42year old with Gleason 6 and a lot of questions

Sorry you need to be here, but welcome. I'm fairly new here too. Others with a wealth of experience and knowledge are sure to weigh in soon.

Most men your age don't have this diagnosis, probably because they don't begin having PSA checked until age 50 unless they're high risk. I'm not familiar with the Detroit study but it seems reasonable since men at age 50 have about a 50% chance of having some foci of small indolent cancers like yours. The likelihood of additional cancers just gets higher with each passing decade of life.

As to your questions, I've read too that prostate cancer cells usually keep their initial relative risk, e.g., GS 6's stay 6's, GS 7's stay 7's, etc., and GS 6's don't metastasize. Other papers will say that it's generally true but not always so. I doubt anyone really knows. I recently found a paper on Gleason 6 interesting. Sorry, for some reason my links don't work. Here's the search: Gleason Score 6 Adenocarcinoma: Should It Be Labeled As Cancer? You don't mention your prostate size or your free PSA. You can calculate your PSA density by dividing your PSA by prostate size. I mention this to say that Johns Hopkins has an AS program that is probably one of the most conservative in the country. You might want to check their website to see if you would qualify, if only to give you additional peace of mind that you're a very low risk.

You have many treatment options open to you and plenty of time to explore them all. Don't be in too much of a rush to decide. Many men opt to have surgery, but there are many good radiation treatments available today.

P.S. A 2nd opinion from JH's on your path would be worthwhile. Dr. Epstein is one of the best in the country.

I'm sorry about your diagnosis at such a young age. That must be all the more shocking. My advice: Read the sticky for the newly diagnosed, and have your biopsy slides sent to Bostwick or Epstein for a second opinion, and then commit yourself to taking your time before making any decisions:
www.healingwell.com/community/default.aspx?f=35&m=2652250

I also want to tell you that according to current NCCN guidelines and specialists, you are a great candidate for Active Surveillance. The fact that you apparently have access to an mpMRI improves your chances of detection and treatment before there can be any serious progression. MSK has an excellent Active Surveillance program.

I'll try to address your questions as best I can:

1. Am I reading the literature correctly that cells cannot move up in Gleason score and that the areas that have been identified will remain Gleason 3s?

That is not correct. The areas where there is GS6 now may remain that way forever, or a long time, or for a longish time. Higher grades possibly emerge from a common ancestor, or there may be clonal progression, or both. If it progresses, it typically progresses slowly. Even with an mpMRI, there's a (small) chance they missed some higher grade stuff.

2. Am I reading the literature correctly that Gleason 6 (3+3) cannot metastasize?

There seems to be little doubt about it. But that doesn't mean that it will necessarily remain entirely innocuous. It can sometimes eat into healthy tissue without metastasizing.

3. Does the Detroit study show that 29% of men in their 40s have Gleason 6 and I'm just one of three?

I don't know the study, but it is rare to be diagnosed at such a young age. That doesn't mean that guys in their 40s don't have it -- they may have it but it may go undiagnosed for many years. It is most often indolent at younger ages.

4. Can someone here recommend a non-surgeon urologist/oncologist (in NYC) that I could get a second opinion on? My feeling is that surgeons have a base setting and I'm wondering if there is someone else that is equally an expert in prostate cancer that might have a different view.

You are lucky to be in NYC where there are so many good ones to choose from. Here's my "favorites" list for NYC:

• for surgery: Ash Tewari, Mt. Sinai, NY (he's the only surgeon who intra-operatively monitors penile oxygenation and does torsionless nerve sparing)
• for SBRT: Alan Katz, Flushing NY - he's done the most of these (see link in my signature)
• for HDR brachy monotherapy: I think Josh Yamada at MSK does it.
• for LDR brachy monotherapy: Michael Zelefsky, MSK

5. Could I do Focal Ablation (or is there something better), then wait and see with some degree of confidence?

Yes. Dr. Jonathan Coleman at MSK has protocols for using something called irreversible electroporation (NanoKnife) and for using focal brachytherapy. I like these because they are non-thermal - less apt to affect surrounding tissue. As long as you have the attitude (which you seem to have) that this may only be slowing things down while providing good quality of life, I think this may be a good choice for you.

5. If RP is the way to go: open vs Robotic?

It doesn't matter. Pick the surgeon with lots of experience in whichever he prefers. With equally experienced surgeons, the outcomes are about the same.

Thanks Jack for confirming. I do believe that some unusual circumstances have brought me where I am and I could just as likely be here with no knowledge of a G6 in my prostate...

Allen, thanks for the detailed post. On the list of names you recommend, do you have a recommendation of an AS urologist (maybe at MSK)? I'd like to go over all this with someone who is an expert but that doesn't have a procedure that they are an expert in. Basically a specialist in referring patients to the best possible procedural specialist. Maybe such a person does not exist.