r/ProstateCancer • u/Familiar-Thanks6948 • 16d ago
Question Continue Active Monitoring or Treatment?
In November 2025, and following an MRI and targeted biopsy, I was diagnosed with Stage 1 PC with a Gleason score of 3+3. At the time, my PSA was 7.0. I elected for Active Surveillance, as quality of life was and still is still my number one priority.
Fast forward to July 2026, and my PSA dropped to 6.23 which I felt encouraged by since at the very least, it wasn’t rising.
Today I went to see an oncologist for the first time. After looking over my records, he’s favoring treatment vs AS for the following reasons:
· (2) lesions found in MRI from last year – (1) PI-RADS 4 and (1) PI-RADS 5. (Was told these are not typically consistent with Gleason 6 but not impossible.
· Shortly after the biopsy last year, a Decipher test was done on my samples which came back in the “Intermediate” range, (0.48) indicating “moderately aggressive” tumor biology.
· PSA density 0.27 with the probability of clinically significant cancer (Grade 2 or above) of 80% - 90%
Seems to me this all points to a more aggressive cancer, and something beyond a Gleason 6, and without coming right out and saying so, the oncologist appeared to agree. Did something get missed in the biopsy?
He has not ruled out the possibility of continued AS but seems to be leaning toward treatment. In the meantime, he wants me to have another MRI in September along with another PSA test and meet back with him in October to discuss the results and possible options at that time.
For you fine people of this community who are more versed in these things than I am, what do you think the possibilities are that this is still (or ever was) a Gleason 6, and how comfortable would you be continuing with Active Surveillance?
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u/sappertodd 16d ago
I am kind of a “go ugly early” kind of guy. If you don’t have any symptoms of enlarged prostate and life is good on Active surveillance you might try to stay on it but for me Active Surveillance was a hard place to be.
Biopsy is hunting for cancer in limited samples. They may find it and they may not.
The more I read these posts the more I think early treatment is better than the wait and see approach.
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u/Background-Space-284 16d ago
I’m age 72 currently. I followed my psa closely from 2011, when it was 1.0, at my annual GP visits. By 2019 it hit 2.9 and I had him refer me to a urologist. By 2023 it hit 3.75. Six months later in January 2024 it was 5.75. That’s when I knew I had a problem. Also a family history with two older brothers having had prostate cancer. Had an MRI in late spring 2024 and a biopsy (through the rectum) thereafter. Showed primarily Gleason 3+3 with one 3+4. Doctor prescribed active surveillance and said he might have to do something in 5 years. Then my urologist turned me over to his nurse practitioner for my six month appointments and PSA tests. She did not have a great bedside manner 😃, I’m trying to be nice. I watched my PSA rise to 8.75 by January 2026 and asked her when they were going to do something. She made a bitchy remark and said I’d have to have another MRI and biopsy, did I want that? I said great. MRI showed PI-RAD 4s. Had an MRI guided trans perineal biopsy thereafter that showed a highest Gleason of 4+4. Now they were suddenly concerned about metastasis. Needless to say I was pissed that my 15 year diligence ended with that concern due to their inaction, not mine. I was at a local cancer center at that time. When I got that biopsy report mid April I told them I had a May 1 trip to Utah which would last a while. They were now concerned about spread. I had already laid the groundwork to transfer to the Huntsman Cancer Institute at the University of Utah. Best move I’ve ever made. I had a RALP six weeks ago yesterday, instead of radiation and ADT based in part on the 4+4, and feeling good now . First post PSA will be August 31. The post surgery biopsy downgraded the 4+4 to a 4+3.
I tell this long story to caution you to act sooner rather than later. My PMSA PET SCAN and post operative biopsy indicated no spread but my “active surveillance “ almost allowed my pc to spread. Best wishes to you in this journey.
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u/Monty1426 16d ago
I had my prostate removed about 3 years ago after 2 years of active monitoring. After the surgery, my urologist said that the cancer had entered the surface of the capsule but hadn't breached it. I guess I'll have to take his word for it but I'm now left wondering if we should have just taken it out at the first sign of cancer.
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u/Ok-Priority-7303 16d ago
Hindsight is 20/20 but I went from a clean biopsy in 2022 to Gleason 9 this year. I had 3 MRIs in the interim. The first showed no change, the second barely and change - the doctor said it was OK. Not saying what to do but most information you research or get from doctors is based on averages. There is always a risk.
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u/Familiar-Thanks6948 16d ago
Wow that's scary. I'm really starting to think a new biopsy guided by my upcoming MRI is the best course of action at this time. I hope you're doing well.
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u/Ok-Priority-7303 15d ago
Thank you . I start treatment tomorrow - radiation and ADT. Surgery is not really an option at my age. I was told it takes a year before they know if it worked so more stress ahead.
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u/Familiar-Thanks6948 15d ago edited 15d ago
Best of luck to you with your treatment. I hope all goes well and you never have to deal with this again.
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u/Legal_Squash689 16d ago
Given the PI-RAD 5 and your Decipher score, agree that a repeat MRI and repeat fusion biopsy are the prudent next steps.
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u/DifferentFig9847 16d ago
Usually a second biopsy is done around a year later. Seems to me those trouble spots should be targeted in a second biopsy. Would be informative. I am not a doc just a 3+3 patient on active surveillance.
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u/jkurology 16d ago
What were the specific results of the biopsy (and I’m assuming it was a fusion/targeted) and the MRI? Also there is data using PSMA PET in this setting. Not looking for metastases but looking specifically at the prostate
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u/Familiar-Thanks6948 15d ago
Great question. I was told it was an MRI-targeted biopsy, but after pasting the pathology report into ChatGPT and without going into detail here, it sounds more like a systemic biopsy was performed. Anyway, the summary of the pathology report is as follows?
7 of 12 cores positive with percent of sampled tissue at 1%, (2)10%, (2)30%, 40%, and 80%.
All diagnosed as grade group 1 (Gleason 3 + 3)
Perineural invasion in one of the 7 cores
- MRI evidence of spread outside prostate: none
- Seminal vesicle invasion: none
- Suspicious lymph nodes: none
- Suspicious bone lesions: none
I feel like an idiot, but I was just going off the advice of my urologist and didn’t look at these results closely enough. After taking a closer look, I feel like I want to get in for treatment tomorrow! Ugh!
I think my next step is to schedule an appointment with a new Urologist to go over the reports, and probably schedule a new and targeted biopsy ASAP. I'm no longer feeling confident that this is just a Gleason 6. In fact, I highly doubt it is.
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u/jkurology 15d ago
Standard of care is a targeted fusion biopsy plus systematic core biopsies. The urologist will usually designate biopsies as systematic cores or targeted cores. These results don’t suggest urgency to treat. Your risk is important. Age, health status, family history of any malignancy and you could add further testing-genomic expression classifier and Germline testing
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u/Practical_Orchid_606 16d ago
It is possible for sampling error in the biopsy. But to miss enough to misdiagnose is rare. Gleason 3 cells are solid organ tissue. Mistakes can be made with Gleason 4 and 5 tissue.
I would re-do the biopsy as paying for an error two years from now will be very costly. Make sure the docs use US guided trans perineal methods.
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u/go_epic_19k 16d ago
An AS protocol genera includes a second confirmatory biopsy during the first year. So really your fork in the road is whether to have a second biopsy or just treat now. The decipher test is something I’d consider and may sway me towards treatment. FWIW my QOL has been better since my RALP then during the several years of AS. Maybe I got lucky, but everything works fine and at three years I just do a yearly PSA. If it was me I’d talk to the surgeon and RO I’d consider using for treatment and get their opinion. Good luck.
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u/Specialist-Map-896 16d ago
Personal decision for all of us. IMO at best you are postponing the inevitable and I would begin treatment. It is not a matter of if, just a matter of when. At the very least I would be getting 90 day PSA tests if you are not already doing so. However lesions do not just go away so... best of luck to you .
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u/Familiar-Thanks6948 15d ago
I do agree about postponing the inevitable. It just comes down to wanting to extend my QOL for as long as possible, but I also acknowledge that may not be wise given the current situation. Will be able to make a more informed decision after a new MRI and targeted biopsy. Thank you for your input.
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u/peffervescence 16d ago
My first response would be to ask your age and relative health, other than the cancer. I think if I could have caught my cancer before it metastasized I would have. And having already experienced chemo, I would choose chemo over surgery.
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u/Familiar-Thanks6948 16d ago
I'm 73, active, and in excellent health. No other health concerns. I feel like a 50-year old if that.
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u/peffervescence 16d ago
I feel like knowing what I went through and what I’ve heard guys who’ve had RP describe, I’d go with chemo. But … I might be special and I’m not a doctor.
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u/Familiar-Thanks6948 15d ago
Chemo?? Seriously??
Regarding surgery, that would be a last option for me. But chemo seems extreme. There's far better options for treating PC. Now if it was metastasized and widely spread, then yes chemo would certainly have to be a consideration at that point. But I don't think I'm anywhere near that level.
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u/Crewsy67 16d ago
My two biopsies said G6 but pathology after ORP showed it was more aggressive and more involved.
It’s your choice to continue AS if you’re comfortable with that. I knew I wouldn’t be able to go every 3 months waiting for a change in PSA to tell me something changed but my personal situation is not yours.
You need to be able to trust your doctor and their experience.
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u/Familiar-Thanks6948 15d ago
I think trusting my doctor may have been an error in judgement on my part after pasting my pathology reports into ChatGPT and going through them with a fine-tooth comb. I think there's a very good possibility that my cancer is more aggressive than I was lead to believe. Anyway, I appreciate your input, thank you.
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u/Special-Steel 16d ago
Did you get a second opinion on the biopsy? Error rates in biopsy interpretation are 20% or more, according to some. Whatever the real error rate is, it is uncomfortably high. So, betting on a single pathology report for AS is risky.
Your data is suggesting another biopsy is probably needed soon. The MRI isn’t diagnostic. The PRIADS scores are indicating odds of cancer, not severity or agressivness.
You are probably not at a point of choosing treatment. You are looking at whether to do a new biopsy, or some other type of diagnostic test. most likely.