From the Guidelines
The prognosis for recurrent prostate cancer with a 4+3 Gleason score following a total prostatectomy is generally guarded, with a 6-year biochemical progression-free survival rate of 32%, and treatment typically involves salvage radiation therapy to the prostate bed, often combined with androgen deprivation therapy (ADT) for 6-24 months depending on risk features. The timing of recurrence after surgery, PSA doubling time, and location of recurrence (local vs metastatic) significantly impact prognosis, with earlier recurrence (within 3 years), rapid PSA doubling time (less than 6 months), and evidence of metastatic disease indicating a more aggressive course 1. The Gleason 4+3 score indicates moderately aggressive disease with pattern 4 being predominant. Key factors to consider in determining the prognosis and treatment plan include:
- PSA doubling time: a shorter PSA doubling time is associated with a poorer prognosis and a greater benefit from salvage radiation therapy 1
- Location of recurrence: local recurrence is more amenable to treatment with salvage radiation therapy, while metastatic disease may require androgen deprivation therapy (ADT) alone 1
- Timing of recurrence: earlier recurrence after surgery is associated with a poorer prognosis and a greater benefit from salvage radiation therapy 1
- Gleason score: a higher Gleason score, such as 4+3, indicates more aggressive disease and a poorer prognosis 1 With appropriate treatment, many patients with local recurrence can achieve long-term disease control, though cure rates decrease compared to initial treatment. Regular PSA monitoring every 3-6 months is essential to track treatment response and detect further progression. Common ADT medications include leuprolide (Lupron) 7.5mg monthly or 22.5mg every 3 months, or goserelin (Zoladex) 3.6mg monthly. The benefits of adjuvant and salvage radiotherapy must be weighed against the risks, and a risk-stratified approach should be used to determine the best course of treatment for each patient 1.
From the Research
Prognosis for Recurrent Prostate Cancer with a 4+3 Gleason Score
- The prognosis for recurrent prostate cancer with a 4+3 Gleason score following a total prostatectomy is generally poor, with a higher risk of biochemical recurrence and prostate cancer-specific mortality compared to a 3+4 Gleason score 2.
- Studies have shown that the proportion of Gleason pattern 4 in a prostatectomy specimen is a critical factor in predicting the rates of biochemical recurrence and prostate cancer-specific mortality, with increasing proportions of Gleason 4 associated with worse outcomes 3, 2.
- A study of 69,116 cases of prostate adenocarcinoma with Gleason score 7 found that patients with a 4+3 Gleason score had an increased mortality risk compared to those with a 3+4 Gleason score, with a hazard ratio of 1.235 for overall survival and 1.606 for cancer-specific survival 2.
- Nomograms have been developed to predict 5-year and 10-year overall survival and cancer-specific survival in patients with prostate cancer of Gleason score 7, which may be useful in guiding treatment decisions 2.
- Neoadjuvant hormone therapy followed by radical prostatectomy may be a viable treatment option for patients with locally advanced prostate cancer, with some studies showing favorable pathologic responses and a trend toward improved pathologic outcomes with the use of enzalutamide and leuprolide with or without abiraterone 4.
Treatment Options and Outcomes
- Radical prostatectomy is a common treatment option for patients with localized prostate cancer, but the risk of biochemical recurrence and prostate cancer-specific mortality is higher for patients with a 4+3 Gleason score compared to those with a 3+4 Gleason score 3, 2.
- Radiation therapy may be used as an adjuvant treatment following radical prostatectomy, but its effectiveness in preventing biochemical recurrence and prostate cancer-specific mortality is limited, especially in patients with a 4+3 Gleason score 5.
- Androgen deprivation therapy may be used as a neoadjuvant treatment before radical prostatectomy, with some studies showing favorable pathologic responses and a trend toward improved pathologic outcomes 4.
- The use of nomograms to predict overall survival and cancer-specific survival may be useful in guiding treatment decisions and identifying patients who may benefit from more aggressive treatment options 2.