Do I think of my psa as gleason 7 or 8?

I am a few months shy of 3 years post RP, with a slowly rising psa, now at 0.087. This is up from 0.01 a year ago. Deciding when to pull the trigger on ADT and IGRT is the current challenge. I have obtained several opinions that range from start now, to wait a bit longer and see if the psa levels out. I had great pathology, no known leakage outside the prostate, had gleason 4+3.

However, in following up with the pathologist, I asked what percentage was gleason 4 and the response was 85%. So in my mind this means I was very close to a gleason 4+4 or 8. None of the doctors I have spoken to believes that I should consider this to be a gleason 8, saying that the 85% is just a guess and hard to quantify, plus there is no research that gives any credibility to this sort of thinking.

Nevertheless, it is clear to me that if I had a true gleason 8, then I would likely start treatment now or would have started it already. Yet none of my doctors, (several urologists and 2 radiation oncologists) feels I must start urgently, and I can wait until I hit psa 0.1 or slightly higher (but less than 0.2). One more psa test will be done next week.

Does anyone have any thoughts on this?

My urologist looks at it as 3, 4 and 5. 3 is indolent and doesn't need treating. 4 can get bad and become a 5 so you go after it. 5 is all hands on deck and go for broke. He doesn't try to nuance a soft 7 from a hard 7. He treats based on the highest number.

Your urologist is right about the Gleason scoring. The first number is the most prevalent grade, the second number is anything above 5%. Because you had 85% Grade 4 and the rest Grade 3, your score is 4+3.

I assume your path report was clean - no positive margins and no T3. In that case, with PSA over 0.03, rising steadily and by more than 0.05 mg/ml/yr, researchers found that almost two-thirds of such men had a full biochemical recurrence with 7 years. Here's the study:

Low detectable PSA after prostatectomy – watch or treat?

You can opt to have your prostate tissue analyzed by the Decipher genomic classifier. It's expensive. It is very good at ruling out those cancers that are not likely to metastasize in the next 5 years, but it's not as good at predicting those who will.

- Allen

Weeeellll, maybe Bozo. It did say no "known leakage"..that's not a lead pipe cinch that there is not any. Sure , if there is no EPE the source of PSA is likely systemic..what else could it be? Anecdotes don't prove the point, though, and it does not attain the status of "intuitively obvioius to the most casual observer" either.
The big medical centers do benefit from a bit of momentum too..almost by defintion.

Teddy
You don't indicate your pathology but you imply no EPE, SVI, positive margins, no Lymph node involvement, nor PCa near bladder neck, and low volume. Yet PSA keeps creeping up. I'm not sure ADT is necessary for your situation. But getting imrt to prostate bed makes sense at this point. Just choose an excellent RO team. Consider calling Dattoli Cancer Center in Sarasota which treats only prostate cancer for a phone consult.
Bob

Terrific news. Enjoy your good health in the New Year!