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Does PC progress from Gleason 6 to Gleason 7 then 8, then 9

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Posted 10/5/2009 1:19 PM (GMT 0)
I am curious  to know if a low grade Gleason 6 cancer, if left untreated like in watchful waiting, will it eventually change and progress into a  Gleason 7 then into a 8 and then 9 and so on?  

Can a gleason 6 cancer metastasize and spread through your body as gleason 6, or does it have to change first to a 7, 8 or 9 before it will metastasize and spread?

 

Posted 10/5/2009 1:25 PM (GMT 0)

Good question. I always wondered about that too. Hopefully someone more knowledgable than I will answer. Just curious if you don't mind my asking. Why the question now?

Posted 10/5/2009 1:37 PM (GMT 0)
My cousin was just diagnosed with gleason 6 in three samples out of 12 with <5% cancer and he is wondering if watchfull waiting is the way to go vs surgey like I had.

Posted 10/5/2009 2:54 PM (GMT 0)
I believe the answer to the first question (does GS-6 eventually migrate to GS-7, GS-8, etc) is possibly. In many cases, a biopsy will show various Gleason stages in the prostate tissues.

I believe the answer to the second question (can GS-6 metstasize)? The answer is a resounding --Yes.

That does not mean someone with a GS -6 should not consider watchful waiting if it is presented as an alternative. One can still be aggressive in dealing with the Pca if at some points it starts "moving."

Posted 10/5/2009 3:17 PM (GMT 0)
I don't think anyone knows for certain. Catalona says that waiting can give tumors time to change from non aggressive to aggressive. That's why you want early detection before the tumor has time to become more aggressive and spread, although obviously that doesn't always happen. The problem is we don't know which stay dormant and which will not.
Posted 10/5/2009 3:54 PM (GMT 0)
First, all generalities are false.
Some tumors obviously progress. Men don't go from a 0 to an 8 in one leap.
So the answer is - Yes, tumors can get worse. I think everyone would agree.
The uncertain question is - Will my (your) tumor get worse?
Now we start talking odds and risk versus reward and loss aversion theory.
Posted 10/5/2009 3:57 PM (GMT 0)
Squirm,

The fact that no one knows whether a tumor will become more aggressive is why watchful waiting is a viable alternative for those in early stages. Watchful waiting can delay the treatments and in some cases, make treatment un-neccesary. If one gets psa tests every 6 months, psa rises can be caught early and treatments can be started without too much lost. Quality of life always needs to be considered in the equation. I will say this, though---if one is under 60, I would not readilly suggest watchful waiting or if one does watchful waiting, he should not waste any time if conditions show any signs of detereorating. 

Posted 10/5/2009 4:13 PM (GMT 0)
From what I have read it is a mixed bag.
3% of gleason 6 tumors are very agressive. They will have already progressed at diagnosis or will progress rapidily within 6 months. about 70% will never progress or progress so slowly that they will never hurt you. The remaining 22% will progress to G7 in a few years, I assume that these will eventually turn into G8 many years later. This corresponds to the fact that those on AS who get treatments years later have the exact same cure rate as those G6's treated immediately.
There are some experts, mostly urologists, that say that all cancers will eventually turn agressive. Almost all oncologists believe there are agressive cancers and non agressive cancers and the only way you can tell is watching how it acts over a period of time. Many more doctors are now believing in the later as more information is getting out. Since PC kills about 10% of those diagnosed it's pretty obvious that the majority of PC is non agressive. There is a reason to believe that younger patients may have more agressive PC, G8 and above, but I have never seen any studies to back this up.
JohnT
Posted 10/5/2009 4:17 PM (GMT 0)
Here is a couple of links related to this discussion. It appears that there is a possibility (30-40%) chance of gleason scores increasing during the first three years after initial biopsy for those that went Active Surveillance.

http://eclipsconsult.com/eclips/article/Urology/S0084-4071(08)79091-2

http://www.medicalnewstoday.com/articles/109513.php

Copy and paste into your browser.
Posted 10/5/2009 5:07 PM (GMT 0)
Hi Joe,
The issue I have with AS is that Gleason scores are upgraded around 25% of time following surgery path reports. So a 3+3 at biopsy could be a 3+4 or worse on the path report.

I don't know, but that is just my take on it. I agree that age plays a huge factor in it too.
Posted 10/5/2009 5:28 PM (GMT 0)
Now some other parameters, plodity tests that could be done, on your pathology which costs addtional money and you can get the info. There are 3 types of plodity-this is different than Gleason scoring stuff, (the dna structure of the PCa cells, the first type is diploid which is more similar to normal cells and it has two strands of dna alike is what my old-guy CRS memory is telling me right now, the second one is aneuploid which is more randomly structure and does not respond to hormone therapies probably as well as diploid, the third type is something like teteraploid(spelling?) or such and it is the worst plodity, random crazy insane cell structures that can get more crazy and may have no response to hormone therapies or very limited.

Yes you can have multiple Gleason scores going on with your gland at the same time, I have 3 different scores and on both sides of the gland, the same crazy 3 sets and finding almost identical. Also, realize many times Gleason grading upon review can end up higher than the original patho-doc found, and occassionally vice=versa.

If PCa cells have a way to travel i.e. perinureal invasion and such, it is conceivable that a Gleason 5 or 6 could travel beyond the gland and apparently such has happened to patients.

Now the other thing, why you need expert pathologists like Bostwick, Epstein, Oppenheimer, et al a few others too. Their are about 18 different variant types of PCa, not everyone has the same one, certain one(s) are more common. Their are a few of these that are very aggressive and prognosis is terrible on, i.e. small cell PCa and maybe 4+ others. An expert patho-doc is your best chance to know, which one you are dealing with, I have not heard of multiple types of PCa in a patient, but that may be possible too.

It is stranger than fiction with PCa, welcome to the 'twilght zone' and the jungle.  Not meant to scare anyone, but to inform of what is the reality of this PCa world. I do hope you and others do well and hopefully find cures or atleast longevity. This cancer seems cureable and tameable sometimes, probably good to keep your guard up, even if you looked cured 5 yrs. down the road, do not take it for granted is decent advice.

Myself-doing better than I thought I would 7.5 yrs. ago with high end stats.

Dx-2002  bpsa 46.7  12/12 biopsies all cancerous, 70-95% ranges in everyone, gleasons found 7,8,9's on both sides, total urinary blockage-emergency room,  protocol-adt-3 prior to radiations (2-types-neutron & photon) a rare gig, on/off hormone therapy, off all drugs 2 yrs., resumed DES,  psa  varies from  .35 to .90 range  (for about 2 yrs. now). Noted: no real side effects to deal with since dropping adt drugs back in  2004-5,  have myself back in decent shape, decent energy and feeling well, something that was lacking when loaded on adt3 drugs.

Post Edited (zufus) : 10/5/2009 11:47:28 AM (GMT-6)

Posted 10/5/2009 9:03 PM (GMT 0)
I would like to weigh in on this a moment. I disagree completely when its implied that it will take years to change the status of one's gleason, from a 6 to 7 to 8, whatever. I agree with squirm too, in that a biopsy reading of a gleason is at best an estimate. The one big plus in favor of surgery, is when the pathology is done on the entire gland, then a truer reading of one's cancers can be determined. It's seldom seen that it's downgraded, though it does happen. It's not so rare to see an up tick of the gleason by at least one number.

Back to the original subject, based on conversations with a uro, a uro/surgeon, 3 radiation oncologists, and my former medical oncologist, an agressive prostate tumor can change in months and possibly over the course of a few weeks in its intensity and agressiveness. You don't always get the luxury of years to wait and see what happens. Some people do luck out and it works out that way.

It comes down to the mixture of the cancer cell grade themselves. In a typical Gleason 7, you will either be 4+3 or 3+4, with the first number being the dominant cell. I was happy when mine changed from a 4+3 to a 3+4 after surgery, but you can see it didn't help me any, as I have re-accurance within 6 months of surgery despite that. I was told that it takes so little sometimes for a type 4 cancer cell to cross over and become a 5, and a 3 to become a 4. Once you have 4 or 5 cancer cells in the mix, all bets are off, and things can happen faster than you think.

Not saying this to scare anyone, but don't want people to get complacent thinking it always takes years for things to change. The modern thinking on most Gleason 7 cases is to treat it as a Gleason 8, because the "4" cells in the mix are very unpredictible at best.

Just something to think about, and factor into any treatment, or lack of treatment options.

David in SC
Posted 10/5/2009 9:17 PM (GMT 0)
I can only say from a personal experience, that my biopsy went from no cancer , only HPINS ( yes I know they coulod have missed the actual tumor, but out of 12 cores, their was none ) to a Gleason 9 2 years later.

This is a debatable topic among urologists, and will find conflicting opinions.
Posted 10/5/2009 10:23 PM (GMT 0)
Hi David,
Glad to see the secondary treatment is starting out okay for you.
I agree, on the issue of active surveillance, the issue I have is that it’s dependant on the biopsy, and the biopsy is just an estimation as you said. I would also think that if someone is doing AS because they’re uncomfortable about potential side effects of surgery and thus delaying it, perhaps they should lean towards radiation and forgo AS. Today’s radiation is much more advanced with the advent of IMRT and IGRT which results in fewer side effects. By acting earlier, at least you have the opportunity for a cure while the tumor is still localized.

Hopefully one day there will be a test or procedure that can distinguish dormant tumors and active tumors.
Posted 10/5/2009 10:53 PM (GMT 0)
Greetings, everyone.  I'm one of those guys that got upgraded from a 3 +3 to a 4+3 after surgery so I was glad I got it out of there.  From what I've read Watchful Waiting or whatever you want to call it is a viable alternative in some cases, but when you do go down that road, you need to be very watchful and be prepared to take action quickly.  For me, it just didn't seem worth it.  It does seem that some cancers can go from relatively controllable to very aggressive and it can happen fairly quickly.  David

Posted 10/5/2009 11:39 PM (GMT 0)
David/CPA - that's one of my ongoing points about A.S., aka watchful waiting. If you meet a very tight criteria for it, then it might be safe for some men, for a period of time. But IMO, watching any variant of a Gleason 7 is risky and dangerous. As one of my doctors said, at that point, what is you are waiting for? If it is to avoid side affects of surgery or radiation for awhile, that's a big gamble in my opinion. Plus, if AS is done correctly, it takes the right mind set to continue with correct observation, frequent PSA tests, and additional biopsies. And if, heaven forbid, during your watching period, your PC makes a major move to the the agressive side. I would never say its wrong to choose AS, but for me, it was never a viable option for me.

David in SC
Posted 10/6/2009 2:10 AM (GMT 0)
NY Sooner

Hello from a Texas Longhorn

1. IMHO WW is for someone 70 or older.

2. I tell anyone my recommendation is to do a lot of research, make a decision, and don't look back.

3. I am an advacate for PROTON because of the minimal side affects. The down side is that there are only 5 places and the cost is high.

4. My journey is on my website at www.gleasonscore10.com. If I can answer any questions I will do my best to answer.

Rich
aka Smilingoldcoot



2.
Posted 10/6/2009 2:11 AM (GMT 0)
NY Sooner

Hello from a Texas Longhorn

1. IMHO WW is for someone 70 or older.

2. I tell anyone my recommendation is to do a lot of research, make a decision, and don't look back.

3. I am an advacate for PROTON because of the minimal side affects. The down side is that there are only 5 places and the cost is high.

4. My journey is on my website at www.gleasonscore10.com. If I can answer any questions I will do my best to answer.

Rich
aka Smilingoldcoot



2.
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