From the Prostate Cancer Forum:
I have a Gleason score of 3+3. PSA of 9
4 cores of twelve positive. Family history. Father hade prostate cancer and had seeds, lived till 90 with complications and Cather last few years. Surgeon tells me they never do surgery on 3+3, but probably need it in 1.5 yrs. Up here in Vermont options are removal or radiation. Based on history debating removal now than later. 64 yrs old, urologist and surgeon want me to wait. But waiting for what, to get worse? Appears contained to prostate but they don’t want to do anymore biopsy due to double infection. Anyone ever had removal at 3+3?
My response:
Here are some thoughts to consider. My own history was Gleason 4+3, CT and Bone scans negative, PSA 6>>8 in six months. I had nerve-sparing surgery.
Last year, the New England Journal published a 15 year follow up of a randomized trial of active surveillance (AS) vs surgery (RP) vs radiation, with over 500 men in each grouping (notably, very few Black men). https://www.nejm.org/doi/full/10.1056/NEJMoa2214122 While there was no statistical difference in death from prostate cancer among the groups after 15 years, the AS group had twice as many cases of metastatic cancer. And 50% of them went on to have treatment within 8 years, rising to 67% after 15.
The two key considerations to me would be complications and erectile dysfunction (ED) after surgery. Personally, I did not want to have radiation and (a) worry if all the cancer had been dealt with and (b) face the prospect of difficult surgery if the cancer “came back”.
Complications: Teachable moment – Defense Sect’y Lloyd Austin had an RP end of last year, then went back in with an unknown complication (rumour says it was a bowel obstruction) which put him in the ICU for a week or two. Also, people do die after surgery, probably less than 1/1000.
ED – 95+ % of us will get ED after RP for a minimum of 9-12 months, some never see spontaneous erections return. If spontaneous, penetrative sex with a partner is part of your life (average for those age 65 is 2 x per month), consider the loss of that for a significant period of time or forever. Note that orgasmic ability is not lost.
Those are the main reasons doctors will caution against jumping into treatment right away in a situation like yours – “First do no harm” is part of the Hippocratic oath. Don’t let the cure be worse than the disease.
On the other hand, I watched my father die from bone metastases from prostate cancer. That was very painful and difficult for him, and I want to avoid that at almost all costs. AS has a 50% higher rate of that over one’s lifetime (10% of the men in the study vs 5% for RP or radiation.)