treatment method is best — or whether, for some tumors, any treatment is even necessary.

At the same time, every doctor knows that some men who undergo treatment for early-stage prostate cancer, and are considered “cured” on the basis of follow-up PSA tests, suffer relapse or “biochemical recurrence” (as measured by PSA levels) years later — indicating that the original cancer spread (metastasized) without being detected and has become active. What is going on? It is likely in these situations that individual cancer cells (micrometastases) shed from the tumor early on, but at levels too small to be detected by computed tomography or bone scans or by physical examination (see “Likelihood of progression,” below). Such micrometastases cause no symptoms initially but may do so in future months to years, as they grow into tumors. Research is under way to find better methods of detecting micrometastases.

What constitutes early-stage prostate cancer?

Tumors with the following profile are considered early stage:

  • Small tumor size (stage T2a or smaller)
  • Low PSA (no more than 10 ng/ml)
  • Low Gleason score (no more than 6)

Likelihood of progression

Investigators followed 81 men diagnosed with stage T1c prostate cancer for at least one year (some for nearly five years). The men underwent semiannual PSA tests and digital rectal exams and had annual prostate biopsies to see if the cancer had become active. At time of repeat biopsy, cancer had progressed in 25 men.

Source: Carter HB, Walsh PC, Landis P, Epstein JI. Expectant Management of Nonpalpable Prostate Cancer with Curative Intent: Preliminary Results. Journal of Urology 2002;167:1231–4. PMID: 11832703.

Complicating the matter still further, side effects of treatment can be devastating, destroying a man’s quality of life. For all these reasons, when I meet with patients, I encourage them to ask detailed questions and perform “due diligence” to ensure that they are making the right decisions about their medical care. Often used in a business context, the phrase “due diligence” means doing your homework, exploring all the options, and taking reasonable steps to protect yourself or someone else. When it comes to prostate cancer, due diligence begins with having the confidence to question your physician about treatment recommendations — after all, you are the person who has to live with the results.

Why due diligence is important

When you receive a diagnosis of prostate cancer, you are inundated with information. Chances are you know the basics about your prostate gland (if not, see Figure 1 for a refresher) and your “numbers” — your PSA level, your Gleason score, and the stage of your cancer. Take the time to process this information, and ask for more details.

Figure 1. Location of the prostate gland

Location of the prostate gland

The prostate gland, about the size of a walnut, produces fluid that forms part of the semen that is ejaculated during sexual activity. The prostate is located adjacent to the rectum and just below the bladder, and wraps around the upper part of the urethra, which carries urine from the bladder out of the body.

This location creates challenges in both diagnosis and treatment. During a digital rectal exam, for example, a doctor is able to feel only the back portion of the prostate. If cancer has developed in the apex, base, or deep inside the prostate, it may not be palpable.

Surgeons and radiation oncologists also face challenges in eradicating a tumor without causing lasting damage to surrounding organs and structures. When removing a tumor from the breast or colon, a surgeon is able to remove enough surrounding tissue to ensure “clean margins,” meaning that all the cancer has been removed. But when treating prostate cancer, a comparable amount of tissue cannot be removed surgically or targeted. It takes a skilled surgeon and radiation oncologist to eradicate diseased tissue without harming portions of the rectum, bladder, and penis, thereby minimizing the likelihood of complications.

As you evaluate treatment options, I’d suggest that you think not only about your situation today, but also about where you expect to be in five or 10 years — because chances are, you’ll still be alive. And you need to be sure that you would make the same treatment decision five or 10 years from now as you will right now.

Will you be able to deal with impotence if it occurs? What about incontinence (which is actually the more devastating complication, if you ask most men dealing with it)? How will the possible side effects of treatment affect your relationship with your wife or significant other — and your very sense of self? It’s vital to really think about these issues: In my experience, truly informed patients are much better able to deal with adverse consequences than patients who are uninformed or rush into making a decision.

As you evaluate various treatment options, keep in mind that studies show that patients do not always mention problems such as incontinence or impotence to their doctors. As a result, when your doctor cites numbers or percentages when trying to convey risk, the numbers may be on the low side. It’s not uncommon for a man to talk with other patients — at a support group or while searching for information — and to hear about higher proportions of people being affected by a particular problem.

It’s also important to understand the limits of current medical knowledge about prostate cancer.

Diagnostic tests are limited

We always knew that prostate cancer is common and that, until recently, it often went undiagnosed: Autopsies of men who died of other causes have shown that about one-third of men over age 50 have some cancerous cells in their prostate, while 90% of men over age 90 have such cells.

As PSA screening has grown more widespread, we are finding more tumors that otherwise would have escaped detection. Yet current diagnostic technology does not always enable urologists to determine which tumors will lie dormant and which will become active, spreading elsewhere in the body.

Studies estimate that anywhere from 16%–56% of men diagnosed with prostate cancer, generally because of an abnormal PSA test, have tumors that might never have caused problems had they not been found. And the landmark Prostate Cancer Prevention Trial (PCPT) unexpectedly yielded data that early-stage prostate tumors are incredibly common, even at PSA levels considered normal.

The PCPT was a randomized controlled study — the type considered to be the gold standard in research (see “Randomized controlled trials,” below). The study, which involved almost 19,000 healthy men, was designed to evaluate whether the drug finasteride (Proscar) could prevent prostate cancer from developing. Finasteride is a hormonal medication originally approved to treat benign prostatic hyperplasia (an enlarged prostate, which can cause problems with urination), but which has also been investigated as a potential treatment for prostate cancer.

Randomized controlled trials

In randomized controlled studies to determine a drug’s effectiveness, physicians randomly assign participants to either take the medication under investigation or join a control group whose members receive a placebo. In this way, physicians eliminate biases in both the selection of patients and interpretation of data that might otherwise lead them to conclude the treatment was more effective than it would be in a random collection of people.

All participants were ages 55 and older with PSA levels of no more than 3.0 nanograms per milliliter (ng/ml) and normal digital rectal exams — in other words, by the traditional testing standards, they showed no evidence of prostate cancer. Investigators randomly assigned participants to take finasteride or a placebo, and the men were followed for seven years. Every year, all participants underwent a digital rectal exam and had their PSA levels tested.

Every participant in the PCPT also agreed to undergo a prostate biopsy at the end of the study, whether he met the clinical criteria for such a biopsy or not. The reason investigators included this requirement was that they wanted to eliminate any “detection bias,” a technical term for unintended differences in diagnosis between comparison groups in a study — in this case, between the men randomly assigned to finasteride and those assigned to receive placebo.

At the end of seven years, investigators found that finasteride reduced the risk of developing prostate cancer by almost 25%. But they also found that the men taking finasteride who did develop prostate cancer were more likely to develop high-grade tumors and experience sexual dysfunction than the men taking placebo.

One aspect of the PCPT did not generate a lot of media attention, but sheds significant light on decisions about whether and how to treat early-stage prostate cancer. Of the 18,882 men enrolled in the study, 9,459 received a placebo. Of these men, 2,950 never had PSA levels greater than 4.0 ng/ml or abnormal digital rectal examinations — and so, normally, they would never have undergone a prostate biopsy. By all indications, they should have been cancer-free.

But when these supposedly healthy men underwent biopsies as a requirement of the study, investigators found something surprising: A significant number actually had cancer that otherwise would have gone undetected. And of the men who developed such tumors, high-grade cancers (those considered significant) were found even at the lowest detectable PSA levels (see Table 1).

Table 1. Why a low PSA does not mean you are “cancer-free”

The Prostate Cancer Prevention Trial included a provision that men randomized to receive placebo undergo a prostate biopsy at the end of the study, even if they had normal PSA levels and digital rectal exams. To their surprise, investigators found that many of these men had prostate cancer — in some cases, high-grade prostate cancer.

PSA level Number of men (2,950 total) Men with prostate cancer Men with prostate cancer whose tumors were high grade (Gleason score 7 or more)
up to 0.5 ng/ml 486 32 (6.6%) 4 (12.5%)
0.6–1.0 ng/ml 791 80 (10.1%) 8 (10.0%)
1.1–2.0 ng/ml 998 170 (17.0%) 20 (11.8%)
2.1–3.0 ng/ml 482 115 (23.9%) 22 (19.1%)
3.1–4.0* ng/ml 193 52 (26.9%) 13 (25.0%)
*Note: A PSA level over 4.0 ng/ml traditionally triggers a biopsy.
Adapted with permission from I.M. Thompson, et al. Prevalence of Prostate Cancer Among Men with a Prostate-Specific Antigen Level ≤4.0 ng per Milliliter. New England Journal of Medicine, May 27, 2004, Table 2.

This study inadvertently provided evidence not only that prostate cancer occurs more often than once believed, but also that PSA levels may not be a reliable indicator of which cancers are most aggressive. Both findings add weight to the growing consensus that many prostate tumors currently being detected may not need to have been diagnosed or treated in the first place.

For more information

To learn more about the PCPT:

Thompson IM, Goodman PJ, Tangen CM, et al. The Influence of Finasteride on the Development of Prostate Cancer. New England Journal of Medicine 2003;349:215–24. PMID: 12824459.

Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of Prostate Cancer among Men with a Prostate-Specific Antigen Level ≤4.0 ng per Milliliter. New England Journal of Medicine 2004;350:2239–46. PMID: 15163773.

Cancer staging may miss errant cells

Once a pathologist confirms that cancer is present, the doctor will next determine how far the cancer extends — a process known as cancer staging — and discuss the implications with you. This is perhaps the most important information of all for you to obtain, as it determines whether the cancer is likely to be curable, or whether it has already spread to additional tissues, making prognosis much worse.

If you were my patient, I would ask you to consider two important points. First, cancer staging actually occurs in two phases: clinical (based on information obtained preoperatively) and pathological (based on information obtained during surgery). Of the two, pathological staging is more accurate.

A second point to understand, however, is that even pathological staging can be inaccurate (see Figure 2). A cancer spreads, or metastasizes, once a primary tumor sheds cancer cells that travel elsewhere in the body and establish other tumor sites. Metastasis is a complex process that researchers do not fully understand. What is clear is that this process involves multiple genetic mutations and steps, and that each type of cancer spreads in a unique way.

Figure 2. Why understaging may occur

Why understaging may occur

When the prostate is removed, a pathologist examines slices of the gland for evidence of cancer. A. Under a microscope, the pathologist can distinguish tiny tumors, consisting of clumps of visibly abnormal cells. B. With current imaging technology, it is not yet possible for a pathologist to identify micrometastases — individual cancer cells shed from the primary tumor — that have gone on to seed adjacent tissue. In this image, for example, cancer cells have already penetrated the capsule and migrated to adjacent tissue, even beyond the margin of tissue removed during surgery.

Individual prostate cancer cells can spread to more remote areas of the body in three ways (see “How prostate cancer spreads,” below). What’s more, they can do so without being detected with our current technology, essentially escaping “under the radar.” So it’s always possible — even if you are diagnosed with early-stage prostate cancer — that the cancer has already spread and will manifest in the coming years. How likely is it that an early-stage prostate cancer will become active without treatment? A small study provides some clues (see “Likelihood of progression,” above).

How prostate cancer spreads

  • The cells escape into the bloodstream, initially by invading small blood vessels around the tumor, then traveling to larger blood vessels that enable the cells to circulate around the body (a situation known as vascular invasion).
  • The cells are filtered through the body’s lymph system; although some are captured in lymph nodes, others may travel elsewhere in the body.
  • The cells migrate along the length of a nerve, escaping from the prostate into adjacent soft tissue (a situation known as perineural invasion, or PNI).

Treatments may have side effects

The treatment options for early-stage prostate cancer fall into three broad categories: surgery, radiation therapy, and active surveillance. Your doctor will make a treatment recommendation based on your “numbers” as well as a mathematical tool known as a nomogram, which can help you and your doctor better assess how extensive your cancer is likely to be and whether it is likely to become active in the future.

Yet clinical studies have not provided any evidence that one treatment is better than another — or that any treatment at all actually prolongs life: The average 5-, 10-, and 15-year survival rates are virtually the same for all treatment options in early-stage prostate cancer, including active surveillance. It’s also important to understand that no mathematical model is foolproof, and some men diagnosed with early-stage, locally confined disease will later find out that their cancer was more extensive than originally believed.

If you are diagnosed with early-stage prostate cancer, you have a number of treatments to choose from. A brief comparison is listed in Table 2.

Table 2. What guides treatment recommendations

Both of the situations below involve men diagnosed with a tumor that is small in size (stage T2a or smaller), yet who may require quite different treatments, based on their PSA level and Gleason score. Of course, many men have clinical profiles that vary from these two extremes.

Clinical profile Probable pathological stage Treatment recommendation
Low PSA (less than 10 ng/ml)

Low Gleason score (no more than 6)

80% of men with this profile probably have locally confined disease.

It is likely that fewer than 3% will have evidence of cancer in lymph nodes.

Surgery, radiation, or active surveillance (depending on exact clinical profile).
High PSA (more than 20 ng/ml)

High Gleason score (8–10)

5% of men with this profile probably have locally confined disease.

More than 20% probably have evidence of cancer in the lymph nodes.

Systemic therapy rather than surgery (may involve some combination of hormonal and radiation therapy).

Radical prostatectomy (surgery). The surgeon removes the prostate and seminal vesicles (saclike glands that release fluid that becomes part of semen). In some cases, pelvic lymph nodes are also sampled. This is most often performed through an abdominal incision; abdominal surgery may also be done with a laparoscope. A third option is the perineal technique, involving an incision in the area between the scrotum and the anus (the perineum). The most common side effects are

  • impotence (affecting 30%–70% of men)
  • mild to severe incontinence (2%–15%).

External beam radiation therapy. After a CT scan constructs a three-dimensional picture of the prostate and seminal vesicles, the radiation oncologist directs rays of high-energy radiation at the prostate tumor and sometimes at nearby lymph nodes. The most common side effects are

  • impotence (30%–70%)
  • mild to severe incontinence (1%–2%).

Brachytherapy. With ultrasound guidance, radioactive “seeds” or pellets are implanted in the prostate itself to irradiate the tumor. The most common side effects are

  • impotence (30%–50%)
  • mild to severe incontinence (2%).

Active surveillance. This involves an extended period of monitoring the cancer with regular digital rectal exams, PSA tests, and sometimes repeated prostate biopsies. If tests indicate cancer has become active, treatment options are offered. The major risk of active surveillance is that the cancer could become active during the period of surveillance, potentially making prognosis worse.

Side effect reporting

When thinking about side effects, it’s important to understand that patients don’t always talk openly with their doctors about the impact treatment has had on their quality of life — or sometimes, doctors don’t ask. The following studies are just a sampling of the patient-reported data that have been published, which may provide a more accurate assessment of side effects.

Fecal incontinence. A telephone survey of 227 men with prostate cancer revealed that 5% of those who underwent radical prostatectomy and 18% of those who had a perineal prostatectomy developed fecal incontinence afterward. Yet fewer than 50% told their physicians. (Source: Bishoff JT, Motley G, Optenberg SA, et al. Incidence of Fecal and Urinary Incontinence Following Radical Perineal and Retropubic Prostatectomy in a National Population. Journal of Urology 1998;160:454–8. PMID: 9679897.)

Erectile dysfunction. A mailed questionnaire returned by 1,236 men with localized prostate cancer who had undergone either prostatectomy or radiation therapy revealed that 36% had erectile dysfunction at the time of diagnosis. Yet when contacted an average of four years after treatment, more than twice as many men (85%) said they had erectile dysfunction. Only 13% were able to have firm, reliable erections spontaneously. Respondents indicated that they were as concerned about the loss of sexual desire and the ability to have an orgasm as they were about erectile dysfunction. (Source: Schover LR, Fouladi RT, Warneke CL, et al. Defining Sexual Outcomes after Treatment for Localized Prostate Carcinoma. Cancer 2002;95:1773–85. PMID: 12365027.)

Urinary incontinence. A retrospective analysis based on Medicare claims submitted by 11,522 men who underwent prostatectomy for prostate cancer found that more than one year after surgery, 18%–24% (the proportion increased with age) had suffered symptoms of urinary incontinence or had undergone procedures to correct urinary difficulties. (Source: Begg CB, Riedel ER, Bach PB, et al. Variations in Morbidity after Radical Prostatectomy. New England Journal of Medicine 2002;346:1138–44. PMID: 11948274.)

Rectal cancer risk. A retrospective analysis of the outcomes of 30,552 men who received radiation for prostate cancer found that they were almost twice as likely to develop rectal cancer as a comparison group of 55,263 men who treated their cancer with surgery. (Source: Baxter NN, Tepper JE, Durham SB, et al. Increased Risk of Rectal Cancer after Prostate Radiation: A Population-Based Study. Gastroenterology 2005;128:819–24. PMID: 15825064.)

On the horizon

Given the current limits in diagnosis, prognosis, and treatment, research advances become even more important. Here’s a brief look at other diagnostic and prognostic tests currently in development.

Prostate cancer “fingerprints”

New types of genetic diagnostic technology, known as gene chips or genetic microarrays, use computers to analyze the activity of hundreds and sometimes thousands of genes at a time. The tests can reveal certain telltale patterns that indicate whether inborn controls that inhibit cancer growth — such as controls of blood vessel growth (angiogenesis), cell differentiation and proliferation, and cell adhesion — remain in place or have failed. Think of these patterns as molecular fingerprints that help researchers identify which are the most aggressive cancers and therefore are most likely to spread. The technology is already commercially available for use in breast cancer. Several gene chips for prostate cancer are in development.

Autoantibody signatures

Other researchers are investigating whether it is possible to analyze blood samples for the presence of particular antibodies, immune system chemicals that attack cancer cells and other abnormal cells. One study published in the New England Journal of Medicine found that a computerized microarray device could use antibody detection to identify people with prostate cancer more accurately than a PSA test. Although more research has to be done, the hope is that antibody analysis will enable doctors to detect cancer at its earliest stages, when your own immune system has identified the abnormal growth and is trying to suppress it. (Source: Wang X, Yu J, Sreekumar A, et al. Autoantibody Signatures in Prostate Cancer. New England Journal of Medicine 2005;353:1224–35. PMID: 16177248.)

Originally published January 2007; Last reviewed April 20, 2011

Comments:

  1. eugene sinta

    eugene one of my 14 cores had 5% cancer cells,doctor said surveillance I have high anxiety over this,3 months later PSA 4.56doctor says I will not die from this. How do you become cancer free ??

  2. Allen

    I am 58 had Psa level 10 last year did 16 poke biospsy no cancer. Follow up psa almost year latter level up to 16. Now doc order mri then mri driven biopsy. I see on site most have levels in 6 to 8 range and have cancer anybody have high psa and not have cancer out there. I think I rather see what happens especially if I have cxncer n spread outside of prostate then what point of taking on all the complications?? Of removing it if already spread. Anybody take out prostate and and not experienced the bad side effects or it for sure?

  3. Paul Cutuli

    I am 65 years old and my PSA is 5.1 I have done 2 retests in the last 2 months and my result has not changed Urol ordered biopsy. I had Prostate Biopsy in 2007 which was negative. I know I have an enlarged Prostate and have been taking medication for it. I have been told that the Prostate medicine can elevate a PSA test. I have also been told that constant bike riding could effect it. Do I really need biopopsy ?

  4. Mrs Jones

    Is there a more recent report please ? The information in this article is excellent thank you

  5. Bob Johnston

    I have low grade prostate cancer I am 74. My PSA has gone up from 7 to 12, I have had a bad cough for 2 weeks after flying home from vacation could that causeit to rise?

  6. Larry Lamb

    My PSA 2.1 6/29/16, 5.54 4/26/17, 4.29 8/30/17 6.7 3/7/18. MRI clean, CT Scan with contrast clean, Biopsy Gleason 6. They want to do another biopsy. First one took 14 with 3 showing something. Doctor performed rectal examine before blood drawn on the high readings. The 4.29 was without rectal examine. Could the rectal examine raise the PSA level?

  7. James

    My Gleason score is 3+4 how ever I went to surgery removing my prostate do you think I still have cancer

  8. Greg Cochran

    I just received the results of my biopsy and was diagnosed with early stage prostate cancer. 6 samples were positive with Gleason scores of 6 ( 3 + 3 ) My Dr. even though a surgeon recommended that I take my time and suggest that I investigate Radiation as an alternative to surgery. He definitely was not a fan of HIFU based on a lack of historical data. Your article was very helpful along with this Blog but still confusing at best as to what alternative I should seek. I am recently retired at 64 years old and looking for any advice you can send my way. My wife based on family history is of the belief of just get it out. Thank you

  9. D M Hasler

    I have moderate Gleason, psa fairly low 4+,small tumors on one side. Went to the big city for 2d opinion #1 survelliance [internet opinion with review of biopsy records], #2″ Hifu”[high intensity focused ultrasound] Docters who offered this lost my confidence because they did not tell me that this is not an accepted procedure for prostate cancer by most of the medical community . Their office people were also coached to keep me in the dark regarding the cost to me which is 25 G’s+.When I asked the cost, they said”no one really knows what a insurance company will pay” This is pure BS.It is not approved yet for cancer- they pay nothing! Brachiatherapy is still the accepted norm for moderate cancer,by my research[NCCN.org and Medscape.com], and has been proven, although these guys consider it obsolete and give a low risk man like myself only the option of focused radiation or surgical removal in addition to the Hifu. I’m going back to my small town urologist who is skilled and ethical. May consider observation only. In my case, my research is indicating that I should not get in too much of a hurry.I am 68, very fit,from heredity possibly will live another 20 years so, I’m not sure if I want this hanging over me, for that long, but research seems to show that radical treatment may not make a difference in the final outcome regarding a case like mine.

  10. Garth Denton

    I was diagnosed with early stage Gleason 6, t1c in May 2009. Confirmed by three different opinions. My PSA was 4.6 ng/ml. I am now 65 years old and have been on watchful waiting for the last 8 years. I have PSA test every 6 months. My last was November, 2017 and my score was 2.6. I am due for another PSA test in March or April, 2018. After diagnosis in 2009, I made radical changes to my diet and stress level. I am hoping to continue watchful waiting, but if PSA goes over 5, I will find a treatment.

  11. H H Doshi

    I suggest reading a book called “THE GREAT PROSTATE HOAX” by Richard J. Ablin, PhD who invented the PSA test. PSA does not detect prostate cancer simply it is not a cancer-specific marker. Biopsy test disturbs the gland. You do not want to awaken up the giant!

  12. Marilyn Clark

    What are the risks of having the initial biopsy through the bowel wall – have heard reports from a couple of people that this caused an infection and the patients died as a result?

  13. Linda Moffatt

    My husband was diagnosed in 1995 at age 49. His PSA was 4 and the tumor could not be felt on DRE. I no longer remember all the staging/grading numbers, but he had a radical prostatectomy. He suffered some incontinence for a while, but not long term, and he did suffer erectile dysfunction and later had a prosthesis surgically implanted. However, the point is, he is now almost 71, and continues to get a 0 PSA every year. I’m checking out this website for info for his brother who age 69 has just been diagnosed with stage 1, level 7 prostate cancer. Surgery has been offered as an option. I’m not sure I understand his hesitancy.

  14. ralph nobo

    I am 68 physician in very good health PSA 4.1/4.4 biopsy 3 out of 12 positive, 5% or less involvement. one small area is 3+4, but the 4 the pathologist says is even very small and very early stages, ( he is a personal friend and emphasis how small area it was and that changes where early if they were there, but he wanted to say 4 with that comment). whats next ?

  15. Jim General

    I’m 73, good health with no under laying conditions with a PSA 6.4. Prostate Volume 32.4, Nothing found on DRE or ultrasound. PSA density 0.2. Biopsy on Dec 13,2017,12 needles, 0 on the right side, LH base Gleason score 3+4=7 in 1 out of 1 core involving 30%. LH lateral medium, 3+4 involving 20% & LH lateral 3+4 out of 1 core involving 30%.
    I’m coming to grips with the Radical Prostatectomy and I was looking for feedback on this choice. Help & suggestions are very welcome.
    Thanks, Jim

  16. Ray Sims

    Ray Sims
    71 yo. PSA in Oct ’17 was 9.8 experiencing ED, weak stream, night time pit stops. 4KScore test result was 38% and doc said it would be best for biopsy. That is taking place Jan. 3. Trying to get as much info as possible and realize there is no “do this then this and all is well”. Appreciate all the comments I’ve read so far. Will try to keep updating as I gather information. At least learning to ask some of the best questions.

  17. Mike Stewart (rr)

    Biopsy revealed five of 12 core samples cancerous, Gleason score 6, T1C, currently Sedentary lifestyle due to other medical conditions. Dr. said could live 10 to 15 more years with no action, currently 60 years old. Please advise best you can and include information regarding FDA approval of HUFI for low aggressive prostate cancer like mine. Thank you.

  18. Mike Stewart (rr)

    Has the FDA approved the HUFI procedure for prostate cancer like mine which is Gleason six, T1C, five of 12 for samples cancerous, Dr. said if I did nothing probably live 10 to 15 years, I am 60 I don’t have existing medical problems that have me housebound/sedentary. Have family history but at much more aggressive levels. Please advise best you can!

  19. mike smyth

    mike s
    I had a rising PSA 2.2 to 3.2 over 4 years, had a PHI test showing 55%, MRI scan showing a small mass, then biopsy 2 of 20 cores had 5% cancer cells and given a Gleason score of 3+4=7.recommended for Di Vinci procedure.

  20. Tom Johnston

    I am 69 with PSA scores averaging .8 over a 10 years of active surveillance. Biopsies have indicated cancer exclusively on the right side. Gleason scores have been 3+3=6 in the base, mid, and apex. Last biopsy indicated 3+4=7 in the mid-apex. I am going to have another biopsy in January 2018. My doctor and consulting oncologist must think of me as the patient from hell, because I ask so many questions. Admittedly, I have been dragging my feet on treatment. I can’t understand why my entire prostate needs to be removed/destroyed rather than just the side with cancer. I am scared to death of the possible side effects of treatment.

  21. Richard Crane

    I was just diagnosed with PC. My PSA increased from 4.2 to 5.2 over a few months. I had a biopsy 10/17 and my Gleason is 4+3=7. 4 of 12 cores had cancer, 3 were 3+4 with low % but one was 4+3=7 with 35%.

    My Urologist (who performs Di Vinci robotic) recommends surgery. I am leaning toward the robotic surgery but worried about the incontinence side effects.

    I am wondering if surgery is the best method to cure my situation vs radiation seeds.

  22. John Foster

    PSA started to go up and eventually was going up 1 point per month to 10.6. Biopsy was Gleason 4+4=8 but M.D. Anderson reread it as Gleason 4+3=7. That meant I could qualify for a clinical trial of double strength proton treatments M-W-F instead of the regular single strength M-T-W-T-F. After a 6 month Lupron shot to reduce testosterone that feeds the cancer, I had 15 treatments that apparently cured it with no side effects, a particular advantage of protons. I still have to go back every 3 months for a PSA test to make sure the numbers stay low.

  23. Smashcancer

    This is great general information, but if you’re looking for something outside of the orthodox treatment methods, you’re going to have to find it on your own. I’ve been researching health for some years now, and most breakthroughs are not going to be revealed to the masses. Do an internet search for smashcancer for more information on cancer and how to beat it.

  24. tonyW

    Recently diagnosed with gleason 6, 1 of 10 cores no DRE – PSA was 6.6 at ttime of diagnosis (rapid psa acceleration from 4.1 in August of 2016, Feb 5.1, April 6.0) after a week on antibiotics and psa still rising -urologist rule out infection and recommended biopsy in May 2017 in which we found the PC. Researching and trying to find the best and most recent data and recommendations for treatment as url did nto offer much and suggested I speak wit a radiology oncologist, surgeon that specializes in prostate cancer – which i am trying to find the best = also learning that a urologic oncologist with those specialties may be the way to go whether surgeon or radiologist but will suggest the latest testing and diagnostic assessments to determine risk of future aggression or other cancer missed on biopsy. Also learning that you must do your own research and question everything, keep reaching out to experts, organizations and most importantly patients and people that can share –
    information and learning – any other advice out there ?

  25. Robin R

    My PSA has been rising over the past five years. Small amounts though. I am 67 and PSA is up to 6.4.It was 5 a year ago and I had a biopsy. Gleason 6 said my Uro, Nothing to worry about. This year it is 6.4 and he wants me to Come in and discuss my PSA history. Is this just a ploy for a visit or, could it be important. I believe he is am excellent Dr.

  26. Thomas F Walsh

    PSA 4.2. Gleason 6. Biopsy 2 sections with cancer 1-5% 1-15%
    Digital – negative
    K#35
    Totally confused by avaible inf
    Get comfortable with watchful survailance and then see article against it
    Thankful that my numbers appear low ; but confused and intimidated.

  27. Gary R Patterson

    Had 2 growths biopsied, the smaller one 1±2=3, second one was 3+4=7. Not want prostate removed but thinking of radiation, as side effects of removal greatly outweigh the need. Lifetime incontinence being major treason. I’m 66, with healthy sex life.
    Need know my best options please?

  28. Mike Cawood

    Thanks for very informative article. I am recovering from TURP procedure as a result of enlarged prostate and difficulty urinating. PSA of 2 and rectal exam before the operation indicated no cancer but biopsy after TURP showed Gleason of 3+3. What further testing and treatment is recommended? Many thanks, Mike

  29. Arnold L. Scarano

    PS. Jay, my PSA is 5.08. Arnold

  30. Arnold L. Scarano

    Hello Jay, I am age 65, Gleason 3+3, one core 5%, one core pre-cancerous, diagnosed in Jan. 2017. Have opted for AS, semi-annual PSA, annual biopsy. As you must be doing, I am reading a lot and learning, I find the side effects of some treatments to be alarming so am taking a cautious approach. Fortunately I have a terrific doctor and have completely put my faith in him. Be well and good luck.
    Arnold

  31. Jay S

    My PSA is 5.2, an MP MRI was nagative, but a TRUS biopsy showed 1 of 12 cores 3% positive, with a Gleason of 3+3+6. My uro favors AS with semi-annual PSAs and an annual biopsy. And I tend to agree, though I am looking into cyberknife if needed if this progresses. I am 73 and otherwise in good health. What do you folks think? All responses appreciated.

  32. Charles Davis

    Just received notification today that the results from my prostate Biopsy showed five spots out of 12 were cancerous. Therefore, I am doing as much research on various treatments and side effects so that I can formulate questions to ask my doctor.

  33. DM Anderson

    Beware of scalpel-happy urologists, who are ready to start carving up your nether regions even before a biopsy confirmation of cancer.
    Of course, performing radical p-ectomies are how they pay for ski villas & boats, but they also want to keep their skills sharp.
    Get a 2nd or 3rd opinion before any surgery and READ READ READ to inform yourself.
    Know your Gleason score, Stage, & PSA and remind your MD of his Hippocratic Oath:
    First , Do No Harm

  34. DM Anderson

    Beware of scalpel-happy urologists!
    They’re eager to start cutting up your nether regions even before a biopsy.
    Of course that’s how they pay for ski villas & boats, but also need to keep their skills sharp.
    Get a 2nd or 3Rd opinion and READ READ READ to inform yourself.
    Know your Gleason , Stage & PSA & remind your Dr of his Hippocratic Oath:
    First Do No Harm

  35. Jim

    I am a 70 years old and I had a biopsy with a Gleason 6 score, but my PSA is 20.7. Am I still a candidate for Active Surveillance?

  36. After a biopsy 23jan 2017,Gleason score 3+3=6 and 3+4=7. Originally my P s a was 5.7 feb,2016 now at 3.5 does it matter at this point? What’s my best option besides surgery? Thank you

  37. Cheryl Lamas

    My dad is 87 and his Gleason score is 5+5 has started on hormonal therapy there is a tumor in his bladder bur no cancer in his bones. Doctors are saying if the hormonal therapy is a success he can have 10 years added to his life.. after reading this I feel like we are treating not curing is this correct?

  38. Kitty

    My boyfriend is young (46) and has a psa of 51. He has cancer and more test to determine if it has spread. We obviously want to him cancer free and not incontinent but our sex life is very important. What is the best suggestion for treatment?

  39. Mark Gilbert

    Just diagnosed with stage t1c, Gleason 6 (3+3), but high volume: 6 areas biopsied, 60% in one, 50% in on, 20% in one, 5% in one, less than 1 % in one and 0 in the last. The two options recommended where Active surveillance and surgery. Radiation is not an option because of ulcerative proctitis. Has anyone had to make a similar decision with low grade, low stage, high-volume prostate cancer?

    • Tony

      Yes i have first psa was7then doneanother in a month and it was5doctor recommend getting it out kind of leaning that way since I’m53 and the side affects are good dad got it hey radiation cancer came back uncle have prostate removed he’s cancer-free both has leakage

  40. Patti

    My husband Gary obtained a second opinion after his urol advised more watchful waiting in Jan. 2016. In June 2016, we saw the second urol who ordered an MRI as PSA was up to 5.8. A targeted biopsy in October revealed that his Gleason is 7 (4+3), which is more aggressive than 3+3 or 3+4 . Laparoscopic robotic surgery followed by radiation is being recommended given that he is very young (54), is healthy but is considered high risk as his father and two brothers had/have it. After 3-4 years of bi annual PSA, DRE and now two biopsies, we are considering getting HIFU even thought it is not covered by OHIP. Really scared of radiation and hoping that HIFU plus lifestyle changes pay off. Thanks for the informative article.

  41. Frank G patterson

    Just had my PSA result levelled at 6 … After a brief discussion with my doctor I have opted for a biopsy .. I have read with interest and some trepidation and fear what prostate cancer is all about, so much to take in so many options and varying factors to take on board .. Depending on the biopsies results and my appointed consultants analysis whatever the outcome the next steps and or decisions appear to be in my hands … Catch 22 comes to mind … Fingers crossed .. We venture into a lot of unknowns, this article can only but help me with my ability to understand and convey my thoughts.

    Thank you to date.

  42. Stephen Van Osdell

    I had Gleason 6 in 5 cores and PSA of 4.5 and UROL wanted me to go under his CyberKnife for complete killing of my gland. I said no, I want to investigate. I had mpMRI done a few months later and it found a 16mm lesion in the apex area (where TRUS biopsy needles can’t reach!!) This lesion was focally biopsied with MRI guidance and it turns out to be a low aggression 3+4 Gleason 7. Only 20% showing 4. I am strongly considering MRI guided focal laser ablation, but issue is that insurance won’t cover it and cost is $20K out of pocket. But insurance will happily cover procedures that destroy your entire gland. What if insurance wouldn’t cover breast lumpectomy but only full breast removal? I believe women would revolt and we men should also!

    • Joe P

      Stephen
      Would you be able to email me?
      I have similar diagnosis and would appreciate a conversation
      Thanks. Joe

    • Hi Steven,
      I went from a Gleason 6 3-3 to a Gleason 7 3-4. My doc recommends a total immediate prostatectomy. My PSP as never varied between 1.9 and 2.1 in fours years. When I was first diagnosed my GP had found a hard spot during a digital exam and referred me to a urologist who biopsied and found 2 tumors, one each side at.a Gleason score of 6. Neither related to the hard spot. He recommended immediate chemical castration and radiation pills. I went to 3 additional urologist before I found one that actually recommended an MRI and active servalance. My understanding is that a 7 3-4 is virtually the same thing as a 6 3-3. Is this your understanding. I do not plan on following my doctors advice for surgery or radiation.

  43. Stephen Van Osdell

    To all people with Gleason 6, PSA’s below around 6 and good low aggressive genetic marker tests… DO NOT let a urologist talk you into Cyberknife or other treatment until you have had a multi-parametric high-res MRI to see if there might be something worse that the TRUS biopsy (only 60% accurate) missed! If nothing higher than Gleason 6 is found in mpMRI, then DO NOTHING and enjoy life and have a semi-annual PSA! Best advice you will get and comes from a LOT of due diligence.

  44. Stephanie

    I stumbled across this article while researching exactly what it means when prostate cancer has escaped the capsule. I cannot stress enough about the PSA levels. My dad is battling cancer which was initially treated twice as an infection due to low PSA levels. Months later when a biopsy was performed, he had cancer in 6, potentially 7 of the 12 areas biopsied. Within 1.5 months had robotic surgery to remove prostate yet the cancer still had escaped the capsule. We will find out next steps from radiologist in the AM. I shared this article to stress how the PSA #s do not necessarily directly correlated to cancer. And 2nd opinions is a wise decision. It’s not worth risking your life in hopes the doctor you have knows best.

  45. Lorrie

    Das ist ja super, dass es schon bei einigen eingetroffen ist und ich freue mich riesig, dass es euch gefällt. Wir haben uns bei diesem Kit wirklich sehr viel Mühe gegeben :)Viel Spass beim StrpKeln!!mathaeina x

  46. CH.ANANT RAM

    MY father(age 65 years) recently diagnosed with prostste cancer.It was identified through TRUS biopsy guided by PET CT SCAN.

    PSA level is 1.66

    the gleason score is 3+3,and doctor is recommending cyberknife technology of radiation.

    actually which method of treatment is better -surgery/radiation/cyberknife technology.

    can you please suggest me the best method of treatment for early stage of prostste cancer.

  47. Karen Norris

    PTEN FISH testing is also an option for discovering the loss of the tumor suppressor gene PTEN. IF lost, there is little to suppress the growth of the tumor.
    Also a Johns Hopkins study discovered that amplification of the ERG gene in prostate cancer results in twice the likelihood of aggressive disease progression outside the prostate.
    Karen

  48. Michael Gerlach

    This article helps bring everything into perspective. Since this article was last reviewed (04/2011) there is new technology, the Oncotype DX Prostate Cancer Test that is genomic-based diagnostic testing. Looks promising.
    Thank you for the interesting information!

  49. John

    Possibly the most important fact/paragraph in the entire report is buried under an unrelated heading, it gets little elaboration, and most importantly, the source reference to “clinical studies” was not made or discussed! That paragraph is the second paragraph under the heading, “Treatments may have side effects” and here it is: “Yet clinical studies have not provided any evidence that one treatment is better than another — or that any treatment at all actually prolongs life: The average 5-, 10-, and 15-year survival rates are virtually the same for all treatment options in early-stage prostate cancer, including active surveillance. It’s also important to understand that no mathematical model is foolproof, and some men diagnosed with early-stage, locally confined disease will later find out that their cancer was more extensive than originally believed.” .

  50. Amjad Ali

    Thanks , This is a great information.

  51. Marcos Elrod

    Great and better information then articles written in 2015. I have PSA 8.3 and 3D MRI shows a significant tumor. So far I am not decided on an initial biopsy. Reading about cancer cells escaping the capsule, I was wandering if they can escape during and after the biopsy when the needle holes bleed a bit.

  52. JP Dubey

    I (age 76) am getting annual checkup for BPH since 1997 when volume was 35 cc. Now it is 70 cc.I have been taking Tamsulosin 0.4 mg OD for several years. Otherwise asymptomatic. However last month PSA was 6.5. Dr asked for PSA profile in which the PSA came down to 5.2 but the free to total ratio was 17.8%. Since I was also experiencing mild burning in urethra suspecting prostatitis for which Dr gave antibiotic and another PSA profile after 3 weeks.If the ratio is still >20 he may go for MRI guided biopsy.

    I am a widower and erectile dysfunction or infertility don’t matter but possibility of living with side effect incontinence for many years worries me. In the event of early stage cancer can I start with hormone therapy or take Dutasteride/Finasteride also instead of just Tamsulosin? Will starting medication improve chances to obviate or delay the need for radiotherapy or surgery?

  53. Nick

    HIFU has been approved by FDA now. I think that is another option that hasn’t made it out to the public yet although it’s been used in Europe for years. It’s non-invasive with less side effects and short recovery. Still a few unknowns with it yet and time will put those to rest, but then again absolutely every topic in regards to prostate cancer is a bunch of unknowns at this point with different opinions by each Dr. Still early yet but the more options the better for patients.

  54. S K NAG

    a commendable write up for layman like me.

  55. S N Deka

    Very nice document with comprehensive information.

  56. Dean

    Thank You, this is the first article I’ve read after receiving the phone call 45 minutes ago.

  57. Sally Miler

    This is great information!!

  58. Eve

    Oh yeah, faouubls stuff there you!

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