Prostate cancer-specific mortality and Gleason grade

Several reports have clearly shown that biochemical recurrence (a rising PSA) after first-line treatment is more common among men with a Gleason score of 4 + 3 = 7 than it is in men with a Gleason score of 3 + 4 = 7. However, there has been no confirmation of an association between these Gleason scores and risk for prostate cancer-specific death.

Wright et al. have now published a retrospective analysis of data from 753 men aged between 40 and 64 years of age who were diagnosed with prostate cancer between 1993 and 1996 in King County, Washington. Prostate cancer recurrence and/or progression was determined by using a follow-up survey and medical record review. Mortality and cause of death were obtained from the Seattle-Puget Sound Surveillance, Epidemiology and End Results (SEER) registry.

The study showed that:

  • 65/753 patients (8.6 percent) actually died of prostate cancer during a median follow-up of 13.2 years.
  • The 10-year prostate cancer-specific survival rate categorized by Gleason score was as follows:
    • Gleason score 6 or less — 98.4 percent 
    • Gleason score 3 + 4 = 7 — 92.1 percent
    • Gleason score 4 + 3 = 7 — 76.5 percent
    • Gleason score 8-10 — 69.9 percent
  • Compared to patients with Gleason 3 + 4 disease, those with Gleason 4 + 3 tumors were at significantly increased risk for prostate cancer-specific mortality.
  • Compared to patients with Gleason 3 + 4 disease undergoing curative therapy with radical prostatectomy or radiation therapy, those with Gleason 4 + 3 tumors had an increased risk for recurrence and/or progression and prostate cancer-specific mortality.
  • There was no observable difference in prostate cancer specific-mortality between patients with Gleason 4 + 3 tumors and those with Gleason 8-10 tumors.

The authors conclude that (in men diagnosed with localized prostate cancer between 40 and 64 years of age) tumors with Gleason scores of 3 + 4 and 4 + 3 tend to have different impact on prostate cancer specific mortality, and that these data “provide important information for counseling patients with Gleason 7 prostate cancer on the natural history of the disease.”

While The “New” Prostate Cancer InfoLink would like to see these data confirmed through analysis of data from another population-based series of patients, we feel that this is an important analysis which does certainly confirm that Gleason 4 + 3 = 7 tumors behave more like Gleason 8-10 tumors, even with respect to the potential impact on prostate cancer-specific mortality. On the other hand, we would also emphasize that, based on the same set of data, the 10-year prostate cancer-specific survival rate of even the patients with Gleason scores of 8-10 was only fractionally under 70 percent.

It should also be noted that men diagnosed with clinically localized prostate cancer between 1993 and 1996 were probably at significantly greater risk for pathologically non-localized disease than men being diagnosed with clinically localized disease today. This suggests that men being diagnosed with Gleason 4 + 3 or Gleason 8-10 disease today may have a significantly greater probability of 10-year prostate cancer-specific survival than comparable men being diagnosed in the mid-1990s.

76 Responses

  1. Does anyone know, did they also report on how many of the men died during those first 10 years of “other causes”? That issue looms higher and higher on my radar screen as I experience the long-term side effects of having and being treated for this miserable disease.

  2. Dear Mr. Arnold:

    As far as I can tell, the complete paper does not contain definitive information about the number of patients who died of non-prostate cancer-specific causes at 10+ years of follow-up.

    One can infer from data provided in the paper that about 80 patients might have died of “other causes.” However, this is not explicitly stated anywhere in the paper.

    If you want to get a precise answer to this question, my suggestion would be that you e-mail the primary author, Dr. Jonathan Wright, and see if he is able to give you this information.

  3. As I understand this new study from Seattle, involving men aged between 40 to 64 years, it showed, in a median follow up of 13.2 years, a 10-year prostate cancer specific survival rate for men with a

    • Gleason score of 6 or less as 98.4% (1.6% disease specific mortality rate)
    • Gleason score of 3 + 4 as 92.1% (7.9% disease specific mortality rate)
    • Gleason score of 4 + 3 as 76.5% (23.5% disease specific mortality rate)
    • Gleason score of 8-10 as 69.9% (30.1% disease specific mortality rate)

    I wondered how these figures compared with the Albertsen study (JAMA 1998 Sep 16;280(11):975-80) which was intended to be a competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer.

    The men in that study were either not treated or treated with immediate or delayed hormonal therapy, and they had the following estimated chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis:

    • Gleason scores of 2 to 4 — 4 to 7% (96 – 93% disease specific survival rate)
    • Gleason score of 5 — 6 to 11% (94 – 89% disease specific survival rate)
    • Gleason score of 6 — 18 to 30% (82 – 70% disease specific survival rate)
    • Gleason score of 7 — 42 to 70% (58 – 30% disease specific survival rate)
    • Gleason score of 8 to 10 — 60 to 87% (40 – 23% disease specific survival rate)

    I know this is not a direct comparison, but feel it is not quite chalk and cheese. I felt that the following points might be relevant and account for some of the apparent anomalies:

    1. The new study makes no mention of tumors with Gleason scores of 5 or less. This seems to be because such ‘tumors’ are no longer classified as prostate cancer.

    2. There has been a significant “migration” of Gleason scores in the last 10 years or so, by a point or two. This would mean that, for example an Gleason 5 in the Albertsen study might be a Gleason 6 or even a Gleason 3 + 4 in the later study.

    3. The men in the Albertsen study were within an older range –- 10 years older –- and therefore were closer to the median age for prostate cancer deaths (which has stayed at about 83 years of age (i.e., half the men who die from PCa are older than 83 when they die)

    Given these, and no doubt, other considerations, there does not seem to be a great deal of difference between the outcomes in the two studies and what difference there is may well be due to the better medical care available now.

  4. My dad has prostate cancer. His PSA level is 121. Is this possible?

  5. Dear Roberto:

    Yes, it is perfectly possible for someone to be diagnosed with prostate cancer with a PSA of over 100 ng/ml. In fact, back in the early 1990s — before widespread PSA testing was available — this was very common.

    The problem with a diagnosis in which the PSA is this high is that that cancer is almost certainly no longer limited to the prostate — but hormone therapy can still be extremely effective at getting your Dad’s PSA level back down to very low levels so that biochemical progression of the disease is delayed.

  6. Mi padre tiene un PSA o Gleason de 7.9. ¿Es muy elevado?, despues de un resonancia le han mandado una prueba de huesos. ¿Eso significa que hay metastasis?


  7. Un valor de PSA de 7,9 no es muy alta. Es sólo un poco por encima de los niveles medios. Esto puede ocurrir por muchas razones. El cáncer de próstata es sólo una de estas razones.

    Sería muy raro que un hombre con un PSA de 7,9 para tener cáncer de próstata metastásico.

  8. Hi, my husband’s PSA was 1060 ! prior to beginning Lupron. After six weeks, it was 10. The prostate cancer is also in the groin lymph node. A CAT scan will be done in the pelvic area to see what’s going on. He had planned on having proton beam therapy at Loma Linda University Medical Center. Is it possible for the cancer cells in the lymph node not show up after 3 months of Lupron therapy? In order to have the treatment at LLUMC, the cancer cells must be confined to the prostate. Help. Our urologist has been remiss in giving us information.

  9. Dear Brenda:

    Something doesn’t “smell right” here. A man who has a PSA of 1,060 ng/ml at diagnosis should have been given a bone scan to look for signs of metastatic prostate cancer as soon as he was diagnosed. Did you husband get such a scan? If so, what waS the result?

    It is almost inevitable than a man who is initially diagnosed with a PSA of 1,060 ng/ml has disseminated proistate cancer (i.e., it is not confined to his prostate). Proton beam radiation seems most unlikley to be appropriate.

    On the other hand, the good news is that your husband seems to be responding extremely well to the hormone therapy. You might want to get a second opinion from a medical oncologist (as opposed to a urologist).

  10. My husband is 55 years old; PSA 850; biopsy Gleason score 10; 6 of 12 left side only cores positive 95%, 75%, and 50%; bone scan clear; CT scan everything clear; treated with Lupron and Casodex; PSA down to 0.2 in 3 months; added radiation; PSA now 0 after 8 months; still on Lupron; everything is too such extremes; can’t find any literature for a comparison.

  11. Dear Shannon:

    The form of prostate cancer you describe is much more like the way prostate tended to be diagnosed 20 years ago than the current situation.

    The good news is that despite the high PSA level and the high Gleason score, your husband still has no sign of metastasis and he has responded really well to the hormone therapy. So long as this continues to be the case, he could do very well. However, you do need to understand that he is at very high risk for progression at almost any time, and he needs to make sure he is getting his PSA monitored every 3 months — like clockwork. There is no known curative therapy for men like your husband at this time … but survival times for men like this still can be many years.

    The other piece of good news is that — by comparison with the situation 20 years ago — there are now many therapeutic options even when primary hormone therapy does stop having the effect it is currently providing … and there are even more such products in clinical development.

  12. The literature I have read on laser ablation treatment seems very promising. How long before it goes “mainstream”?

  13. This is a complete guess, but I would figure it is going to be at least another 10 years and maybe never.

    For laser-based radical prostatectomy to start to go “mainstream,” most urology residency programs would need to have the relevant equipment, an expert skilled enough to teach the technique, and enough data to demonstrate that it was at least as effective and easy to carry out as “standard” robot-assisted laparoscopic prostatectomy. Just to give you an example, it took about 20 years for laser-based transurethral resection of the prostate to become commonplace.

  14. My dad was diagnosed with prostate cancer in 2004 His PSA was 19.3, Gleason score 3 + 4 = 7. He was scheduled for a radical prostatectomy but declined at the last moment. Now, 7 years later, his PSA is 121. I’m so afraid and almost certain that the cancer has metastasized beyond the prostate. He is scheduled for a CT next week.

    Am I close to being correct and — if metastasis has occurred — what treatment will be best, if any?


  15. Dear Denia:

    First the bad news … Yes, there is a very high likelihood that a man with a PSA > 100 ng/ml has at least micrometastatic and potentially metastatic disease — especially after a diagnosis of localized prostate cancer 7 years ago. (In the former — micrometastatic — case, the cancer has spread outside the prostate but extraprostatic tumors are not yet visible on a CT scan or a bone scan. In the latter — metastatic — case, there will be clear evidence of metastatic tumors on a bone scan or a CT scan.)

    Now the good news … The vast majority of such patients respond very well to hormone therapy, and may do so for a considerable period of time — 15+ years is not unknown. There are some side effects to this type of therapy, but ideally the hormone therapy will drop his PSA level back down to near to zero, and he will be able to adapt to the side effects.

  16. Denia,

    My website incorporates the experiences of over 1,000 men diagnosed with prostate cancer. (You can click here to find the index to all the personal stories on the Yananow web site.) As the SiteMaster says, there is no doubt that your Dad’s situation is high risk, and on the Yananow site there are the stories of men who have passed on after having such diagnoses, BUT … there are also stories of hope, of men who had even worse diagnoses who have survived for years, and are still there to help with advice on how to manage this awful disease.

  17. Hi. My Dad (68 years old) has a PSA of 74 and got a biopsy with a Gleason score of 3 + 4 = 7. His pathology report says adenocarcinoma of the prostate and presence of perineural invasion with mild inflammation. Total linear amount of carcinoma is 99 mm. The proportion of total issue involved by tumor is 72%. What do you think and advise? What should be best therapy? What should be the survival rate? Any precautions? … THANKS!

  18. Dear B:

    The important question here is whether your father already has metastatic disease … which is very possible with a PSA of 74 ng/ml and so much cancer in his prostate on biopsy. Your father needs to get a bone scan to see if there is evidence of metastatic disease. However, it is also possible that he has so-called micrometastatic disease (in which the disease has already spread far outside his prostate, but only in very small foci that would not be evident on a bone scan).

    Until you can get some idea of whether your father’s cancer has metastasized or not, it is quite impossible to know what the most appropriate type opf treatment might be.

  19. Thanks for quick response. His bone test was clear. No sign of spread. How to find out micrometastatic disease?

  20. There is no easy way to know whether cancer has micrometastasized. You could ask about having a laparoscopic lymph node dissection prior to any actual treatment to see if there was cancer in the lymph nodes. You could also ask about having a bone marrow biopsy to see if cancer is already present in the bone marrow. However, what you really need to do first is have a serious discussion with the doctors about the risk that the cancer has already micrometastasized, and if so what sort of treatment they would recommend. It seems likely to me that you father may need some form of combination therapy (e.g., radiation + hormone therapy), but your father’s doctors may have additional insights that need to be considered.

  21. What is the best route to go with …

    Surgery > Radiation > Hormone therapy
    Hormone therapy > Radiation > Surgery

  22. Dear B.

    You really should join our social network, where you can get opinions from lots of different people what have already had treatment for prostate cancer.

    No one should get surgery after hormone therapy + radiation except as an absolute last resort. If surgery is appropriate, it is always best applied as a first line of treatment.

  23. Thanks for your response … Do you know if there is any article on this treatment option …

  24. Dear B.

    There are literally hundreds of articles on the management of men like your father. However, there is no consensus on “the right” way to treat men like him because there are too many unknown variables.

    Unless you father’s doctors are able to give you some clear understanding of the degree of risk that your father is at for micrometastatic prostate cancer, no one can tell you what “the right way” is for him to get treated.

    Some physicians would tell you that if you take his prostate out and then give him hormone therapy, you may be able to delay progression of his cancer for years … and that is true. Others will tell you to radiate his prostate and give him hormone therapy … which is also a valid option (but if that doesn’t work, I wouldn’t suggest surgery afterwards). A third group of physicians would tell you to just give him hormone therapy because neither surgery nor radiation is going to have any meaningful effect.

    I find it difficult to believe that your father wouldn’t have at least positive lymph nodes with a PSA of 74 ng/ml, but he could have extensive micrometastatic disease, into his bone marrow. If the latter is the case, then there is not a lot of point in either surgery or local radiation to the prostate, because the disease has effectively spread extensively through his body. We just can’t image it yet. First-line hormone therapy would probably be the most appropriate treatment in such a circumstance.

  25. Hey, Sitemaster.

    I’m 60 years old and I had my prostate removed in 2008. My Gleason score was 4 + 5 = 9 in 6 out of 12 biopsy cores. My PSA started going back up 2009 and in August I did Calypso-guided radiation therapy. By March of 2010 my PSA was up again and when I went to M D Anderson they found prostate cancer in my lymph nodes. I started hormone therapy injections every 4 months and also take a hormone pill every day. The PSA still on the rise. I go back to M D next week for a CT scan and a bone scan. For all veteran’s of the Vietnam War and Agent Orange, Get your prostate check!

  26. I just came across this site and would like an opinion. (I will speak to my surgeon/urologist.) My report on the pathology came back with BOTH 4 + 3 = 7 and 3 + 4 = 7 Gleason scores. There is a significant difference in the mortality rates. What is the significance of having two scores? I will be undergoing cryoablation in a few weeks. Thanks for any information you might be able to offer.

  27. Louis:

    (1) The only Gleason score that is important is the highest one … in your case, 4 + 3 = 7. Any lower Gleason core is irrelevamt.

    (2) Whole-gland prostate cryoablation is associated with a very high rate of post-treatment erectile dysfunction. Focal cryoablation is a different story if that is what you are referring to.

    (3) We strongly recommend you join our social network to get addition input on your clinical options before you commit to any specific form of treatment.

  28. Hi.

    My 49-year-old brother was just told he has prostate cancer with a Gleason score of 8 (4 + 4) He is going to have a bone scan soon. If I am reading the information correctly the he has a 69.9% chance of beating or living with it with treatment? We do not have his PSA numbers as they just did it today.

    After 29 years of employment he lost his job last year and his insurance in June. Now he has no insurance. What is he going to do?

    Rich’s sis

  29. Dear Tammy:

    (1) I very strongly suggest that you and/or your brother join our social network and post all the available information you have there. Someone will get back to you quickly to offer assistance.

    (2) It is impossible to be able to accurately assess your brother’s risk profile without knowing his PSA level, but it is high because of the presence of Gleason 8 disease. We can’t answer the 69% question without a PSA level.

    (3) Are you telling us that he was diagnosed without ever being given a PSA test? That would be unusual today, and would suggest that he may have had clear symptoms suggestive of prostate cancer as well as a positive digital rectal examination. Is it possible that his primary care doctor got an original PSA and that the urologist is now repeating it? You need to check on this please.

    (4) With respect to treatment, there are a variety of options, and some of those will depend on exactly where your brother lives.

  30. My 72-year-old husband was diagnosed with T1c prostate cancer after a biopsy. Only 25% of one sample out of 12 came up positive. His PSA is 5.3. However, we were told his Gleason score was 4 + 4 = 8.

    We are presently getting a second opinion of the biopsy as well as a bone scan and MRI of the pelvic/abdomen area. Radiation therapy has been recommended as opposed to surgery. We are going to see a radiation oncologist next week. What would his life expectancy be if he underwent radiation therapy?

  31. Dear Nancy:

    If your husband is otherwise reasonably healthy, his normal life expectancy as a man who has lived to 72 years is about another 12 years.

    Based on the information you have provided, high-dose external beam radiation therapy carried out by a skilled clinical team using modern technology (i.e., image-guided and intensity-modulated radiation), perhaps with a short course of neoadjuvant hormone therapy for 4 or 6 months, really ought to be curative, and so he ought to be able to live out his normal life expectancy or more. Of course one cannot make any form of guarantee for an individual patient.

  32. I am 71 and in excellent condition. I had a PSA of 7.0 in september. Biopsy showed seven cores with cancer. Highest core is Gleason 9 (4 + 5) with two others at 8 and one 7 and three 6. All high ones are on left side of prostate. Bone scan showed no spreading. MRI suggests that seminal vesicles “may” be involved. I am now on 6 months of Lupron preceded by a month of Casodex. MY PSA now is 0.07 so this treatment is working well. I am seriously considering HDR with IMRT but concerned about radiation side effects. I am really concerned about RP surgery and its even more scary side effects.

    How long can I go with only Lupron with regular 3 month PSA checks?

    IS HDR and IMRT my best chance of living a long time?



  33. Gene:

    Please join our social network, where we can address all of your questions in more detail. What I can tell you here is that surgery is not usually appropriate for men of your age; that some form of radiation therapy would likely be a good option in your case; that HDR + IMRT is certainly one appropriate type of radiation therapy; and that the side effects of radiation therapy today are far less serious than they used to be 10 and 15 years ago because the radiation can now be targeted with much greater accuracy.

  34. Hi … My Dad has prostate cancer. He had a pre-surgery PSA of 19, and a Gleason score of 7 (4 + 3). He had surgery last August to remove it but it didn’t work, as his first PSA reading afterwards was 0.2. This rose to 0.3 in February and he is now beginning IMRT

    My question is about his prognosis. … I know that everybody’s case is different, but I would like to know his chances of still being around in 10/15 years?

    I am especially worried that the radiation therapy may not work, and want to know how quickly the disease would progress.

  35. Dear Jane:

    I would encourage you to join our social network and provide this information about your Dad and his cancer when you sign in to that site. On that site we can get into detail about your Dad’s prognosis without it being visible to the whole world!

    Additional information that would be helpful includes the following:

    — His age
    — His post-surgical, pathological Gleason score
    — His post-surgical, pathological stage (e.g., pT2bN0M0 or pT3aN1M0 or similar)
    — Whether he has received any hormone therapy in association with his ongoing IMRT

    At the moment, the only slightly worrisome information you have provided is potentially explained by his original, relatively elevated PSA of 19 ng/ml on diagnosis. There is stell good reason to believe, on the basis of the available data, that second-line therapy has been given with curative intent.

  36. Dear Sir:

    My father is a heart patient. He had bypass surgery in December 2011. Now he is having a urological problem. His PSA is shown as 94.72% and his Gleason score is 3 + 4 = 7. The report shows no sign of perineural invasion; however, his tumour occupies 70% of the prostate tissue.

    Please guide me and allow me to get your opinion. My name is Vijay.

  37. Dear Vijay:

    We can help you best if you join our social network and provide us with as much detail as you can about your father and his condition. Also when you say is PSA is 97%, do you mean that it is nearly 100 ng/ml?

  38. Hello,
    My dad (age 74) was recently diagnosed with localized prostate cancer. His PSA is 1.52 ng/ml. Gleason score 4 + 3 = 7. I’ve read many different studies and researched a lot about survival statistics, but would like to hear another opinion. What do you think his prognosis would be? I would appreciate your insight. Thank you

  39. Dear CH:

    We would be happy to address questions like this about individual cases on our social network, which was set up for exactly this sorst of conversation and guidance. In addition to your Dad’s age, PSA level and Gleason score, we would also want to know his clinical stage (possible T1c), the total number of biopsy cores taken by his doctor, the number of those cores that were positive for cancer, and whether you Dad has any other signifciant health issues.

  40. Husband has PSA of 4. Last year PSA 2. Biopsy: 2/12 cores positive, both with Gleason 3 + 3. Negative bone scan and CT scan of pelvis. Age 57.

    Prior pulmonary emboli 5 years ago following febrile illness of unknown origin. Urologist suggests surgery. What do you think? Also had recent illness [for 2 months/] months … pneumonia … crazy lab results seemed to push for these tests of prostate after a negative chest CT scan.

  41. Judy … If you haven’t done this already, please join our social network, where we can give you more specific guidance and the opportunity to ask more questions.

  42. My Dad (63 years of age) was diagnosed with prostate cancer after his TURP surgery and when he had a Gleason score of 4 + 4 = 8 and a PSA level of 17.

    Our doctor suggest two options: (1) an injectable drug every 3 months plus casodex daily; (2) orchiectomy plus casodex daily. Which is more appropriate?

  43. Dear Maricris:

    We would need to know a lot more about your Dad and his situation to be able to help you. Depending on the details, either one of the two options you mention might be appropriate. However, if you were to join our social network we could ask you some more detailed questions about your Dad, stating with whether there is any evidence of metastatic disease on a bone scan or a CT scan.

  44. My dad has been diagnosed with prostate cancer. His PSA level is more than 100 ng/ml and his bone scan report indicates that he has skeletal bone mtastases. His biopsy shows a Gleason score of 4 + 4 = 8.

    Please tell us the method of treatment he should undergo. His doctor has suggested orchiectomy and radiation therapy on January 3. what shall we do now?

    Please reply me soon.

  45. Dear Vidhya:

    Some form of androgen deprivation therapy (either by orchiectomy or by use of drugs like LHRH agonists and/or antiandrogens) is the standard and appropriate form of treatment for a man diagnosed with metastatic prostate cancer like your father. If you join our social network, we can discuss your father’s treatment there in a great deal more detail if you wish.

  46. Dear Sir,

    I received my biopsy findings which showed that 4 of 12 core samples showed carcinoma. Three samples had Gleason scores of 3 + 3 = 6 and one core showed 3 + 4 = 7. The three cores with Gleason scores of 6 had less than 5% of each core biopsy positive for cancer. However, the core with a Gleason score of 7 involved cancer in 30% of the core. Should I have more testing done in order to determine if the cancer has spread?

  47. Dear Dan:

    You can use the Kattan pre-treatment nomogram on the Memorial Sloan-Ketting Cancer Center web site to project your clinical risk for cancer confined to or outside the prostate (or, if you wish to join our social network, we can help you to do this and offer you additional guidance).

    What I can tell you at this stage is that you have at least intermediate-risk prostate cancer (because of the Gleason score of 7 in one core). If, in addition, your PSA is > 20 ng/ml or you have a clinical stage of T2b/c disease or higher, then you would have high-risk disease. If you only have intermediate-risk prostate cancer, then the need for additional tests such as a bone scan and a CT scan is debatable and you should discuss this with your doctor.

  48. I received biopsy findings which showed that 4 of 12 core samples showed carcinoma. Three samples had Gleason scores of 3 + 3 = 6 and one core showed 3 + 4 = 7. The three cores with Gleason scores of 6 had less than 5% of each core biopsy positive for cancer. However, the core with a Gleason score of 7 involved cancer in 30% of the core.

    I have decided on brachytherepy treatment after consultation with Dr. Klein who is the Director of the Glickman Institute at the Cleveland Clinic. Can you advise and/or comment on my decision?

  49. Dear Dan:

    Based on the information you have provided, permanent implant brachytherapy carried out by an expert in this technique is certainly a reasonable form of treatment for you if you have a life expectancy of 10+ years (which we don’t know because you don’t give your age), if your PSA level is < 10 ng/ml, and your clinical stage is either T1c or T2a (which we also don't know).

    Dr. Klein is a well-regarded expert on the treatment of localized prostate cancer, and we certainly wouldn't dispute his recommendation. After all, he has had the opportunity to examine you and all of the available data. We haven't!

  50. Dear Sir/Madam,

    I am 78 years old and in otherwise good health. My last blood test showed a PSA level of 8.1 ng/ml . The clinical stage the cancer was determined to be T2b. Three of four of the 12 core samples which showed carcinoma were located on the left (lobe?) and one was on the right.

  51. Dear Dan:

    Given the additional information you have provided, one can use the Kattan pre-treatment nomogram to estimate the possible extent of your disease. This nomogram projects that you have a 59% probability of extracapsular extension, a 16% probability of seminal vesicle invasion, and a 5% probability of lymph node invasion. However, it also has to be said that this nomogram was never really designed or intended to estimate prognosis in men of your age, so quite how accurate it is may be open to question.

    None of the information above rules out the idea that brachytherapy would be a perfectly good option for the treatment of a man of your age with your clinical characteristics. However, you should be aware that surgery (i.e., a radical prostatectomy) is usually a very poor option for men of your age because of the high probability of failure to recover good continence post-surgery. You are being advised by a highly experienced clinician. I would suggest that you need to put more confidence in his judgment than in anything that we can tell you!

  52. I truly appreciate your comments and suggestions. I have a very active lifestyle which includes upper body exersise and cycling. My hope and concern is that I will be able to resume activities after my procedure.

    Once again, thanks.

  53. You’re welcome. Make sure you talk to Dr. Klein (or someone) about how soon they think you can resume the cycling after the procedure because you don’t want to take any risks about dislodging the seed implants until they have done what they are meant to do. You should be able to maintain the upper body exercise regimen throughout and perhaps substitute regular walks (gentle in the beginning) for the bicycling for a while. Be on the cautious side.

  54. My husband (age 60) was diagnosed in December of 2012 with Gleason score of 8, PSA 7.9 and mets to sacral region on bone scan and MRI. He had little to no pain on diagnosis and is now a 3-6 on pain scale of 0-10. We are unsure of what current bone scan and MRI showed in relation to first bone scan and MRI, but we were referred to a radiation oncologist. Radiation is set for 14 treatments to sacral region. I am wondering if you can give an approximate prognosis with this information? He had an initial Lupron shot in December and is having another PSA drawn on Saturday this week.

  55. Candy:

    I see that you have already joined our social network, so I have addressed most of the issues you mention here in my reply to you on that site (where they won’t be evident to the entire planet).


  56. My 87-year-old father has just been diagnosed with T2 Gleason 9 prostate cancer. His urologist has recommended Casodex hormone deprivation therapy.

    I need to understand the risk v. reward of such therapy; that is, does the reward of hormone deprivation to slow the cancer outweigh the risk of death or quality of life reduction from other causes (like myocardial infarction, stroke, diabetes, osteoporosis) caused by getting rid of his testosterone (or, more precisely, by the blocking of androgen receptors).

    Are you able to point me to trials or statistical CoD analyses?

  57. Dear Ian:

    If you join our social network we can discuss your father’s situation in detail. When you join the network, please also let us know your Dad’s PSA level and the general state of is health other than his prostate cancer. What I can tell you immediately is that the reason the urologist is recommending Casodex montherapy is may be to lower the risk of associated side effects of androgen deprivation therapy (ADT) that are associated with standard treatments like LHRH agonists. However, you — and we — will need some more information to help to understand the possible options here.

  58. Hello.

    I just received word that my dad was diagnosed with prostate cancer yesterday. I have never dealt with this cancer or know anything about it. I have heard that it is one of the better cancers (if there is such a thing).

    My dad is 52 years of age and I have been told that his PSA level at diagnosis was 3.7; either 5 or 6 of 12 biopsy cores came back positive for cancer; and his Gleason score is 3 + 4 = 7.

    Can I have some help understanding these data and what the future looks like for him? Is it very treatable at that stage? What are the survival rates? Best treatment?

    Any help would be very much appreciated, I feel very lost.

  59. Zoey:

    (1) It certainly sounds as though your Dad has a very manageable form of prostate cancer that can be treated with curative intent.

    (2) Please try to find out whether it was actually 5 or 6 cores that were positive for cancer. (It will tell your Dad this in the pathology report he should have been given on the results of his biopsy.)

    (3) Please also try to find out your Dad’s clinical stage at diagnosis (e.g., T1c, T2a, T2b, etc.).

    (3) If you come and join our social network (and perhaps get you Dad to join it too) we can discuss the implications of his diagnosis and how to think through his treatment options in significant detail … and he would be able to talk to other men who have had differing types of treatment. And we can do this in a relatively private forum where all the details aren’t “open” to the entire planet!

  60. Thanks very much for the quick reply.

    It is 5 cores out of 12 and we aren’t sure what the clinical stage, e.g., T1c, etc., means? How do we find this out, as his paper work mentions nothing simialar to those examples? We are very new to all this, have also mentioned this site and the social network to him.

    Thanks again

  61. Zoey:

    Re clinical stage, click here for an explanation … or just call the doctor’s office.

  62. Hi:

    My husband had a radical prostectomy in May 2013, as advised by his, after being diagnosed with a PSA of 22, a Gleason score of 8, and a negative bone scan. They also removed a third of his bladder sphincter, is this normal?

    His PSA doubled from 0.1 to 0.2 in 4 months. He was also diagnosed with a urinary tract infection, which his urologist said was more than likely the cause of his rise in his PSA. We’re treating the infection with another PSA due in 4 months time. For a 67-year-old man, would you think this treatment is aggressive enough, or is wait and see reasonable.

    Thank you so much for your opinion.

  63. Dear Maureen:

    If you would please join our social network, we can deal with your husband’s case in detail there. We are going to need some more information from you which should be available in his post-surgical pathology report, if you have a copy of that. We are also going to need to know whether his PSA ever dropped down to below 0.1 ng/ml after surgery.

  64. Hi,

    Found out I have PC. Has been 2 months. PSA is 16. All 12 cores were positive 70 to 95%. Most were 4 + 3 = 7. Waiting for my radiation oncology appointment. I am considering HDR brachtherapy with IMR. Is hormone therapy for life?


  65. Will:

    If you join our social network, it is set up exactly to help newly diagnosed men like you to deal with all the sorts of questions you are asking.

  66. My dad is 87 with a PSA of 22. He has been on Avodart for several years, which I know suppresses the number by 50%. He has had hip replacements and an aortic heart valve replacement (pig valve) 8 years ago. He had back surgery 5 years ago — but it didn’t take away much pain. He just retired from work 2 years ago. He does want quality of life. His urologist wants him to get a biopsy and go on hormone therapy. He had a biopsy 5 years ago and it was negative. But now his PSA is rising. He hates any hospital stays whatsoever. Should he just enjoy life?

  67. Dear Kris:

    So it would be normal, in dealing with a man of your father’s age, who is on dutasteride/Avodart, with a PSA of 22 that has been rising (perhaps slowly) for years to say, “Don’t do anything until there is a really good clinical reason to do so.”

    However, the three really key questions in your father’s case are these:

    (a) How fast is his PSA rising (what is known as his PSA doubling time)? If you know his last three PSA values and the dates that blood was drawn for those tests, you can use this online calculator to estimate his PSA doubling time.
    (b) What is his life expectancy? Is he more likely to live to 90 or to 100?
    (c) Is there any specific reason to believe that the back pain is associated with his prostate cancer or was the back pain he was treated for 5 years ago being caused by something else entirely?

    I certainly would not get a biopsy myself with your father’s clinical characteristics. However, I would seek answers to the three questions above and, depending on the answers, I might agree to certain types of imaging test to see if they showed anything significant.

  68. Thank you for responding. I really appreciate it. They say his life expentancy is closer to 90 than 100. His back is degenerative disc, scoliosis, stenosis, etc. — He also has a pacemaker. He would consider starting the hormone therapy; however, insurance will not cover it unless he gets a biopsy. I was not comfortable with a biopsy because of infection. My brother told him to not check his PSA anymore — but my dad is one who wants to know. So more to ponder. Thank you again.

  69. I was diagnosed in 2013 with prostate cancer from a digital exam. PSA of 3.1; biopsy showed T2a, Gleason 3 + 4 = 7, and 21 cc size.

    June 5, 2013 had daVinci prostatectomy, with removal of nerves and 17 lymph nodes. Since then I have had an undetectable PSA. Has my life expectancy returned to normal? How many zero PSAs are required to give peace of mind?

  70. Michael:

    You can use the Kattan post-surgical nomogram to estimate your risk of biochemical recurrence. I don’t have enough information about you to be able to do this for you, however. Given that you had at least one set of nerves removed and 17 lymph nodes tested, I have to assume you had at least extracapsular extension and perhaps also positive seminal vesicles at the time of surgery.

    The nomogram will tell you your risk for recurrence at 2, 5, 7, and 10 years post-surgery. (However, you are clearly at zero risk for recurrence within 2 years!)

    While the majority of men who see no rise in their PSA level at 10 years post-surgery are considered to be highly likely to have been cured of their prostate cancer, you do also need to understand that there is a small set of men who seem to have recurrences much later on — up to and including as much as 25 years post-surgery. To that extent, unfortunately, it is impossible to ever tell anyone treated for prostate cancer that their life expectancy is going to return to “normal” (i.e., its pre-diagnosis level). Even if your PSA level is still effectively undetectable at 10 years post-surgery (i.e., in 2023), you are still almost certain to be advised to get a PSA check at least once a year.

  71. Sorry about giving too little information.

    There was no evidence of cancer cells outside the prostate and no lymph node involvement. Post-surgically, they downgraded the Gleason score to 6. The removal of the all erectile nerves and lymph nodes was at my insistence that I wanted the best possibility of complete removal of all cancer. While the cancer had grown from the March biopsy to the June prostatectomy, it was completely contained within the prostate.

  72. Hi Michael.

    Well I am not sure how anyone could have told you with accuracy that “the cancer had grown from the March biopsy to the June prostatectomy.” They couldn’t possibly have known with accuracy how large the cancer really was until after carrying out your surgery! Things like biopsies and TRUS imaging do not give highly accurate information about tumor size at diagnosis.

    Based on the additional information, if I make the assumption that you are now 65 years of age, the nomogram tells us that your probabilities of remaining biochemical recurrence free are currently:

    — 98% at 5 years post-surgery
    — 97% at 7 years post-surgery
    — 95% at 10 years post-surgery

    and your probability of not dying of prostate cancer in the first 15 years post-surgery (i.e., by June 2028) is 99%.

    Is that “cured”? Well, on a strictly statistical basis, no, it isn’t. On a likelihood basis, well it’s about as close as anyone can get, and since your pathological Gleason score was 3 + 3 = 6 there may be very real questions about whether you needed to have treatment at all (but that was entirely your decision, and I am not criticizing, especially since I don’t know your age).

  73. 88-year-old with Gleason score 8. What are the options?

  74. Georgios:

    If you join The “New” Prostate Cancer Infolink’s social network, we help individual patients like you to think through they’re options on that site.

  75. My dad was diagnosed with prostate cancer, Gleason 9, grade 5 , Is there any chance that with that score, the cancer has not been spread. How %. Does the person with metastasized cancer have any symptoms.

    Thank you

  76. Dear Julie:

    First, a man with Gleason 9 prostate cancer can still have such a cancer confined to the prostate or to the prostate and other nearby tissues. It is NOT necessarily metastatic, but it is certainly a high-risk form of prostate cancer.

    Second, a man who has metastatic prostate cancer does NOT necessarily have any clear signs or symptoms of spread of the cancer. Tests such as a bone scan and a CT scan are commonly used to see if there is any evidence of metastasis.

    Third, if you join our social network, we can work with you to see if we can get some greater clarity about your father’s risk level and things that you (and he) will want to ask the doctors about.

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