questionaboutit said...
Why bother with AS? If a g6 is incapable of spreading outside the capsule and cannot metastasize to lymph nodes or anywhere else and does not progress to a higher grade, why bother even with AS or anything else. I have read in this thread about all of these studies that show no g6 has ever spread anywhere. If these doctors are so certain of their test results and others' research, why don't they tell their patients to pull up their pants and go home? If a g6 is as harmless as these doctors claim, they should not preach AS and charge men for years of AS for a cancer they claim cannot spread anywhere.

In fact, what you suggest is the current trend. Many institutions are questioning whether their AS protocols are too rigorous and place too great a burden on the patient. Johns Hopkins, for example, which has one of the most stringent AS protocols -- only very low risk and annual biopsies -- is in the process of relaxing those standards:

Expanded Criteria to Identify Men Eligible for Active Surveillance of Low Risk Prostate Cancer at Johns Hopkins

NCCN includes AS as an acceptable option for all low risk men, and some question whether that ought to be expanded to include favorable intermediate risk men as well. Some institutions are following a pattern of progressively longer periods between biopsies.

The hard part will always be identifying a true GS6. about a quarter of GS6 will upgrade at prostatectomy (about 90% to GS3+4, often of indolent type). Developments in improved image-guided biopsies will make that determination more reliable. Already mpMRIs can rule out higher grade cancers with about 96+% reliability. Also, progression to higher grade may occur over time at an estimated rate of about 1% per year, so some kind of vigilance may always be necessary.

AS protocol development is evolving, with fine-tuning occurring all the time (Just as radiation and surgical protocols are evolving). I agree that current protocols are probably over-intrusive, but they err on the side of caution. As more studies like this emerge, and as we refine the best indicators of progression, I expect protocols will change.

- Allen

Newporter, one should make the very careful distinction that the PC architecture of the lymph nodes has NOT been associated in this study with the architecture of the primary tumor.   When I first read what you wrote, this seemed to be your implication by adding it to this thread (I'll ask you in advance to forgive me if this was completely unintentional on your part)...but that is definitely NOT an outcome of this study.   Any correlation between surgical pathology of the prostate and the Gleason pattern of the positive lymph nodes was NOT reported in this study. The two key findings from this study were (i) that the Gleason patterns of lymph node mets could be either Gleason 3, 4 or 5, and (ii) that those with patterns 4 and 5 were more likely (higher probability) to have BCR.   Also very noteworthy, the authors commented that nearly 60% of the entire study population (which ALL had lymph node mets) was free of additional disease progression 13 years (duration of the study) after initial treatment, while only 19% of the group had Gleason pattern 3 (78% had Gleason pattern 4, and 3% had Gleason pattern 5).  Positive lymph nodes does not necessarily portend additional disease progression. Tall Allen said... NCCN includes AS as an acceptable option for all low risk men, and some question whether that ought to be expanded to include favorable intermediate risk men as well. Tall Allen, in addition to your helpful comment about men in the Low Risk category, it may also be helpful for many PC newcomers reading this thread to note that 2013 NCCN Prostate Cancer Guidelines for Patients recommends ONLY Active Surveillance for men with up to 20 years additional life expectancy who are in the Very Low Risk category...this represents a large proportion of newly diagnosed men in the US.   

Tall Allen,

According to this study the answer is NO.

"Of over 14,000 totally embedded radical prostatectomies from multiple institutions, there was not a single case of a GS ≤6 tumor with LN metastases. "

http://www.ncbi.nlm.nih.gov/pubmed/22531173

There were all graded using the ISUP 2005 guidelines.  The study Newporter referenced was done in 2006.  I wonder if they used the newer ISUP guidelines?

Post Edited (ChrisR) : 9/18/2013 11:03:16 AM (GMT-6)

Newporter,

You're assuming that single cells escape the prostate and seed in the lymph nodes. There are several other possibilities and there is evidence that they are more likely what is really going on here.

1) progenitor cancer stem cells escape the prostate and spawn cancer cells of various types.

2) tumors undergo something called the endothelial-to-mesenchymal transition (EMT) whence they are capable of growth and proliferation outside of the prostate. These can spawn cancer cells that can invade the lymphatic system. Gleason 3+3's have never been found to undergo EMT.

What was lacking from the study you cited was a cross-tab of lymph cancer grade by prostate cancer score. I suspect that would show that 3+3's never spawned lymph tumors.

Good answer Mr. Tall Allen. I appreciate your thoughtful response.

toyoung, You've already had your first "re-biopsy", and now your question is when to have the next re-biopsy.  You are probably already well-aware that there are numerous AS protocols which are all similar, but different.  Your more specific question was "But has anyone else heard of an AS program with a biopsy every 2 years." The answer is YES...with the critical clarifier that this is AFTER the super-important first "re-biopsy" (which, again, you have already had).  The first re-biopsy should always be within about a year or 18 months of the initial biopsy for someone following AS; yours looks like it was about 6-months apart.  Excellent. You may or may not know that in a study of low risk patients who underwent re-biopsy within one year of their initial biopsy/diagnosis, about 25% were upgraded to GS7 or higher, about 50% stayed at GS6, and about 25% (like you) were downgraded.  This important finding is the key basis behind the important rule-of-thumb for newly diagnosed men that nobody with 3+3 low-risk PC should ever rush to an aggressive treatment without first having a "re-biopsy" to see what—if anything—is really going on. So I looked up an old post I had written almost exactly 2 years ago; I'll just copy/paste it here with a link to a diagram which answers your question: The article you linked to points out that a TRUS re-biopsy is recommended by a number of centers, but there is no consensus about the need at this time…but they do pretty much all recommend re-biopsy.   In fact, I have never seen anyone who does not make it a part of their AS program recommendation…with the exception of those patients who cross-over from the active surveillance mode to watchful waiting.   A key difference in AS and WW is the ongoing maintenance of “curative intent.”   The very small amount of PC in those who meet the initial, very stringent criteria for AS may or may not undergo a measurable cancer progression later which triggers an exit from the AS program.   As you pointed out from this article (and has been demonstrated in other studies), those who exit the program have the same rates of success from subsequent (deferred) aggressive treatments as those who make an immediate decision to undergo aggressive treatment.   In fact, those who deferred treatment may have the opportunity to participate in any of the improved techniques which are continually being developed leading to better outcomes and fewer side effects.   Of course, the greatest benefit to AS come from those whose PC remains indolent, or even regresses (perhaps as a result of the lifestyle changes that most AS patients embrace to “stack the odds in their favor” for the best possible outcomes).   These patient avoid “overtreatment.” Anyhow, I think that this ( LINK ) “Time Table for Follow-Up” helps to visualize one program’s recommendations for re-PSA, re-DRE and re-biopsy.   As you can see, re-biopsy is recommended within the first year, then in the 4 th , 7 th and 10 th year, and subsequently every 5-years while on the program.   If one of the other measures under “surveillance”, for example PSA DT goes out of the program’s acceptable range, then this would also trigger a recommendation for re-biopsy (and might lead to an exit of the program for curative treatment). I think that the more people understand the rigorous, but common sense approach of the well-established AS programs, and the more that we can keep any possible irrational hysteria about having the “big-C” out of the discussion, then the more impact that AS can favorably make on the current PC overtreatment epidemic .   The results from the study you posted here, like so many others which preceded them, go a long way in helping folks understand the benefits of AS…as long as they don’t get unnecessarily rushed into treatment before even getting exposed to these facts. We need to aggressively treat those who need aggressive treatment, and not aggressively treat those who don’t need aggressive treatment. Please review the AS table in the link above, toyoung...but the bad news is that I'm not sure where the source document is.  I'll look for it and see if I can get back to you with it...   Post Edited (Casey59) : 9/18/2013 5:28:05 PM (GMT-6)

I was told mine was a G7 but on the g6 side of the G7....duh...