My Gleason 3 + 3 Prostate Cancer Is Now Metastatic

Rob, I agree with your statement about only knowing your exact pathology if you have surgery. That is one of the advantages of surgery for some...but that knowledge still doesn't mean there will be no recurrance hence it's lack of importance for others. Re your statement about the first thing that people hear perhaps you are exaggerating for effect but that's not my reading of what new members hear. I think you'll see that long time members, both surgery patients and radiation patients alike, recommend that new members look at OPTIONS before selecting surgery or any other treatment.

The fact is that most of us, myself included, get their initial diagnosis from a urologist who is often biased toward surgery and often lacks the knowledge to provide an unbiased view of radiation treatments. To me it's only logical for us to suggest to new members that they visit with radiation experts as well as surgical experts so that they can make an educated decision. That's a far cry from saying "you should not have surgery", rather it seems to me it is proper support so that newbies don't make knee jerk decisions based on partial and biased information from one doctor.

Jim

RobLee said...

For the benefit of those who have chosen surgery over radiation, it has its advantages. You have considered your options, and those options are YOURS and yours alone. Those who try to talk a member out of surgery are doing a tremendous disservice to someone who is already in a stressful situation.

Everyone you meet is fighting a battle you cannot see... be gentle, be kind"

Amen to that Rob.

Trying to talk someone OUT of the tough decision they've already made is most unkind. Most of the time it's just the poster trying to convince HIMSELF.

Surgery = pay me now with some unknowns: Radiation = pay me later with a myriad of unknowns. IMHO, of course, no one size fits all.

Mostly well stated, JNF, except for the money-shot:

JNF said...
...and once in a while we have the very rare occurrence like this where a G6 becomes metastatic.

That should read: "...and once in a while we have the very rare occurrence like this where a case is originally diagnosed as G6, undergoes treatment, treatment fails and ultimately the case becomes metastatic." (The 3+3 cancers cells do not "become" (or "morph") metastatic, new more aggressive cancer cells can develop.)


This fact is not really the interesting news, in my view. What I think is really interesting and meaningful is that the rate of failure is the same (about a percent or so) whether those originally low-risk men underwent immediate treatment or instead opted for Active Surveillance and later underwent deferred treatment once their indicators revealed change. This fact is a clear statement that everyone with low-risk PC should first go on AS...there's no harm in trying, and many men will totally avoid unnecessary treatment.

Post Edited (Blackjack) : 12/13/2018 3:04:03 PM (GMT-7)

In some cases (depending on other case characteristics), 3+3 is properly categorized very low risk. In either case (low risk, or very low risk 3+3 cases), immediate treatment is NOT recommended because the harms from treatment outweigh the remote benefits.

Post Edited (Blackjack) : 12/14/2018 12:37:21 PM (GMT-7)

Blackjack said...
In some cases, 3+3 is properly categorized very low risk. In either case, immediate treatment is NOT recommended because the harms from treatment outweigh the remote benefits.

You never know what your score really is until the post surgery hist. report and they've got your prostate in a jar. Mine from biopsy was 3+4, but the post surgery report said 3+3. Could have equally been in the opposite direction and a worse result..

Back to the OP--this is an unusual and rare case. It is rare for a patient, diagnosed G6, and treated with brachy, to have a recurrence--much less a recurrence that is metastatic. Really, really rare.

It does go to show, IMO, that he did most likely have some G4 cells lurking around there--after all, if 25-30% of surgery patients have a different final pathology than the biopsy showed (including me)--it makes sense to assume the same for radiation patients--that their true pathology is different from the biopsy.

It's also unusual for brachy patients with a low risk diagnosis to have a recurrence. By definition, brachytherapy--and all the radiation therapies--treat a larger area than just the gland. And this is usually seen as a good thing--that it's better at getting at the little bits in the surrounding tissue without causing major problems.

And, as others have pointed out, it is only the surgical patients who really know what was lurking around in there. And, in reality it is only truly important for the low-to-intermediate diagnoses to be split out that way. Someone who has any significant level of G4 or G5 at biopsy is going to be treated with some variation of aggressive treatment that will likely include ADT from the start--which is the big difference between the low to intermediate risk vs high risk--the actual scores become less important, from a treatment perspective high risk is high risk (unless you're getting into crazy high risk land with PSA in the hundreds or thousands and massive G5 loads in the biopsy cores).

Once and for all.......

Jasper- Your PCA is not classified like your fathers was....the Gleason system has been revised since he as diagnosed...G6 today is much lower risk than it was back then...they weeded out all the variations of G6 that proved later to be an aggressive variant. G6 today does not include those "wild cards"....so it is a lot less risk.

Below is a quote from a study Klotz...from this year. All cases were "surgery"

"There are virtually no well documented cases of pathologically proven Gleason 6 cancers that have metastasized
This issue of non-metastasizing Gleason 6 very fundamental. Two studies, well known, just briefly the Eggener study of 12,000 Gleason 6 treated with surgery. They basically did not find one patient with true Gleason 6 confirmed on re-review who metastasized. They report 2 in 1,000, but they were all upgraded eventually, and the same thing with the Ross paper, 14,000 cases, essentially no pure Gleason 6 that metastasized to the lymph nodes in all those cases. So this is pretty compelling evidence I would say. And even if it is 0.1%, it doesn’t mean that you should alter your management based on that."

Here is the link to the full article
https://grandroundsinurology.com/active-surveillance-from-biology-to-bedside/

Here is another quote from Epstein from July this year..
"Dr. Epstein: Because a pure Gleason 6 score determined at radical prostatectomy—where you can examine the entire tumor—has no risk of metastasizing and no risk of leading to the patient’s death, some people question whether we should call Gleason 6 an indolent lesion of epithelial origin (or IDLE) rather than cancer. But morphologically, Gleason 6 is cancer. It looks like a higher-grade cancer under the microscope. It can invade nerves and extend outside of the prostate and has all the features of local aggressiveness that you don’t see with benign tumors."

Again, pathology after surgery. Here is the entire paper
http://www.ascopost.com/issues/july-25-2018/when-can-patients-with-gleason-6-prostate-cancer-safely-undergo-active-surveillance/

Also, form the poster who claims "Gleason score is dead"
Again, from Epstein,

"Dr. Epstein: The best tool we currently have other than pathology is the multiparametric MRI, which is not perfect, but it relatively selectively identifies higher-grade cancer. Molecular tests, including PTEN/ERG, are unproven in predicting the risk of prostate cancer progression in the active surveillance population, and that throws into question their utility in the treatment paradigm."

If you want to argue whether, a G6 cancer can or cannot metastasize, please start a new thread.

Going for brachy said...
If you want to argue whether, a G6 cancer can or cannot metastasize, please start a new thread.

I suspect that most agree that it cannot.

The point is, as Gary stated, you likely had more than just a pair of threes to start with. For the new guys who may come here with a G6 biopsy and believe that zapping it based on scans and be done with it are ignoring the possibility (or likelihood) that there may be more advanced tumors in there than the scans indicated and the biopsy missed.

Biopsies DO miss tumors... unless my G8 developed in the two years between my negative biopsy and the MRI two years later. And on the subject of scans, that MRI showed my PCa contained, but the surgeon discovered that it had spread.

halbert said...
Guys, he has asked for the debate to stop on this thread, and to stop telling him what he already knows. Let's respect that.

Yes, if you want to continue the debate please start a new thread. Let's honor GFB's wishes...

Jim

Everything about Gleason 6 has already been stated. But, in considering the OP’s situation, I am reminded of a slide show I saw that was presented by the chief urologist of a large local hospital. It was a series of graphs that supported the 2012 Task Force recommendation against PSA testing. Don’t want to open that box, either, but to highlight one fact from the charts.

The charts started with the basis of 1,000 men getting PSA tests, and ended with only one or two having it save their lives. What struck me was the assertion that another 6 or 7 men had been identified and treated, but that the treatments could not save them, in any event.

In the following discussion, the urologist confirmed that some cases, which appeared to be low risk, progressed to mortality despite appropriate treatment.

That’s not good to hear, but important to be aware of.