What is the best treatment for rising PSA with Gleason 3+4?

Question

Hello doctor,

I am 72 years old, and my PSA has increased from 6.5 to 11 ng/mL over the past six months. A biopsy confirmed adenocarcinoma with a Gleason score of 3+4. My recent bone scan and pelvic MRI are clear.

I am currently considering my options between active surveillance and radiation therapy. Would genomic testing be helpful in better assessing my risk and guiding treatment decisions? At my age, is watchful waiting a reasonable approach, or does it carry significant risk?

Thank you for your guidance.

Answer 1

Hi,

Welcome to icliniq.com.

Thanks for giving me all the information. It definitely helps me understand what is going on with you. This is intermediate-risk prostate cancer because the PSA level went up from 6.5 to 11 ng/mL over six months, and a biopsy showed adenocarcinoma (Gleason 3+4). It is good that your Magnetic resonance imaging (MRI) and bone scan are clear because that means there is no sign of spread.

The most important choice today is how to balance the effectiveness of the treatment with the quality of life. Genomic testing can be very helpful in making this decision.

Reasonable cause:

The PSA increase is being caused by prostate cancer with moderately aggressive characteristics (Gleason 7).

Things to think about when looking into:

Genomic testing (such as Oncotype DX, Prolaris, and Decipher) to see how aggressive a tumor is.
Monitoring PSA trends if you are thinking about surveillance.
If you are thinking about radiation therapy, you should get a metabolic panel and a heart checkup.
If it has not been done recently, do a DRE and check the size of the prostate.

Differential diagnosis:

Benign prostatic hyperplasia (concurrent, but not the primary etiology).
Prostatitis (less probable due to biopsy-confirmed malignancy).
High-grade PIN (which has already been ruled out by biopsy).

Most likely diagnosis:

Localized prostate adenocarcinoma with an intermediate level of risk

Things to think about when treating:

If you are 72 years old and have other health problems or a decreased life expectancy, it may be okay to wait and see.
If you are generally healthy, active surveillance with regular PSA, MRI, and possibly repeat biopsies is a safer and more organized way to keep an eye on things.
Radiation therapy is still a possible cure, especially for diseases with a medium risk, and it can be used alongside short-term androgen deprivation.
Genomic testing can help you make a better decision. Low-risk results suggest that you should keep an eye on things, while high-risk results may suggest that you should get treatment right now.

Recommendations for follow-up:

Talk to your doctor about genomic testing before you make a final decision about your treatment plan.
Give information on comorbidities and life expectancy estimates to help decide what to do.
If PSA levels go up or symptoms change, check again.

Things to avoid:

Keep your weight in check.
Stay active physically.
Do not take too many supplements that could change PSA.

If you choose surveillance, make sure to stick to scheduled follow-up appointments.

This method lets you make a smart, individualized choice that takes into account both your quality of life and the long-term effects.

I hope this makes sense.

I am here to help you in this process, so feel free to get in touch if you have any more questions.

Thank you.