Understanding your prostate pathology report

At least initially, the pathology report is one of the most important factors in the management of your prostate health, especially if you have been diagnosed with cancer. For example, it can provide valuable information about the location and extent of the cancer, thus helping your physician decide whether to recommend active surveillance, hormone treatment, radiation therapy, or surgery.

With that in mind, you might think that preparing and reading a pathology report would be straightforward — but unfortunately the opposite is true. Pathology reports are not prepared uniformly (compare Figures 3 and 4, below, for example). In fact, they can vary considerably even within a single institution. They may not be labeled thoroughly or contain enough specifics for you and your doctor to make a good treatment decision.

At the same time, the information that is included in the report may be difficult to decipher. You may also get conflicting interpretations depending on how the report was prepared and who is reading it. It is entirely possible for two pathologists to look at the same biopsy slides and yet disagree about whether you have cancer! (For more information about this, read the article “Why pathologists may disagree.”)

In this article you will learn what your pathology report should include and how to make sense of the information it contains. Other articles on this site explain when to get a second opinion about the pathology report and why it is sometimes necessary to have a repeat biopsy, as well as what questions to ask to obtain the information you need to decide which treatment is best for you.

Deconstructing the report

It is always a good idea to request a copy of your pathology report. A thorough reading will give you the information you need to have informed discussions with your urologist, surgeon, and oncologist, and better guide any decisions you need to make about what to do next.

If the findings on the pathology report are abnormal, it is likely that the diagnosis will fall into one of three major categories:

  1. An atypical finding
  2. High-grade PIN
  3. Prostate cancer (adenocarcinoma).*
*Note: Although there are other, rare forms of cancer that can arise in the prostate gland, this article will focus on the most common type, adenocarcinoma.

An atypical finding means that the pathologist cannot confirm or rule out cancer. Sometimes this finding is reported as “suggestive of” or “suspicious for” cancer but not diagnostic of cancer. This frustratingly equivocal diagnosis usually means that the pathologist looked at the tissue on the slides and saw cells that were not typical, but they were not abnormal enough to classify as cancer (see “What makes it cancer?”).

What makes it cancer?

Although PSA levels or a digital rectal exam may hint at cancer, only a pathologist looking at cells in tissue samples can make the diagnosis. The following are among the key features they look for:

  • Proliferation of relatively uniform small glands lined by a single layer of cells
  • Cells with prominent nucleoli, components of the nucleus that help build proteins
  • Enlarged nuclei
  • Lack of basal cells, which sit below the epithelium in normal tissue
  • Cells that stain readily with dyes
  • Evidence of perineural invasion (PNI).

There is no consensus about the correct terminology to use for such lesions. Often you’ll see the term atypical small acinar proliferation, or ASAP, but it could also be labeled atypical hyperplasia, atypia, atypical glands, or focal glandular atypia.

Fortunately, such atypical findings are reported in only about 8% of pathology reports, according to a review of 39 studies involving needle biopsy specimens. But the trend toward doing more biopsies and finding smaller cancers has led to an increase in atypical diagnoses. Studies have shown that nearly half of the men who receive such an atypical diagnosis initially will find they have prostate cancer during a follow-up biopsy. This happens regardless of PSA levels or results of a digital rectal exam (DRE), which appear to be unrelated. In addition, compared to other pathologic diagnoses, atypical findings have the highest likelihood of being changed on expert review, usually to a diagnosis of cancer.

High-grade PIN, short for prostatic intraepithelial neoplasia, is another broad diagnostic category. This finding involves a subjective reading of the pathology slides and also generates debate about follow-up and treatment. It is now thought that high-grade PIN might increase a man’s risk of developing cancer, but because the steps involved in cancer progression are still elusive, the degree of risk remains unclear. It is usually not considered an important factor when associated with a definitive diagnosis of cancer.

Beyond these basic distinctions, and sometimes even within them, things can get hazy. The pathologist weighs numerous complex factors when making these broad diagnostic statements, and if you have been given a prostate cancer diagnosis, the report usually contains descriptive information about the type, amount, and grade of cancer found. All of these factors can affect risks and influence treatment decisions.

For all these reasons, your pathology report is not something you should skim but rather scrutinize. It is important to understand every component, discuss how the pathologist arrived at his or her conclusions (or lack thereof), and share the details with every physician involved in your care. The major components of a good pathology report are reviewed here briefly.

Gleason score

If your biopsy finds cancer, the first piece of information you’ll want to note is the Gleason score. This numerical value grades prostate tumor cells according to how they look compared with normal cells and how mutated they appear under a microscope, a quality known as differentiation. (Normal cells are well differentiated and cancer cells are not.) Because tumors often consist of multiple cell types, the pathologist assigns two values between 1 and 5: the first to the predominant cell type, and the second to the next-most-prevalent cell type (see Figure 1). The sum, ranging from 2 to 10, is the Gleason score; the higher the number, the more aggressive the cancer.

Figure 1: The Gleason score

The Gleason score is a numerical value that grades prostate tumor cells according to how they appear compared to normal prostate cells (a quality known as differentiation). Because tumors often consist of multiple types of cells, the pathologist assigns two values: the first to the predominant cell type, and the second to the next-most-prevalent cell type. These two values are added to come up with the Gleason score.

Well differentiated

The Gleason score: Well differentiated

  1. Glandular cells are small, of fairly uniform shape, and tightly packed together.
  2. Cells display more varied and irregular shapes and are loosely packed.

Moderately differentiated

The Gleason score: Moderately differentiated

  1. Cells are even more irregular in size and shape and are more dispersed; some cells are fused, and cell borders are less distinct.

Poorly differentiated

The Gleason score: Poorly differentiated

  1. Many cells are fused into irregular masses; some cells (see those darkly shaded) have begun to invade the connective tissue that separates cells.
  2. Most of the tumor consists of irregular masses that have invaded the connective tissue.

The Gleason score is one of the most important factors in determining whether the cancer is likely confined to the prostate and how aggressive it is (see Table 1 for a quick guide to what the scores mean).

Table 1: Gleason score risk assessments

Total Gleason score Simple risk assessment Points to consider when assessing risk
2 to 4 Lower risk
  • Total Gleason scores of 2 to 4 are rare. Less than 2% of men who undergo a prostate biopsy have a score in this range.
  • Pay attention to the first value assigned, as this is based on the preponderant area of cancer. That is why a Gleason score of 7 has a worse prognosis if it is based on the values 4 + 3 than if it is based on the values 3 + 4.
  • Most cancers detected as a result of PSA screening are Gleason 6 (3 + 3) or 7 (3 + 4).
5 to 6

7 (if 3 + 4)

Moderate risk
7 (if 4 + 3)

8 to 10

Higher risk

Number of cores

An ideal report also specifies how many samples, or cores, were removed during the biopsy. The standard number of cores used to be six: three from the right side of the prostate and three from the left. However, this limited sampling meant that cancerous portions of the prostate, if there were any, might be missed. As a result, as many as one in four patients eventually diagnosed with prostate cancer was told, on the basis of the initial biopsy, that he did not have cancer — meaning that the test provided a false-negative finding.

Today, most doctors agree that an initial biopsy should include at least 10 to 12 core samples. In certain situations, some doctors recommend doing a saturation biopsy, which typically removes 12 to 14 cores — and sometimes as many as 20 or more — but less agreement exists about this practice.

Anatomic location

Ideally, the pathologist who prepares your report will have separated and labeled the core samples according to what part of the prostate they came from. This labeling will tell you and your doctors whether the cells came from the right or left side and whether they were drawn from the apex (counterintuitively, at the bottom), mid zone (middle), or base (top) of the prostate. In a saturation biopsy you may see even more detailed labels, such as RMA and RMB to differentiate between the right mid zone near the apex and the right mid zone closer to the base. Similarly, the report may refer to three zones: the peripheral, central, and transition zones (see Figure 2). All of this information can be invaluable in helping to determine the general location of the tumor, which helps guide treatment decisions.

Figure 2: Zones of the prostate

Zones of the prostate

To help your doctor more precisely determine the location of prostate cancer or another condition, such as high-grade PIN, your pathology report may name specific areas. For example, it may refer to the apex, located at the bottom of the prostate; the base, at the top; or the mid zone, the area between the apex and base. Alternatively, it may note three zones: the peripheral zone (1), the central zone (2), and the transition zone (3). Seventy percent of prostate cancers arise in the peripheral zone. Few arise in the anterior prostate.

Extent of cancer

In addition to paying attention to the number of cores taken, you’ll want to look at how much cancer was found. This information may be provided as the number of positive cores, the length of cancer in millimeters among all cores, the percentage of cancer per core, the fraction of positive cores, or the total percentage of cancer in the entire specimen. Regardless of the type of measurement, your doctor can use this information to determine the likelihood that the cancer is confined to the prostate or has spread.

Clinical data

In the clinical portion of the report, you may see notes from your physician to the pathologist offering any relevant information about why the biopsy was performed and what the physician is looking for.

Gross description

Your pathology report should also include a gross description with such important identifying information as the container in which the tissue was shipped to the department, length of various pieces of tissue, their color, and how the tissue is labeled.

Don’t be alarmed if you see mention of rectal or colonic tissue. Small fragments of bowel lining (colonic mucosa) are common in needle core biopsy specimens since the needle has to poke through this tissue to get to the prostate.


Sometimes, you will find notes to your physician or urologist in a section labeled “Comments.” This may be an important source of additional information such as whether the pathologist has found high-grade PIN or any atypical tissue. This section may also describe various features of the tissue and offer clues about the pathologist’s thinking, especially if the final diagnosis is not entirely clear.

Identifying details

Last, the report should include identifying information such as your name, age, and patient number, and the date, as well as the name and signature of the pathologist who prepared the report, the name of the person who performed the biopsy, and the name and address of the laboratory.

Figure 3: An ideal pathology report

City Hospital
Department of Pathology
123 Main Street
One City, Anystate USA


Patient Name: John Doe

Medical Record #: 01020304

Date of Birth: 04/01/26 (Age: 81) Sex: Male

Procedure performed by: Dr. I. M. Best

Specimen #: S00-9999

Procedure date: 07/15/07

Report date: 07/16/07

Gross description by: Dr. Eagle Eye


Prostate needle biopsies: 21

A) R5A: Fibromuscular tissue only; no prostatic epithelium seen.

B) R5MA: Atypical glandular focus suspicious for adenocarcinoma.

C) R5M: No malignancy identified.

D) R5MB: No malignancy identified.

E) R5B: No malignancy identified; focal chronic inflammation.

F) R4A: No malignancy identified.

G) R4MA: No malignancy identified; focal chronic inflammation.

H) R4M: No malignancy identified.

I) R4MB: No malignancy identified.

J) R4B: No malignancy identified; focal chronic inflammation.

K) L5A: Fibromuscular tissue and colonic mucosa; no prostatic epithelium seen.

L) L5MA: Adenocarcinoma, Gleason score 7 (3 + 4), involving 50% of core.

M) L5M: Adenocarcinoma, Gleason score 8 (4 + 4), involving 70% of core.

N) L5MB: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

O) L5B: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

P) L4A: No malignancy identified.

Q) L4MA: Adenocarcinoma, Gleason score 7 (4 + 3), involving 80% of core.

R) L4M: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

S) L4MB: Adenocarcinoma, Gleason score 8 (4 + 4), involving 80% of core.

T) L4B: Adenocarcinoma, Gleason score 8 (4 + 4), involving 70% of core.

U) L seminal vesicle: Seminal vesicle, no malignancy identified.

Note: Perineural invasion is seen. Focally, a tertiary Gleason 5 pattern is noted.

Clinical Data: None given.

Gross Description: Received in 21 formalin containers labeled with the patient’s name, “John Doe,” the medical record number, and additionally labeled “R5 apex,” “R5 mid-apex,” “R5 mid,” “R5 mid base,” “R5 base,” “R4 apex,” “R4 mid apex,” “R4 mid,” “R4 mid base,” “R4 base,” “L5 apex,” “L5 mid apex,” “L5 mid,” “L5 mid base,” “L5 base,” “L4 apex,” “L4 mid apex,” “L4 mid,” “L4 mid base,” “L4 base,” and “left seminal vesicle” are multiple prostate cores measuring up to 2.5 cm, entirely submitted in cassettes A–U respectively.

Report Electronically Signed Out — Eagle Eye, M.D. 07/16/07

Figure 4: A less-than-helpful pathology report

State Hospital
Department of Pathology
123 Elm Street
Another City, Anystate USA


Patient Name: John Doe

Medical Record #: 01234567

Date of Birth: 04/01/26 Age: 81

Sex: Male

Specimen #: S2007-X123

Procedure date: 06/11/07

Report date: 06/12/07

Gross description by: Dr. I.M. Brief


Prostate needle biopsies:

#2, right prostate: Adenocarcinoma, Gleason score 3 + 3 = 6, present in <5% of one of seven cores

Clinical Data: Prostate cancer.

Gross Description: Received from outside institution — three (3) H & E stained glass slides labeled “S2007-X123” and sub-labeled “2-1,” “2-3,” and “2-5” from procedure dated 06/11/07.

Originally published Oct. 1, 2007; last reviewed April 27, 2011.


  1. Kendallowski, Joel

    Diagnosed Prostate Gleason 7 (4+3). Showed Adenocarcinoma in Rt apex and base
    What treatment should I have?
    Bone scan, CT scan normal

  2. saeed amouian

    how we determine the final gleason score,If we have 3+4 in 3 specimen and 4+4 in 2 specimen?Final gleason score is 7 or 8?

  3. Anonymous

    Men beware!

    Read the hard facts about prostate cancer testing and treatment what no one will tell you about, even after it’s too late. This is information all men over 40 should have. Also anyone concerned about cancer in general or privacy issues should read this warning. Prostate cancer patients are often elderly, over treated and exploited for profits, AKA elderly abuse.

    $ $

    The overtreatment of prostate cancer for profit must stop! The treatment and well documented overtreatment of prostate cancer often results in devastating and unnecessary side effects and sometimes death. Profit vs. QOL (quality of life).

    Per some studies:
    1 man in 6 will be diagnosed with prostate cancer in his life.
    About 233,000 new cases per year of prostate cancer.
    About 1 Million blind biopsy’s performed per year.
    6.9% hospitalization within 30 days from a biopsy complication.
    About 1.3 to 3.5 deaths per 1,000 from prostate blind biopsies.
    .2% deaths as a result of prostate cancer surgery.
    60% had a prescription filled for an infection after a Biopsy.
    Medical mistakes are the third cause of deaths in the USA.
    Prostate cancer patients are at an increased risk for fatigue, depression, suicide, heart attacks and accidental death.

    Prostate cancer patients are often elderly and exploited for profit, the treatments offered almost always have horrible side effects, and newer treatment options are ether unavailable or not offered to patients or available outside the USA. Also men are often over treated for profit. Prostate cancer is often slow growing and of low risk and can just be monitored. Often no treatment is the best treatment.

    If a surgeon is financially responsible for a building lease or a large staff or an oncologist is also responsible for a lease on 5 million dollars of radiation treatment equipment, do you think they would be more or less upfront about the benefits and hazards of treatment? Do you think the profit margin would compromise some doctor’s ethics?

    The risks percentages for side effects from a blind biopsy and Prostate cancer treatments are usually understated to patients and some side effects are often not disclosed at all.

    Men with a high PSA tests result are usually sent to an urologist for a blind biopsy. Men should be told about other options: Percent free PSA test, PCA3 urine test or a MRI test before receiving a blind biopsy. These tests can often eliminate the need for a more risky and invasive blind biopsy. Insertion of 12 to 18 large holes through the rectum into a gland the size of a walnut, a blind Biopsy can result in prostate infections, a risk of permanent or temporary Erectile Dysfunction, urinary problems and sometimes even death from sepsis (About 1.3 to 3.5 deaths per 1,000 from Blind biopsies). A blind biopsy can also increase PSA reading for weeks or months.

    Prostate cancer patients are often sent for a bone scan. A bone scan has about a 13% chance of having a false positive and only 3 men in 1,000 have bone cancer who have a bone scan. Bone scans are usually unnecessary in lower risk prostate cancer patients.

    Low risk Cancer patients or patients with advanced age are often sent for aggressive treatment by some doctors when monitoring is usually a better option. An extreme example of overtreatment is one SBRT (a 5 day radiation treatment) clinical trial. Prostate cancer patients where intentionally treaded with a huge dose (50 Gy) of radiation resulting in disastrous long term side effect for some of these men. A large percentage of prostate cancer patients in this study had low risk prostate cancer.

    Clinical trials may or may not be hazardous to patients. The goal of a clinical trial is to gather information; the intent is not necessarily to help or cure patients. In a clinical trial, if someone is given a treatment that will harm them (as in the above example) or given a placebo in place of treatment or needed treatment is withheld, the patient may be deceived or harmed. Investigate before you participate in any clinical trial.

    Prostate cancer patients are asked to fill out a series of EPIC questioners and other questioners. The EPIC questioners ask intimate details about patient’s sex life, urinary and bowl function. By a prostate cancer patient completing a EPIC questioner, he may be able to assist his doctor, nurse or other office workers track his progress or decline. By refusing to fill out these questioners he can help insure his privacy and insure he do not unknowingly become part of a study or clinical trial or other collective survey. He may be told these questioners and records are confidential; this statement is an exaggeration. Most of the time a patient has no idea who has access to the records or why the records are being looked at. Who has access to medical records? Records are vulnerable. Probably everyone that works in a medical office or building has access to the records. This may include/however not limited to non-medical employees, office workers, bookkeepers, janitors, insurance companies, temporary high school or collage interns, etc.. This may include other medical facilities, programmers, hackers, researchers, drug companies, etc. Often records are placed on a health information exchange (HIE), dozens, sometimes even hundreds or thousands of people may have access to the records. Sometimes information can even be placed on a databases at any location in the world. Some major databases (SEER) are linked to Medicare records to determine “the final outcome” for researchers, collage students and studies. Allegedly sometimes in some databases identities are anonymous, however how can patient records be updated and tracked without a name or some other patient identity? Records may be packaged and offered for sale, this does happen. If a doctor or a patient or insurance company is involved in a criminal or civil case, medical records may become public court or law enforcement records. All patients should get a copy and read any confidentiality disclosures statements (HIPAA statements). HIPAA laws will only partially protect patients. Patients can also become the victims of medical Identity theft. Patient privacy is under attack. Under the HIPAA laws you are entailed to a copy of all your medical records, however if you try to obtain a copy of extensive records as in doctors notes or a hospital stay you may be met with resistance. All patients should avoid supplying unnecessary information whenever possible, supply relevant information only.

    The most common treatment options for men with prostate cancer are radiation, Brachytherapy, surgery, cryotherapy and hormones (ADT). Sometimes chemotherapy, immunotherapy and castration (orchiectomy) are used. A combination of treatments is often used. All of these treatments have long term or short term side effects. Often men are not told about all of the true risks and side effects or they are downplayed for both a blind biopsy and treatments.

    Brachytherapy is radiation seed implant. This treatment procedure implants 50 to 100 radioactive seeds in the prostate, commonly resulting in urinary problems. The patient will literally become radioactive for about a year. The patient can set off radiation alarm and metal detectors at airport. His semen will become radioactive. The patient will become like a walking Chernobyl, having radioactive scrap metal in his crotch. He will also be required to carry a card in his wallet stating he is radioactive. The videos of this procedure seem disturbing and bizarre. However Brachytherapy seems to have less sexual side effects than some of the other treatments available.

    Men are sometimes prescribed hormone therapy (ADT therapy), AKA chemical castration as an additional or only treatment. Hormone therapy is often very expensive (profitable for doctors) and has horrible, strange and devastating side effects, feminization, fatigue, etc.. Hormone (ADT) therapy is sometimes over prescribed for profit. This treatment has so many temporary and permanent mind and body altering side effects that doctors will not inform patients about all of them. Men are sometimes actually castrated (orchiectomy) as a cancer treatment to reduce testosterone.

    Nerve sparing Robotic-assisted DaVinci surgery is touted as being a better treatment and having fewer side effects, this is usually an exaggeration. The nerves can not always be spared. Robotic surgery can result in a faster initial recovery. However the long term risk of sexual dysfunction, incontinence, fatigue, etc. is about the same as conventional surgery. Patients undergoing surgery are at a small risk of developing post traumatic stress disorder (PTSD) and a 25% chance of long term or permanent fatigue. Also .2% risk of deaths as a result of prostate cancer surgery or medical mistakes.

    Patients should not be naive. Medical mistakes are the third cause of deaths in the USA. Medical mistakes cause more deaths then suicide, firearms and motor vehicle accidents combined. Countless other patients have been harmed by medical mistakes If you are having surgery, brachytherapy, a biopsy or a procedure take precautions if possible. Have someone qualified or knowledgeable monitor you and your medications, etc.. Doctors, nurses and technicians can be profit motivated, use obsolete procedures, be lazy, incompetent, make mistakes, be apathetic or rushed. In some cases harm can be done or not prevented with intent. Doctors offices and clinics see hundreds or more patients in a relatively short amount of time. This is often a disadvantage to patients, empathy and quality of care can be compromised. Sometimes a medical assistant or an office staff member may be the person that overseeing much of a patients care. Patients should be aware that often QOL (quality of life) may be secondary or an absent goals in treatment. Overtreatment for profit or to prevent an unlikely death or metastization from low risk cancer may be the primary or only goals of cancer treatment.

    A blind biopsy or treatments are often worse then the disease: Resulting in Chronic/permanent fatigue, incontinence, depression and sexual dysfunction. Hormone therapy has an extensive list of side effects that can be devastating for men. Biopsies and treatment are degrading, stressful and often unnecessary.

    The risk of long term chronic and permanent fatigue (that can result in depression) is almost always understated if mentioned at all to patients. Depending on your treatment; the risk of long term or permanent fatigue is about 25% to 60%. Radiation with Hormone therapy has a high risk of fatigue. Long term fatigue also increases the risk of clinical depression and suicide.

    In my opinion: Castration, hormone therapy (chemical castration), Brachytherapy (radiation seed implant), surgery and blind biopsies are often psychically and emotionally brutal, traumatic and disturbing. These types of treatments (Frankenstein stile medicine) are primitive and almost beyond belief in today’s world of advanced technology. Newer treatments like hyperthermia, Boron Neutron capture therapy, Focal Ablation (only treating the cancer and not the entire prostate) and orphan drugs should be approved and used when appropriate. Biopsies should be limited to selective MRI guided samples only, no blind biopsies should be performed.

    Advances in prostate cancer treatment mostly consisting of newer more accurate radiation treatments, robotic surgery and new drugs. These advances sound like greater strides have been made. However most of these approved advances are of limited benefit to prostate cancer patients and still have about the same amount of side effects. Compared to other technologies, computers, communications, electronics, aviation, etc., Cancer treatment approved advances have been dismal. QOL (quality of life) issues have not been adequately addressed. Profit often outweighs QOL.

    Some oncologists are using Radiotherapy (EBRT-external beam radiation therapy) for cancer treatment. New technology consists of: IMRT, SBRT, IGRT VMAT, TrueBeam, Cyberknife, etc. This newer, faster, more accurate and easer to setup radiation equipment is of much benefit for doctors, staff and a good selling point to patients. However as far as reducing long term side effects, only very small gains have been made with the newer radiotherapy equipment. A patient should be extremely skeptical if exaggerated claims are made about reduced long term side effects, especially fatigue and ED rates.

    Radiotherapy can result in a 5% to 30% temporary or permanent drop in testosterone levels. This drop is determined by the testicular radiation dose (treatment equipment and planning). A significant drop in testosterone can result in increased fatigue, depression and sexual dysfunction.

    Radiation can also occasionally result in secondary cancers and damage to “organs at risk” (organs close to the prostate). Radiation has high probability of sexual dysfunction. Sometimes radiation can also cause bowel and urinary problems. A 5 day SBRT radiation treatment is now commonly available with about the same results and side effects as a 9 week radiation treatment.

    It seems all of the best treatments for prostate cancer have not been approved and most are only available outside the USA. Treatment options outside the country or under development are HIFU, Laser, Hyperthermia, Boron Neutron capture therapy and orphan drugs, Just to name a few. Focal Laser Ablation is a good option with fewer side effects however it is not widely available in the USA and sometimes not practical.

    Any cancer patient (Man or woman) who are being offered chemotherapy should be particularly cautious. Most Chemotherapy is extremely toxic and sometimes deadly. Without genomic testing or proof of the effectiveness of the specific drug being used on the exact cancer type being treated, Chemotherapy is often more toxic to the patient then to the cancer. Chemotherapy is also extremely expensive, profitable for doctors and often misused or overused.

    Do you think the AMA, FDA or any other regulatory agency will stop the exploitation of elderly men with a high PSA or prostate cancer or approve new treatments at the risk of financially bankrupting thousands of treatment facilities and jeopardizing thousands more jobs? Do you think any regulatory agency will set guidelines for treatment and monitoring at the risk of upsetting the doctors who are over treating? Most elderly men are not willing to openly discus there sex life, incontinence or other personal problem making them a more vulnerable victim.

    Most of the time few good choices exist for treatment. A prostate cancer patient treatment choice often ends up being the least worst choice or the choice with the side effects a patient thinks he can tolerate. Patients are often misled about the expected side effects and results of the treatment being offered. The risk of chronic fatigue is almost never disclosed.

    Long term care consists of regular PSA testing for years. Long term care for side effects is often lacking or exploitive or ineffective. Often complaints of side effects are disregarded by nurses, doctors and sometimes referred out to other doctors. The patient is sometimes left to figure out what to do about his side effects with the resources available to him. Long term side effects often consist of fatigue, bowel or urinary problems, sexual dysfunction, depression and other symptoms. Patients with complaints of chronic fatigue are often told to exercise, get plenty of sleep, pace yours self and eat a healthy diet; this advice is of limited help for chronic fatigue. Often treatments for long term side effects are embarrassing, degrading, unavailable, nonexistent, costly, not effective, not offered or bothersome. Prostate cancer treatment often results in fatigue, depression, isolation and sometimes suicide. Billions of dollars are profited from ED. drug and other ED products, catheters, pads and diapers, drugs for depression or pain or insomnia or incontinence, additional treatments and surgeries for side effects. Also treatments for the multiple and bizarre side effects from hormone ADT therapy (chemical castration) is required.

    Depression in prostate cancer patients is common, about 27% at 5 years (per some studies) and for advanced prostate cancer patient’s depression is even higher. Prostate cancer patients are at an increased risk of Suicide.

    Almost all prostate cancer treatments usually result in erectile dysfunction. Loss of libido occurs at about 45%. Often claims of prompt effective treatment for ED if it occurs after treatment are often misleading. Statistics for ED percentages from treatment are quoted after treatment with Viagra, muse or other ED treatments, therefore the statistics are very misleading. ED rated at 5 years may be as high as 50% to 80% or higher for most treatments. ED rated at 15 years may be as high as 90% or higher for most treatments. For cryotherapy ED rates are about 100%. The cost for ED drugs like Levitra, Cialis, Viagra and Muse are kept very expensive by drug companies, about $9 to $45 per 1 pill. Most insurance companies will not pay for ED drugs or treatment. Less expensive generic drugs are usually unavailable. Viagra should have already become available in a generic form for about $1 to $2 a pill. This is further exploitation by the drug companies of men in general. Men are further exploited by counterfeit mail order ED drug sales. ED drugs are not always effective and may have side effects. ED treatments can also be embarrassing, not offered, not practical, painful, expensive/not covered by insurance.

    In conclusion: Prostate cancer patients are often elderly and exploited for profit. A blind biopsy is unsafe and newer test methods should be used. The treatments offered have horrible side effects. Some doctors are treating patients with low risk cancer or advanced age when monitoring is often a better option. Patience with low risk cancer or advanced age should often be offered “watchful waiting” or “active surveillance” instead of treatment. Aftercare for long term side effects is frequently ineffective, expensive, not offered or nonexistent. Prostate cancer patients are seldom told about chronic fatigue and the true risk of side effects are usually understated. Modern medicine often fails and victimizes prostate cancer patients.

    If a patient has intermediate or high risk prostate cancer and dose not have advanced age he may need treatment. He should look into other advanced treatments if available. Also he should try and avoid Hormone therapy if possible because of the multiple side effects. If advanced treatments are not available a 5 day SBRT radiation treatment may be considered (In my opinion, it could be the best of the bad choices). SBRT seems to be fast, least invasive and traumatic. ED and fatigue is still a long term risk. Radiation with Hormone therapy has a high risk of long term fatigue.

    Protect yourself: Do not let the sterile, friendly and professional environment of a doctor’s office denture you from protecting yourself from overtreatment or any unnecessary life changing tests and treatments. If you are concerned about misuse or privacy issues, refuse to fill out EPIC questioners and limit the information given to relevant information only. If you have a high PSA or prostate cancer, educate yourself. A patient should be extremely skeptical if exaggerated claims are made about minimal long term side effects from conventional treatments or blind biopsies. Bring someone educated or astute with you to your consultations and appointments. Avoid doctors that are mostly profit motivated. Do not submit to a blind biopsy if other options are available. Get a second or third opinion if you are being offered treatment with low risk cancer or have advanced age. Learn about all your treatment options, testing and side effects. Verify everything you are told. Under the HIPAA law you are entitle to a copy of all your medical records and bills. Be very cautious if you are ever refused a copy of your records; demand a copy of your records and a reason for any denial and seek other advice. Get a copy and keep a file of your test results, biopsy report-Gleason score, PSA, MRI report, treatment plan, bills, insurance payouts, etc.. Carefully monitor your PSA. Expect a temporary increase (for weeks or months) in PSA after some procedures. If treatment is necessary talk to your doctor in advance about side effect management, chronic fatigue, ED, Etc.. Contact a good prostate cancer support group like PAACT or a local support group without a conflict of interest.

    Disclaimer: I have no confect of interest. I have no affiliation with any support group or other organizations. I am not a doctor. I do not prevent, treat, diagnose, cure or advise on medical matters. The information above is for educational purposes only. If you need treatment or medical advice, consult a competent and trustworthy medical doctor.


  4. mike

    I had a psa of 25 so had a trus biopsy no cancer found . psa then 22. had mri nothing conclusive. they want me to have perineum biopsy now .
    if the psa is not a cancer indicator wonder why I’m so high

  5. Juan Lugo

    I am 62 years old, healthy. Still working 40 hours/week. No prostota symptoms. I was diagnose with adenocarcinoma grade group 3, gleason 7(4+3) one month ago. I was suggested to have a Davinci surgery soon. I will like to know how soon I have to do it and if there is something else that can be done before the surgery. Thanks for any inputs.

  6. Juan Lugo

    I am 62 years old, healthy. Still working 40 hours/week. No prostota symptoms. I was diagnose with adenocarcinoma grade group 3, gleason 7(4+3) one month ago. I was suggested to have a Davinci surgery soon. I will like to know how soon I have to do it and if there is something else that can be done before the surgery. Thanks for any inputs.

  7. benjamin newman,md

    What does pT3a mean?

  8. Ash

    Hi, my father’s 72-Indian male. was relatively healthy, but last couple years, has been active, but not very healthy. lost weight too since his bypass surgery 3 summers ago.

    underwent a TRUS-guided prostate biopsy last week.
    of the 14 samples – here’s the break-up:

    1) Left lower lateral (F) – Benign prostatic glands in stroma, with focal stromal lymphocytic infiltrate and focal presence of 3-4
    atypical small glands.
    2) & 3) Right mid & Right mid lateral (K) – Benign prostatic glands in stroma, with focal stromal lymphocytic infiltration.
    4) – 14) the others all read benign prostatic glands in stroma.

    His PSA in the last test in Oct ’16 was 10.4.
    it was a 9 in may ’16 and 6 in the summer of ’15.

    Grateful for any inputs on the above.
    thank u!!

  9. Cliff Hauswirth

    Hi I’m a healthy 61 yr old man.My forest Psa test three weeks ago was 2700 the next was 3700 and last week it was 4008.Just had a biopsy Friday with 14 samples.My Urologist has not idea what causes these high numbers Any input would be appreciated Thanks

  10. Cliff Hauswirth

    Hi I’m a 61 yr old healthy male.3 weeks ago my first Psa score was 2700 a week later 3700 and a week after it wa 4008.i had a biopsy with 14 samples last Friday.My urologist has no explanation of these high score.i would appreciate and input thanks

  11. Richard

    The images for the Gleason Score and Zones of the Prostate are not being displayed. Please fix it. Thanks.

  12. Richard

    Please fix this page. The images are not being displayed.

  13. Magda

    My husbands diagnosis was


    1. Tru-cut prostrate biopsies : No Pin or Carcinoma identified

    2. Transrectal prostate biopsied: Acinar Adenocarcinoma (Gleason 3+3=6) / Grade Group 1)
    NO pin or Perineuural indentified

    WE would like to know what this means exactly in layman terms..

  14. Jim Shelton

    66 yr old male with following score: 3=3 adenocarcinoma right base
    involving 5% of cores 1 and 2

    3=4 right mid gland core up to 0.7cm and 0.8 cm

    MD recommends surgery.
    Unsure of which type is best

    I am type II diabetic, 6’1 and 223 lbs. No other medical problems

    Thank you

  15. Carmen Basso

    In 2013, my husband’s(age 57 at the time) PSA levels were 4.2 and he underwent 12 random biopsies sampling all of which came back benign. In 2014 during fup his psa levels were higher 5.4, but right before the fup appt, he was diagnosed and was treated for Squamous Cell Carnicoma in the Head and Neck with unknown primary. He underwent radical dissection adn 26 lymph nodes were removed including the mass (6cm, they also excised a piece of the back of his tongue and his right tonsil. He underwent 32 sessions of radiation as well as chemo once a week. The PSA took a back seat. 2016 and he is doing good from H&N, however, during an annual visit his psa levels came back @ 10.9. He underwent an MRI Dyna Cad and today the doctor informed us that 2 lesions were found, the Pi rads are 4 and 3. They are scheduling guided biopsy. My question is: Is it possible that the unknown primary cancer was the prostate and it was too small to show up on MRI or PET scans back in 2014? Could it have metastasized through the lymph nodes? What should i be concerned with and discuss with his doctors after the biospy?

  16. Peter Serawicz

    In addition to the comment above, there are several new treatments as Rezum and Urolift. And even a new product called Spanner stent that substitutes the catheter

  17. Tom

    This article was written before newer treatments became available. Lower grade prostate cancers can now be treated with far less risk of side effects (incontinence or impotence) through Focal Laser Therapy and Cryo (freezing) therapy. Check out those options through web research, as they are opening up a whole new range of decisions.

  18. Kay Schubert

    My Husbands PSA was 10.5 and we just got his results back and awaiting our appointment to go over results in two weeks. I was concerned about waiting two weeks but the information above was extremely helpful in reading his biopsy report and realizing the two weeks is not a big deal. He only had one of 12 come back with a adenocarcinoma Gleason 3+3=6 5% core on the left med lateral. He had a colonoscopy scheduled way before this was done and the doctor saw multiple nodules on the left lobe saying he had an extremely large prostrate. It will be interesting to see what the doctor will decide is our next step.

    • Bob Grooms

      Kay, I hope everything is turning out well for your husband.

      My PSA was 10.5. My prostate is 89 CC. I have one core that is Gleason 3+3=6. 7% of the core.

      I would be very interested in his path of treatment since our results are so close.

      Thank you,
      Bob Grooms

  19. Vedran Vidic


    I am interested in second opinion about my father’s results (65 years old) regarding prostate biopsy. It was performed about a month ago in Croatia at Medical institute “Rebro,” Zagreb. Surgery is scheduled for the end of this month. What we could expect from values listed whether this is an aggressive type of prostate cancer, has spread already outside of prostate or not if possible to read. Values are as the following for 12 needle biopsies:
    1. Cylinder 1.2cm length, histology benign prostate
    2. Cylinder 1 cm length, histology benign prostate
    3. Fragmented cylinder total length 1.2 cm, histology adenocarcinoma Gleason 7 (3+4) involving 20% of core
    4. Cylinder 1.2cm length, histology benign prostate
    5. Cylinder 1 cm length, histology benign prostate
    6. Thin cylinder length 0.7 cm histology benign prostate
    7. Cylinder length 1.2 cm, histology adenocarcinoma Gleason 7 (3+4) involving 90% of core
    8. Cylinder length 1.8 cm, histology adenocarcinoma Gleason 7 (3+4) involving 80% of core
    9. Cylinder length 1.3 cm, histology discontinues focal adenocarcinoma Gleason 7 (3+4) involving 90% of core
    10. Cylinder length 1.2 cm, histology adenocarcinoma Gleason 7 (3+4) involving 25% of core
    11. Cylinder length 1.3 cm, histology adenocarcinoma Gleason 7 (3+4) involving 70% of core
    12. Fragmented cylinder total length 0.6 cm, histology fibromuscular stroma.

    Thank you very much,

    Vedran Vidic

  20. Suresh

    My father 65 years age has gone through prostate surgery 2 months back and Doctor recommended Biopsy report.. Biopsy report shows 3+3. Now the doctor is asking for removal of testicles to remove the cancer.. Can he go for surgery immediately or need to wait for a gap as he had surgery just 2 months back.
    Also he developed a leakage problem after the prostate surgery.

    thank you for your advice.

  21. Dina Wyrick

    My father has his prostate removed in 6/2013 the pathology report indicates the following.
    Gleason score:8
    Primary pattern grade 3
    Secondary pattern grade 5 (approx. 35%)
    Tertiary pattern 4 (approx. 5%)
    Percentage of prostate involved by tumor 30%
    seminal vesicle invasion present right
    Lymph-Vascular invasion present
    perineural invasion present multifocal
    Primary tumor pT3b

    His PCA score last year was .02
    This year PCA is 20

    What does this mean? How long is the life expectancy? What can we do?

  22. Michael

    I guess by now Sen, you have found out more results. There are a number of treatment options depending on what they find, age, etc. I opted for radical prostate surgery. From my understanding it is an excellent option given that it is conducive to other therapy if needed. I’m old school get the darned cells out of my body. Many talk about over-diagnosis and over-treatment. Mine was a Gleason 6 until the post-surgery pathology report. Then it was scored Gleason 7. That is something a biopsy may not show. Also, the extent of the cancer isn’t really known until it’s looked at under a microscope. I am really an advocate for rip ‘er out – even though that comes with lifestyle changes. Prostate cancer is a good reminder to all of us that life doesn’t go on forever. We don’t stay 20 throughout our lives. I’m thankful for the 53 years I have had up to this point. Blessings on all.

  23. Sen Incavo

    I had a biopsy on Jan. 18, 2016 because my PSA was 40.5. The result of the biopsy (12 cores) 11 were benign and the right apex show Gleason 6 and 10% of the core was cancer.

    My doctor is concerned with WHAT is causing the high PSA. So am I. He’s scheduled an MRI to look at lymph system and bones.

    I’m just curious as to what is the best course of action. I am 62 years old, diabetic and 233 lbs. on a 5’9″ frame.

  24. Bob s

    I have a psa of 13, on Dec. 2, 15, I had a 12 point biopsy. The right side was neg
    Left side shows some cancer. My Gleason score is 4 plus 4=8 I have 2 procedure ct body scan. Pelvic and then a full body scan. I am looking at advice to what would be the best procedure recommended I am 59 very active work 80hr week.
    A week

  25. Cande

    Yikes! This must have given a fright. Good luck on your rvreoecy!I was just reading how often breast and prostate cancer are misdiagnosed; during my mom’s cancer much was learned about this disease, not the least of which is there is indeed a conspiracy to hide all, but the poisonous cancer treatments.Cats Claw is good for the prostate and is quite amazing at fixing, within days, any pain that emanates from that region. A good Milk Thistle source, Vit C and a Glutithion (sp) enhancer like whey is a solid regimine too is important. Before any surgery major doses of C will greatly decrease inflamation/pain and decrease down time; a naturopathic doctor with an MD informed me of this when her husband needed major surgery. (They resisted and she threatened to SUE if they did not give HUGE C doses IV.); N.D. #2 who was the Green party candidate at one point, told me this also and that 1000mg/hr will cure cancer . Detoxing and taking good care of your liver to aid your body in this area is key to activating your immune system. See Gerson Therapy for extensive research on organic juicing and coffee enema effects; quite impressive what adding concentrated nutrients can do for some, but the coffee enemas are not optional to get the toxins GUSHING out of your body!Take care!

  26. marie mallery

    HI, My fiancee just had a biopsy done a week ago. He’s had 3 severe infection with his prostate. After almost 4 yrs with his first attack he finally had biopsy done. His doctor let his nurse assist him with the procedure. She used the 12 needle while the doctor watched the screen. Is this normal for the urologist to let his nurse do the procedure. My fiancee goes to the bathroom a lot he has blood in his urine at times. He has pains on the side where his testicle swells ip the size of a small orange. Well we went for his results . Listen well to what I’m about to say. He had no file in his handfrom the lab results. All he said was no cancer . It was inflamation. When he asjed the doctor what is causing this inflamation. He said he didn’t know. What is your take on these results. Should we get a second opinion

  27. John Jarvis

    Had biopsy mid April 2015 (71cores taken) which demonstrated very small volume of Gleason 3+3 in one core. PSA was 4.8 and MRI clear. Have been on active surveillance and just had result of first follow-up PSA today. Has gone up to 11. Should I be worried? My consultant says the increase may be due to the trauma caused to the prostate by the large number of template biopsies and proposes another PSA follow up in 3 months. Any advice or comment?

  28. Sam, given that there is cancer in both sides of your prostate. That would indeed indicate T2 disease. The positive margins are a bit worrisome, however your report states that there is no extra prostatic extension(cancer that has escaped the gland) and no involvement of the seminal vesicles is good. It said there was focal involvement at the margins, and focal means localized and not widespread, so while perhaps the fact the margins are positive is concerning, it would seem the degree to which they are involved is limited, and that is certainly a good thing. I have heard of cases of focally or minimally positive margins being considered insignificant becauSe there is thought in cases like these that once the prostate has been removed, those cells at the margins have lost their source of nutrients and ultimately die off without means of sustainment. If your report had said something like “significant margin involvement” and/or seminal vesicles involvement, I’d be far more concerned, as this would indicate a likely more aggressive cancer and one more likely to spread.

  29. Brandon

    Hi Harry, good news is Gleason 6 prostrate cancer is not an aggressive form of prostate cancer. While your report states you do have perineural invasion, the word “focus” implies a localized spot and does not seem to indicate extensive perineural invasion. The high grade PIN(prostatic intraepithelial neoplasia) is insignificant given that you have confirmed cancer in your prostate. PIN would be an important finding in a case where no obvious cancer cells were identified, as high grade PIN does raise suspicion of cancer being present somewhere, though it is not diagnostic of it. Hope this helps.

  30. Diane Ortez

    My husband Richard’s Urologist says his prostrate cancer is 10% in the prostate and 90% hiding somewhere in the body. All cat scans and lung biopsy are clear…he is 78 and was told no treatment..we asked for hormone shot that was said would weaken him and it hasn’t. What we are doing is building his immune system with a healthy diet..no sugar, white flour, etc. He has lost 20 pounds and is feeling great. Don’t understand the 10%/90% hiding in body. Are we doing the right thing?

  31. Harry

    At age 54 years old on my biopsy report they had the following:focus of perineural invasion, prostatic adenocarcinoma grade (3+3)score 6, high prostatic intraepithelin neoplasia indentified. Malignant neoplasm of the prostate. Does this mean I have aggressive prostate cancer.

  32. Ella

    What is the meaning of a core biopsies right prostate Gleason score 3+3=6 or3+4=7

  33. sam

    my report states:
    prostatic adenocarcinoma gleason score 6 involving both lobes.the apex in the right lobe is involved including focally the margin.other focally positive margins are in the left lobre.extensive perineural invasion is noted.
    no signs of extraprostatic extension are present.the base and seminal testicles are free of tumor.

    my question-from the above are you able to say whay stage t(tnm) is diagnosed?
    is it t2 ?thank you

  34. Don

    2013, my PSA was 3.3, within the “normal” 0-4 range, no nodule felt. 2015, a few weeks ago, I went to a urologist for unrelated discussion, and blood test showed PSA up to 4.5, now considered high. DRE performed, nodule felt. Biopsy recommended. Got a 2nd opinion, same results, went ahead with biopsy. 12 samples taken, 4 of which were on the nodules, and these 4 came back as cancerous. One had Gleason of 3+4, the other 4+3. Unfortunately, I also got a blood infection from biopsy, and bacteria found in blood was impervious to Cipro (primary anti-biotic for prostate biopsy). Still battling infection, hope to be done with that by next week, at which time I need to decide on treatment plan. Recommendation from my general doctor and urologist is to have prostate removed.

    Pathology report seemed like the “good kind” in terms of details, but has anyone ever ordered a 2nd read of the samples? I realize we always wish it was anything but cancer, and I’m sure that plays into this, but I still have to wonder how often these reports could be in error.

  35. gus kennedy

    I had my annual done at a urologist office. My PSA was a 4.5. I was told that I had a rating of 16 from a number 25. I was told I should have a biopsy done. my question is this: after a rectal and blood/urine sample I have a 4.5. I am 65 year’s old. Do I have a problem?

    • Frank

      Gus, I’m 54 ye old Caucasian in very good health. Had a PSA of 3.9. Just had the biopsy done with a diagnosis of cancer. Gleason score 6. I’m now deciding on robotic surgery. Don’t know your age, but I suggest you get a biopsy. It’s an easy procedure if you ask to be unconscious for it. Good luck buddy.

      • Tom

        Hi Frank,
        Not sure if you had your surgery yet but your diagnosis sounds like you would be an excellent candidate for active surveillance. I don’t know where you live but larger institutions like Memorial Sloan Kettering in NYC has a very large active surveillance program for Gleason 6 patients. Good luck.

  36. Richard LaBarca

    I’m 65 yrs old.I am in good health. I work out 4-5 times a week eat a healthy diet and keep my weight down. On 03/24/14 my total PSA was 3.3 —04/15/14 it was 2.4 —07/28/14 it was 2.5. At the same time the PSA’s were taken they also had 2, PCH-3 tests done. On 03/31/14 the score was 133 —on 08/07/14 it was 178. a biopsy was recommended. I just got the results this week. 12 samples were taken, eight of the 12 showed cancer. One sample showed 20% another showed 10% and 6 showed 5%. My Gleason score is 6. I have had a full body PET scan and a CT scan on 10/23 to determine if it is anywhere else and the results were negative. On this call he mentioned that my biopsy also detected PIN. My question is now that PIN was detected can I be a candidate for cyberknife, which I was seriously considering.

  37. John Davies

    A biopsy of my prostate was performed on June 18, 2014, followed by the pathology consultation report on June 23, 2014, which provided the following information:

    Needle biopsy of prostate x 8:

    1. Right mid medial: 4mm length of Gleason 3+4=7/10 adenocarcinoma
    2. Right mid lateral: 2mm length of Gleason 3+4=7/10 adenocarcinoma
    3.Right apex: 2mm length of Gleason 3+3=6/10 adenocarcinoma
    4.No evidence of extraprostatic extension
    5.Left base: microscopic focus of high grade PIN
    6.Remaining cores show benign prostatic tissue

    My radiation oncologist discussed the results of the biopsy with me in general terms,and recommended continuing with my active surveillance program for at least the next year to ascertain whether or not there has been any significant changes in my PSA and a DRE.

    I am 75 years old and in good health. I was diagnosed with prostatic cancer in 2005 based on an initial Gleason score of 3+3=6 in the right apex, at which time I was put on an active surveillance program. Bi-annual PSA tests and annual DRE’s have been performed, with biopsies every second year. This last biopsy was the first time I had a Gleason score of 3+4=7. I have never had any adverse effects in respect to my prostate gland over this 9-year period.

    Any feedback in respect to the foregoing would be much appreciated.

  38. gerald mcbride

    my overall gleason score is 3+5=8 comment: shows a moderate to poorly differentiated adenocarcinoma 10% of care #2, 25 % pf core #5 20 % of core #6 50 % of core #10 and 10 % of core #11 focal atypical glands are presented in core #3. what does this mean?

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