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Is gleason6 really cancer

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Posted 1/26/2014 3:42 PM (GMT 0)
A 2012 article written by H. Ballentine Carter, M.D. of Hokpins entitled Gleason Score 6 Adenocarcinoma: Should It Be Labeled As Cancer? raises the question this thread began with. His insight is worth the read of this full text journal article. http://jco.ascopubs.org/content/30/35/4294.full.

I was G-6 with 2 0f 25 cores taking during two biopsies showing only focal adenocarcinoma (<5%) and a psa of 3.1. Dr. Carter told me to take my time and I did (3 months), but he lead me away from AS because I was too young and cancers are believed to be more aggressive in younger patients. Post Op pathology at Henry Ford upped Gleason to 3+4 (70%/30%), T3a due to focal extraprostatic extension. Dr. Menon's exact words: "Thank G-d we acted when we did." Point is that AS for G-6 is not without risk since one never knows from biopsy and MRIs the extent of the disease.
Posted 1/26/2014 4:10 PM (GMT 0)
Some comments on the ISUP conference in 2005 that updated the Gleason grading system:

1. The idea that Gleason 4 and 5 is not considered cancer anymore is not quite correct. What has happened is that, a a consequence of the new system, the Gleason scores have been upgraded: what used to be considered Gleason 4 or 5 is now, more often, Gleason 6, and "old" Gleason 6 is now , more often, Gleason 7.

2. an important consequence of the new standard is that there is now more agreement between the clinical needle pathology and the post-prostatectomy pathology with respect to the Gleason score. What this means is that this tends to lead to more treatment since Gleason scores of 6 and less occur less often. However, the flip side of this hasn't really happened: people are still concerned that their Gleason score 6 will be upgraded post-prostatectomy and refuse to take the risk. I wonder if this notion of not calling Gleason 6 cancer that is presented by some of the same people who were responsible for the updating (I am thinking, in particular, of Dr. Jonathan Epstein of Johns Hopkins) is not some attempt at a correction.
Posted 1/26/2014 5:36 PM (GMT 0)
Alf,
yes there is a chance that Gleason can be upgraded to a G7. In all but rare cases this is due to a missed biopsy rather than a progression in grade. The vast majority of progressions are identified within the first 3 years. Because of the probability of a missed higher grade on biopsies many patients feel the need to treat. At this point in time a patient has only two pieces of information on which to base a decision, his psa score and his Gleason grade. A much better strategy would be to gain more information about one's situation before basing a decision on so little data. I would question your doctors statements about not telling who will get mastastisis. There are many nomograms that do this to a very accurate degree.
1. Review of biopsy slides by an expert.
2. A confirming scan, either multi parametric MRI or a CDU by an expert radiologist.
3. An advanced test like "Polaris" to identify aggressiveness.
4. Calculate PSA density.
5 use nomograms

Again, this will not be 100% accurate, but well into the 95% confidence level that one can start AS with little risk. Monitoring PSA every 6 months and a follow up scan or biopsy within a year can give one an even better idea of AS is still the proper course or whether treatment is warranted. Remember the basis of AS is to separate those who definitely need treatment from those that don't, knowing full well that 30% will eventually need treatment and sparing the 70% that don't.
If you look at Dr Carroll's work at UCSF, his control group of AS patients using diet, exercise and group therapy have had no progressions in 5 years compared to a 30% treatment rate for the control group, so it seems that progression can be delayed for years by lifestyle changes.
Posted 1/26/2014 6:01 PM (GMT 0)
Re docs opinions - they know that a certain pecentage will not have a great future and the rest will be okay, but it's the usual saga of not being able to say in whcih group you will end up.
As I also had a rising PSA within a few months (0.1 up to 0.4) and had to have SRT, I think I was not wrong to have opted for treatment on the basis of the info I had before surgery, but clearly there are many with the same info I had that may feel thay have a trickier decision.
Alf

Post Edited (English Alf) : 1/27/2014 4:00:04 AM (GMT-7)

Posted 1/26/2014 8:01 PM (GMT 0)

Frackme said...
If it cannot metastasize then it isn't cancer in the way a layperson thinks of that term.


Basal cell carcinoma, a cancer that unfortunately I've had a lot of experience with, never metastasizes, yet it can eat through other tissue and even bone if left untreated. My dictionary uses the term "malignant" as a necessary part of the definition: "a malignant growth or tumor resulting from the division of abnormal cells," and, other than the obvious definition of malignant to mean harmful, it defines it as: "(of a tumor) tending to invade normal tissue or to recur after removal." So the question hinges on whether a true GS6 is malignant.

TurpT1a, my understanding of the 2005 revision of the Gleason grading system was that it decreased the risk associated with both GS6 and GS7, via the "Will Rogers Effect." This occurred because the highest risk GS6s were moved into GS7, thereby lowering the risk of both categories. It's called the Will Rogers Effect because he said, perhaps apocryphally: "When the Okies left Oklahoma and moved to California, they raised the average intelligence level in both states."

Alf said...
But where is a 3+4 supposed to come from if it doesn't come from what used to be a 3+3?

It is not at all clear that cells "evolve" up the chain from grade 3->grade 4->grade 5. There may be a stem cell-like common ancestor that spawns higher grades as well as lower grades. So higher grades may evolve in parallel with lower grades, rather than from lower grades. One very small pilot study found: "These data support a model of parallel evolution of lower and higher Gleason score disease, rather than progression from Gleason 6 to higher Gleason scores." This is not settled science -- just a hypothesis for now about the natural history of PC.

The genomic relationship among matched prostate cancer foci.

- Allen
Posted 1/27/2014 3:55 AM (GMT 0)
All,

The more I read and discuss this subject the more I know that I really only know what I choose to believe. You can find arguments and counterarguments for every possible position or topic regarding prostate cancer. That is before introducing ethical and other subjective non-scientific variables that affect patients and physicians alike.

At the end of the day, it is your decision and responsibility to research, analyze, and decide what it is that you want to do with your condition. It is not the doctor's, nurse's, your neighbor's or anyone's in this forums decision to make.

I was diagnosed PCa in September of 2013. My PSA was 2.0, which for a 52 yr old was within "acceptable as normal" range". Three different doctors determined I had a positive DRE. I could have began discounting the diagnosis then, gone into watchful waiting and get hit by a car at age 58. Cancer would have never had the chance to kill me. The biopsy later that month showed a Gleason 3+4=7 and a Gleason 3+3=6 on two nodes respectively out of 12. Could have questioned the technician reading/grading the biopsy results. Could have entered into ethical judgements of their motivations and biases. I chose to trust the "experts".

My personal decision was... get it out of me. I am 52 and the odds of making a full recovery were good. After visiting with a robotic surgeon and a radiologist, I decided on the DaVinci Robotic Procedure. On November 5, 2013, I underwent surgery. They told me that they were able to spare both nerve bundles. They remove the prostate and lymph nodes. Post op biopsy confirmed the biopsy and found negative margins and no evidence of spread beyond the prostate capsule.

6 weeks later, had post op PSA with result of 0. 20 days after the surgery I had my first semblance of an erection. Was moderately incontinent for the first 60 days. Up and down. Suddenly, almost overnight, I have 95% continence and wear a small pad a day as a precaution.

My personal decision was based on knowing myself well enough to know that if I did nothing and later at age 70 I was told the cancer had progressed, I could count on not having as many options because of age, the stage the cancer would have been by then, and my then, projected life expectancy. And I would have been cursing myself for not having done anything when I first knew at 52.

My friends, at the end of the day, it is your decision. And it will not be for lack of information. Perhaps the opposite. You must do your due diligence sifting through all the information and resources that exist out there including this forum. Make you decision, live with it, then never look back. Lots of faith and family support helps a lot.

All the speculation and conspiracy theories do nothing but muddy the already murky waters of PCa. Good luck to you all and stay connected. Hopefully, for the benefit of those growing behind us, there will be a pill or vaccine that will make PCa a non-issue for them. For us though, it is still a challenge.

Best to all,

Newborn
Posted 1/27/2014 4:17 AM (GMT 0)
I will agree with the doubts on the "metastasis" argument. My dad died of a melanoma that grew from a single mole to invade the spinal column, then the brain stem. It did not metastasize, it simply spread. I have that as well, and after a major surgery, have yearly "excisions" to try to rip out what remains.

I would be happy to only have to worry about my PCa mets. But to go from no problems to a G4+5 (9) based on a blood test tells me again what I already knew. If you wait for real symptoms to discover PCa, you are already one of the walking dead.
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