Where things stand
A quick recap. The May biopsy came back as Gleason 3+4 (a middle-grade prostate cancer — Grade Group 2 on the 1-to-5 scale — the kind that needs treatment but isn't an emergency). The report also flagged two patterns under the microscope with suitably menacing names — cribriform and intraductal — that can signal more aggressive behavior. Those two words drove everything that followed: because of them, both radiation oncologists said radiation would need to come with hormone therapy (months of medication that shuts down testosterone, with the side effects you'd imagine). The hormone part was my dealbreaker, so I was drifting toward surgery mostly by process of elimination.
You may have noticed I 404 Coded for almost two months — updates not found. Who wants to trade yoga on the pier for a recovery pee-filled summer without being certain the reason for it holds up? So instead of deciding, I spent the summer getting more expert eyes on the same slides.
What the re-reads found
Read two — Memorial Sloan Kettering. Their pathologist re-read one of my three positive cores in late June. Same 3+4 grade, but only 10% of the aggressive pattern (Northwell had called 20%), and no cribriform seen.
Read three — Dr. Jonathan Epstein. MSK's re-read covered only one core, and the concerning features had been called on the other two. For those, I wanted the most authoritative opinion that exists — so I sent all three positive cores to Dr. Jonathan Epstein, the pathologist who created the Grade Group system that labs around the world, including mine, use to grade prostate cancer. (Sending your slides to the man who invented the grading system itself is, the kids tell me, peak aura farming.) His report came back July 28: same 3+4 grade, but the aggressive pattern share dropped in all three cores (halved in one), no large cribriform, no intraductal carcinoma, and no perineural invasion (cancer tracking along nerves) either. And a detail that matters: he had Northwell's report in front of him while he read. He knew exactly which features had been reported in these slides, looked at the same tissue, and found neither. A disagreement made with full knowledge carries far more weight than something simply going unnoticed.
The machines agree. The tumor's genetic test (Decipher) came back intermediate-leaning-low — a 2% chance of spread at 10 years. The AI test (Artera) came back low risk. The PET scan found nothing outside the prostate. Four independent checks, none of them able to see the others' answers, all pointing the same direction.
And then, the confirmation. Last week I had a final follow-up consult with Dr. Lipsztein, the Northwell radiation oncologist who had originally recommended hormone therapy. He'd reviewed the new pathology and the AI result, and he withdrew the recommendation — in his assessment, hormones would now add complications without advantage. That closes the loop: both radiation oncologists now agree that no hormone therapy is needed.
What's on the table now
The dealbreaker just got deleted. It's now a real choice between two hormone-free options:
Surgery — robotic removal of the prostate. A few hours in the OR, overnight stay, a week with a catheter, several weeks of recovery. The main risks are urinary leakage and erectile function. The upside: the full gland goes to pathology so we'd know exactly what was in there, and afterward PSA should drop to zero, which makes monitoring simple.
Radiation — five outpatient sessions, about ten days start to finish, with a protective gel spacer placed beforehand to shield the rectum. No catheter, no OR, back to normal life essentially immediately. The main risk is long-term urinary irritation, and PSA never hits zero, so monitoring is less clean.
On the question everyone actually cares about: the neurovascular bundle that matters sits right against the prostate on the side where my tumor is, and both camps gave me the same honest answer — it takes a hit one way or the other. Surgery tries to spare it and might succeed; radiation can't avoid dosing it. Nobody gets to promise anything.
This week. The re-reads turned this from surgery-by-default into a real two-way choice, and I now have everything I need to make it. I'm picking a treatment path in the coming days — that gets its own post.
I'll share more when there's more to share.