Treatment Recommendations for Gleason 3+3 Prostate Cancer with PSA of 15
Active surveillance is the recommended treatment for patients with Gleason 3+3 prostate cancer, even with a PSA of 15, as it avoids unnecessary treatment side effects while maintaining excellent cancer-specific survival rates. 1
Risk Stratification
- This patient has Gleason 3+3 (grade group 1) prostate cancer, which places him in the low-risk category based on the Gleason score alone 1
- However, the PSA of 15 ng/mL exceeds the typical low-risk threshold of 10 ng/mL, placing this patient in the intermediate-risk category despite the favorable Gleason score 1
- This represents a case of "favorable intermediate-risk" prostate cancer, where the only adverse factor is the elevated PSA 1
Treatment Options
Active Surveillance
- Active surveillance is the preferred approach for low-risk prostate cancer and selected favorable intermediate-risk cases 1
- Benefits include:
- Avoiding side effects of definitive therapy that may be unnecessary
- Maintaining quality of life and normal activities
- Avoiding overtreatment of indolent cancers 1
- The Canadian protocol for active surveillance includes:
- PSA testing and digital rectal examination every 3 months for 2 years, then every 6 months
- Prostate biopsies at 1 year and then every 3-4 years 1
Radical Prostatectomy
- Surgery is an option for patients with intermediate-risk disease and life expectancy >10 years 1
- Potential complications include erectile dysfunction (up to 80% of patients) and urinary incontinence (up to 49% of patients) 2
- Younger patients (<65 years) are more likely to experience cancer control benefits from prostatectomy than older men 1
Radiation Therapy
- External beam radiation therapy (minimum dose of 70 Gy) is an effective option 2, 3
- Brachytherapy alone can be considered for patients with favorable intermediate-risk disease 2, 3
- Short-term (4-6 months) androgen deprivation therapy may be added for intermediate-risk disease 1
Monitoring Protocol for Active Surveillance
- PSA testing every 3-6 months 1
- Digital rectal examination at least annually 1
- Confirmatory biopsy within 6-12 months of diagnosis 1
- Subsequent biopsies every 1-3 years 1
- Consider multiparametric MRI as a component of surveillance 1
Triggers for Intervention During Active Surveillance
- Gleason grade progression (finding Gleason pattern 4 or 5 on repeat biopsy) 1
- PSA doubling time less than 3 years 1
- Increase in number or extent of positive biopsy cores 1
- Clinical progression on examination 1
Important Considerations
- Despite the elevated PSA, the Gleason 3+3 histology is the most important prognostic factor, indicating a very low risk of disease progression 1, 4
- Studies show that men with Gleason 3+3 prostate cancer have extremely low rates of cancer-specific mortality, even with delayed intervention 4, 5
- The PSA elevation may be due to benign prostatic hyperplasia or prostatitis rather than cancer aggressiveness 6
- Patients must understand that PSA may rise and tumor may grow with time, necessitating regular monitoring and potential future intervention 1
Common Pitfalls to Avoid
- Overtreatment based solely on PSA elevation without considering the favorable Gleason score 1, 6
- Underutilization of active surveillance due to anxiety about the elevated PSA 1
- Failure to perform confirmatory biopsy, which is essential to ensure accurate risk classification 1
- Inconsistent follow-up during active surveillance, which could miss disease progression 1