If the term "cancer" weren't part of the diagnosis, would more people consider AS?

When the term "Gleason 5" was used, it must have been considered a diagnosis of cancer since G-3 cells, cancerous, were detected...

To me, it makes more sense just to use the single Gleason scoring numbers:, 3, 4, 5.. On a biopsy, if ANY G-4 cells are found, then that's what you are treated for..Same with G-5.. So what if the majority of the cancer is made up of G-3 cells. You aim treatment at the most aggressive cells found...

You often see 3+4=7 is better than 4+3=7 Oh really?? Both have aggressive G-4 tumor tissue and that's what must be treated.. Statistically, one may have a slightly better survival chance, but treatment is likely to be the same...JMHO

Purgatory said...
Since men's PC diagnosis are determined by a biopsy, a Gleason 6 has more than often, been upgraded to a Gleason 7 after surgery, with a full specimen to examine. While I agree with the sentiment of most low grade Gleason 6's being probably indolent, a biopsy, on a good day, is just an estimate.

People talk about overtreament, are usually talking about other, unknown people, and not about themselves.

David, well said. When I first joined this site there was a chorus of people suggesting that my husband was crazy to do anything but AS due to his single core 3+3 biopsy. His surgery showed that the primary tumour was anterior (as 25% of tumours are) and this position makes it hard to biopsy properly from the rectal position. It was a 3+4 tumour and we know that Paul made the right decision.

The issue is not whether AS is a good idea or not. If the screening methods we had did a much better job of what Gleason score a tumour actually was then it would be a no brainer to do AS. The problem is the screening method.

We tried MRI with Spectroscopy, prior to surgery to see if it would tell us any more as it was one of the methods that is considered to be an alternative colour doppler. The MRI-S proved to be completely incorrect in every detail when compared to the post prostetectomy report.

And the anecdotal: I started a thread called the August surgery thread late last year. Quite a few people with surgeries in August joined up. Three of the 4 people with Gleason 3+3 cancer had an upgrade to Gleason 3+4. A couple of months later another member with identical stats to my husband who was following our story also decided to have surgery against the advise of many here. He had extensive 3+4 cancer with his doctor saying that it was good he went in for definitive treatment.

David, I agree with you that it is a good choice for other unknown people because it relies on faith in biopsies hitting the worst Gleason score in the prostate, faith that you don't have an anterior tumour, faith in the imperfect MRI-S or colour doppler and most of all the discipline and the nerves to religiously follow a rigorous biopsying and PSA testing schedule (for 20 years if you are 50 years old). There are some people who have all of this and I salute them.

Regards,
An

An, thanks, you proved my point to a "t".

This post addresses the recently added questions about Gleason upstaging...

Dr Peter Scardino recently gave a presentation titled "Does Every Prostate Cancer Need Active Intervention?"  Scardino is the Head of the Prostate Cancer Program at Memorial Sloan Kettering and Chairman of the Department of Surgery...he is a well-respected prostate cancer surgeon.

Dr Scardino addressed the question of upstaging in his presentation.  He provided statistics of re-biopsy results of "low risk" PC patients.  Gleason score in about half (47%) were unchanged, about a quarter (27%) went up, and about a quarter (26%) went down...repeating, these were the results of a set of men limited to initially "low risk" criteria, not total population.

The point Scardino went on to make is that (and I'll just use his words), "The risk of understaging/grading can be reduced or eliminated with repeat biopsies..."   This is, perhaps obviously, one of the main reasons for doing repeat biopsies in patients who present with "low risk" cases at about 12-months after initial diagnosis (1st biopsy), and periodically thereafter...to reduce or eliminate risk of understaging.

 ----------------------------------------

Another point I wished to address in this post was the question earlier in the thread about younger men (men in their 40s or 50s) on AS and how they might fare over time.  The studied outcomes show that as the decades go by, there is an increased probability that a deferred treatment will be indicated based of the defined triggers for safe intervention. 

When a patient stays on AS, OR successfully defers treatment, this is a success!    It is a win-win.  One only needs to examine the improvements in surgical success in the last decade to realize that a treatment deferred another decade would lead to an even more likely successful outcome!  Bladder neck reconstruction improvements have improved continence outcomes, and the "veil of Aphrodite" enhanced nerve sparing technique has improved erectile function...both breakthroughs in the last decade.

 ----------------------------------------

I'd like to be very clear...the discussion by me in this thread and others is absolutely NOT about making anyone here feel bad or guilty about their own journey paths which have already been taken.  It is, however, about helping this community give good guidance to newcomers in the future.  While I have never "recommended" AS to anyone (nor have I "recommended" any other treatment...I don't "do" recommendations), I will continue to encourage new patients to closely examine all options including AS, and will help expose them to the benefits of AS because they tend to be underexposed in by the typical doctor/small businessman who too frequently tries to rush treatment.  To me, there is nobody better suited than a community like this (HW) to provide that kind of input and experienced guidance to newcomers...in the spirit of healing well.

questionaboutit said...
Ziggy: Because being honest and using the c word triggers irrational fearful reactions in too many.


Thanks, tht statement provides a perfect example of a person that believes the rest of the population is too "irrational" to think clearly and make their own decisions.
Thank God we have a few people like you that can keep your wits and protect the rest of us dummies from our irrational thoughts, rather we like it or not. Is there a fee for this service?

I am going to take off my tin hat and come up with my own conspiracy theory. I think doctors that recommend AS crunched some numbers and realized that they can make a helluva lot more money by recommending that CANCER patients come in every three months for a DRE (cost: one latex glove, some KY and a tissue if you are lucky for clean up) and a PSA, add on a few hundred bucks for consultation, repeat 4 or 5 times a year and they are already making more than by doing surgery. Carry it out for several years and 30% of the time you still get to do surgery, with a little luck you may be able to order some radiation also. True, the patient's cancer is a little larger but so is your bank account. Doctors get to double dip and make all sorts of money. Sounds like a great racket to me. I just need to go on the internet and cut and paste some statistics to support my theory because we all know that a number followed by a % sign has to be unquestionably true.

Do any of you really think that there is anyone out there that is not going to realize that it is still cancer, especially with "lesion" in the title? Even if they are confused by the big brother double talk in the doctor's office, as soon as they hit google, they will know that their absurdly titled disease was called CANCER last year. Give people some credit for having a brain. Maybe the Gleason 6 guys should have to turn in all their computers and be banned from the internet forever lest they read some scary stuff and get all 'irrational."

Oh, what are you going to call those cases when that Indolent cancer gets off its lazy ass and jumps the fence and leaves the reservation? Does the BS stop then and sanity return and it gets called cancer again? Maybe we should call those varieties a "InDolent Lesion of Epithelial Origin but with a Really Bad Ass Attitude." Will the obitiuaries say "after a long struggle with InDolent Lesions of Epithelial Origin." What utter nonsense. I hope none of these morons are getting tax funded grants to come up with this crap.

Sorry I've seen too many arrive here in a panic once they are dx. The word cancer is scary and thus many men never get past that point and react just out of fear. I understand we have all been conditioned for years to check for cancers early and remove it. Most think that means every cancer but medical science moves on, and we have learned that's not true for all.

Your paranoid conspiracy is ridiculous, has been brought up before and disproven many times. It brings in much more money getting men to have men rush into radical surgery than undergo AS. It's not even close and you are also accusing some of the best doctors in the field as to having a national conspiracy, get real.

" what are you going to call those cases when that Indolent cancer gets off its lazy ass and jumps the fence and leaves the reservation? "
I call them very rare and not justified as to have thousands of other men submit to radical life changing treatments whose cancer will remain indolent.

Your total argument is based on emotion and fear. Let me ask you if this were two years ago before your dx and surgery would you be saying the same here? Many of these heated views to AS are those who need to justify their surgery, believe me I understand and am sympathetic. Also why at times I strongly recommend those new here with low risk Pca to take their time educating themselves on all options and side effects and to not rush into treatment. The AS argument may no longer be valid for you but it's for those who will be diagnosed in the future. Besides with your psa numbers radical treatment may have well been your best option. But as I keep pointing out this disease and its options are not a one size fits all. Treatment choices need to be based on medical facts and yes percentages for what else do we have to go by?

Post Edited (Ziggy9) : 4/12/2011 10:14:42 AM GMT

clocknut said...

...medicine doesn't always move forward in a straight line. 

 

This is true, clocknut, but in the context of AS it is quite a "stretch" to think that the lobotomy example would be a plausible reason for qualified individuals to give even a micro-moment's pause.  AS is also known as "conservative management."

In a perfect world, with educated patients, with cooperating doctors, and non-greedy hospitals, AS could almost be setup for a required step or staging, by not allowing immediated treatment for indolent-class Gleason 6 cases, at the least, allow a full year to go by, and a second biopsy to see if the cancer has changed, before allowing permission to treat. Again, the key word is the perfect world, which we don't have. As long as men get dx with the limited tools we have at our disposal, and as long as they have insurance and demand of their own free will for immediate treatment, its never going to change.

I only wished to God that I had had the choice of AS at the time. I didn't. I couldnt even have seeds.

David in SC

clocknut said...
Ziggy, in an earlier post in this thread, you said this to Questionsabout it: "This massive over treatment of low risk PCa since PSA(even the inventor of it wished he never had as much as it has been abused) testing came about has to end some day. It wouldn't be the first disease's treatments where years later are looked back on in horror and not only the amount of money wasted but the cost in mens quality of life along with their family members. If the way many here think was true years ago we would still see people undergoing lobotomies."

There was a period of time, before the introduction of antipsychotic medications that proved effective for treatment of mental illness, that lobotomies were considered sound medical practice. What your illustration actually proves is that medicine doesn't always move forward in a straight line. Occasionally, it embarks on something new that looks like a good idea, but which turns out to do more harm than good.

Right now, AS is being promoted as the next big thing. As your lobotomy example illustrates, the next big thing sometimes turns out to be a wrong turn. I hope for the sake of the men who are choosing AS, especially the young ones, that we don't find out some years down the line that it was cost effective and delayed certain side effects, but inadvertently led to many men having to deal with advanced diseases which could have been effectively treated when first found. It's not impossible that AS might also turn out to be something "looked back on in horror." I hope not.

I don't know if you can call AS the next big thing. It's just close monitoring after all, not a revolutionary concept by any means. In fact AS has been around a long time with elderly men. Basically now it's a reaction to the huge increase of radical treatments since the advent of Psa testing. After the dawn of Psa testing, the expected results were to be a huge drop in Pca deaths. It has not happened, only a small increase due to the now huge numbers of men tested who before only had the occasional DRE.

I for one have never recommended AS to younger men. I have really mixed opinions on that age group and what they should do with low risk PCa, and remain undecided. When asked I put the cutoff at around 55 when I would seriously consider AS after a low risk dx.

Post Edited (Ziggy9) : 4/12/2011 12:42:11 PM (GMT-6)

ziggy, it scares me how much i agree with your posts lately, another good one from you.

bachez, i am glad that AS is working for you, wish more men that qualify would consider it, and as you said, if you are proven to need treatment, you can still do it

clock, i completely agree with your last part, of the acronym, renaming cancer to something else, is fooling whom?

and AS isn't rocket science, use to be called Watchful Waiting.

Aww shucks thanks guys. I know that opinion isn't held by all. Purgatory that is scary maybe it's the meds?

The International Society of Urological Pathologists (ISUP) agreed that biopsy samples graded with GS 3 + 2 were to be upgraded to GS 6(3 + 3). That did not eliminate GS 5 because TURP chips of tissue still can be graded GS 5. GS 5 is still cancer.

In a previous post I asked for references about a statement by John T: “Study after study has shown that 70% of low risk PC never shows any sign of progression and progression is usually identified within the 1st 3 years. Not all tumors grow. Some remain small and stable indefinitely.”

He provided references for 5 active surveillance studies that included a total of 1108 men with median follow up of 3.3 years on AS and who had to be treated (27% of them) because of progression at biopsy with a higher GS.

Prostate cancer is a slow growing malignancy, but that is not to say it is indolent even when diagnosed with low grade disease. Let me say that I support active surveillance as a preferred therapy for men that qualify under the various protocol qualifications. That said, the references provided by John T do not contain enough long-term evidence to demonstrate that those tumors will not progress in time and be stable indefinitely.

As other male comorbidities that kill many men are better controlled (coronary disease, diabetes, lung cancer) men will have increased life spans and with that prostate cancer will be an opportunistic cancer that if undetected by the common absence of symptoms will be diagnosed at a more advanced stage. There is plenty of evidence that untreated prostate cancer has a higher mortality than recognized these days. More so if diagnosed at a young age. The implication is that although slow in proliferation and growth, given enough untreated time this cancer can be lethal.

Over diagnosis and over treatment might cause unnecessary harm, but it doesn’t kill patients. Under diagnosis and late or no treatment can kill. This is in my view the present situation in many countries in which PSA testing is in low use. In the US, although in wider use, too many men continue to be diagnosed with disease that can be considered more difficult to treat with currently available treatments with intent to cure.

The current dilemma with active surveillance here in the US is that there is not enough support from the urology community. They are not united to benefit patients that can benefit from AS. Add to this that most men are uninformed about their risk of PCa and/or confused by the current debate between those that support PSA testing with those that oppose it. This is a formula with potential for stopping and reversing the PCa mortality reduction in this country…

I use to be a fish said...
What is the definition of low risk/indolent cancer?

 

 

There are several similar definitions out there which have not yet been driven to consensus...but they are all quite similar.  Here's one:

The NCCN, the National Comprehensive Cancer Network (they are the organization that develops treatment protocols which doctors follow) updated it's Prostate Cancer Guidelines to more clearly define both "low risk" and a new category called "very low risk" PC.  Im going to just copy/paste from an article:

Patients in the low-risk category are those with a stage T1-T2a tumor, a Gleason score of 2-6, and a PSA level less than 10 ng/mL, whereas very-low-risk patients are those with a stage T1a tumor, a Gleason score of 6 or less, a PSA level less than 10 ng/mL, fewer than three positive biopsy cores with no more than 50% cancer in each, and a PSA density below 0.15 ng/mL per gram.

I hope that this answers your question.  The Guidelines goes on to say that AS should be the only option offered by doctors to low-risk patients will <10 yrs life expectancy, and very-low-risk patients with <20 years life expectancy, AND should be offered as an option (although not the only option) to men in those risk categories at any age.

LINK