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Posted 7/9/2014 6:13 PM (GMT 0)
I had occasion last night to re-read my biopsy/pathology report, and it brought to mind a question that has crossed my mind at times.

To begin with, I was fortunate to already be under care of my URO prior to my Diagnosis..In fact I was late for my annual appt. and PSA testing & they called me to insist I get my Butt in for the tests.

Well, the rest is history, of course... Gleason 7 w/ 5 cores of 12 positive.

So, my question is this....obviously my PC was caught early & was G7...What would it might have been if I had waited until symptoms forced me in to the URO ?? I.E. might it have been 12 of 12 , and possibly G9 ??

What say you expert Brothers..??

Posted 7/9/2014 6:19 PM (GMT 0)
Impossible to tell.

Personally, I would not characterize your PC as "caught early."  In all likelihood, you probably were walking around with it for 20 years...you merely found it (or your doctor did) more recently.  Most men over 50 are walking around with it and don't know it...most never will.

Symptoms might have shown up in another decade, maybe more, maybe much more, maybe less.  With 3+4 maybe not at all. 

Impossible to tell. 

Posted 7/9/2014 6:33 PM (GMT 0)
I asked my surgeon how long he thought my Gleason 9 had been in my body. He said 7-10 years. I asked if it was always Gleason 9 and he said possibly. My issue was that my PCa had spread beyond the prostate which meant I caught it too late. I blame my GP for not knowing that finasteride had lowered my PSA and for not doing a test in 2010. Now I have a battle on my hands!
Bob
Posted 7/9/2014 8:44 PM (GMT 0)
Most assuredly a G7 will grow and spread left untreated due to the G4 component. It also has the probability of further mutating to a more aggressive 8 or 9 left untreated. Thankfully you caught it now and there are a variety of treatments that can be very effective.
Posted 7/9/2014 8:44 PM (GMT 0)
Good question. I'm no expert but I remembered reading somewhere in the past that Gleason grades might not progress over time. I just Googled and found this:

www.medscape.com/viewarticle/809443 which says that yes, it is possible that Gleason grades might not progress. But --- the paper also takes care to distinguish between Gleason grades and staging (e.g., T2a, T3b, etc.) and notes that although Gleason grades might not advance over time, staging may advance. In other words, a Gleason 7 might remain a Gleason 7, and nevertheless advance from T2 (organ confined) to T3 (extension beyond the prostate).
Posted 7/9/2014 11:36 PM (GMT 0)
NKINNEY....

The reason I presumed it caught early was because I was having PSA test annually for 10 years or more. My baseline was 3, and then suddenly it was 6.

At the time of my biopsy the URO reportd a PSA of 790. ( which still puzzles me )..

The Doctors routinely were saying caught early, too..

So, just being honest ( and ignorant ) I presumed 'caught early.

Posted 7/10/2014 12:46 AM (GMT 0)
I remember reading a magazine article recently in my urologist's office which reported a 20% reduction in prostate cancer severity (stage) over the past 20 years as a result of regular PSA testing. What surprised the researchers was only an 8% reduction in the Gleason grades. The answer seems to be that many prostate tumors keep their early Gleason.
Posted 7/10/2014 12:55 AM (GMT 0)
I was doing some research today about the Gleason system as I await my 2nd opinion from JH. Dr Epstein said he would call tomorrow before noon with my results and I want to be ready with my talking points.

If someone has a Gleason 8 for example, that means his cancer is aggressive. I assume aggressive in this context means fast growing. If another man has a Gleason of 6, for example, that would mean his is slower growing. Lets say the man with the 8 has a very small 5% involvement of cancer in 1 of 12 cores. His PSA was 5 at diagnosis. The other man had 6 of 12 cores positive with 40% cancer in each core. His PSA was 9 at diagnosis. Which man is at greater risk of spread?
Posted 7/10/2014 1:28 AM (GMT 0)
I was diagnosed in January 2009 with 2 out of 12 cores Gleason 8 (4+4). My PSA had jumped from 2.41 to 3.78 in approx. 14 months. My pathology report confirmed the Gleason score. The volume was relatively small (only 15%) but I did have EPE. All margins were negative. I did have the nerve bundles removed which may have helped. My PSA has been <.01 since surgery back in Feb. 2009. Had I not gotten the surgery done when my PSA jumped, I think my cancer would have spread.
Posted 7/10/2014 2:38 AM (GMT 0)
Good Question!
I was diagnosed October 4, 2013 and a subsequent psa test showed a psa of 187.5. I missed my annual in 2012 but in 2011 my psa was 3.31. Up from 1.87 the previous year. It's likely that was the first sign of trouble but my doctor failed to take notice. I had a complete urinary shutdown on September 29,2013 which landed me in emergency. So you likely have a better prognosis than if you would have waited.

DX 10/04/2013 PSA 187.5
07/11/2013 psa 3.31
3/10/2010 psa 1.87
1/24/2006 psa .87
Biopsy 10/28/2013 4 cores positive gs 9 (4+5)
Bone Scan 12/09/2013 2 hot spots in spine
Hormone Therapy started 12/17/2013 22mg lupron, 50 mg Casodex
Bone biopsy 01/09/2013 negative
RALP 2/19/2014 Non Nerve sparing, Lymphovascular invasion
Pathology T3B NX, MX, prostate size 4.2 X 4 X 3 cm, 31 grams
Bilateral cancer found involving 6% of prostate
03/07/2013 PSA .6
05/29/2014 psa <.01
Posted 7/10/2014 12:41 PM (GMT 0)
Interesting question BUSH.

NKinney, I've heard that every man will get prostate cancer sooner or later if he doesn't get killed by something else first, but I hadn't heard that most of us will have it by age 50.

In my own case, I've been quite surprised by the contrast between my two biopsies. In 2010 (age 60) I had 0/12 cores showing cancer and figured, obviously, that there wasn't any cancer there. In my second biopsy this spring (age 64) I had 3/12 cores cancerous, but the Gleason score was 4 + 5 = 9/10. Can PCa go from 0 to 9 in four years even though conventional wisdom says it's a slow-moving cancer? Or could the first biopsy have managed to miss it?

My father died of prostate cancer last year at 87. As far as I know, he was only diagnosed earlier that year, and Mom was told it was an "old man's cancer" that didn't need treatment because it wouldn't be the thing that would take him, but to our surprise that was the official cause of death. He had some major urinary problems before that, which I now suspect were prostate-related but it wasn't recognized or stated at the time. He had advancing Alzheimer's too, so I wonder whether the doctors just thought it wasn't worth anyone's while to treat the PCa.
Posted 7/10/2014 2:25 PM (GMT 0)
Arue2011, addressing your question/comment here:

Arue2011 said...
NKinney, I've heard that every man will get prostate cancer sooner or later if he doesn't get killed by something else first, but I hadn't heard that most of us will have it by age 50.

These two "rules of thumb" are essentially rooted in the same science.  There have been data collected from men of all ages who died in accidents.  Their prostates were examined and the found that starting with high consistency at about age 40, the percent of men who had detectable PC was roughly equal to their age.  So, about 50% of 50 year olds were found to have PC, 60% of 60 year olds, 70% of 70 year olds, etc.  So extending this to 100, roughly every man living to be this old is likely to have detectable PC...or put in other words, every man will get PC sooner or later if he doesn't get killed by something else first.

So, by age 51, the rule of thumb coming out of the autopsy studies is that most men (just about half, really) are walking around with detectable PC.  Of course the detection rate is lower.  The cancer causes symptoms, or the set of circumstances which leads someone to a biopsy, in only a subset of men.  Of course another way of saying this is that most of the cases of PC, although they COULD be detected if we went looking for them, are only indolent and would cause no harm.  This is the basis for understand the epidemic levels of Prostate Cancer overtreatment of favorable risk cases that is taking place today.  There are guys who hear "You have cancer," and they panic and "want it out now."  Many surgeons are happy to quickly oblige rather than take the time for favorable risk cases and explain that they really should really not rush into a costly (lucrative) procedure with irreversible and quite often severe consequences.  One of the most common complaints of men who find out after that fact that they were overtreated is that their clinician "undersold" the severity of the treatment side effects.

In your father's case, what you described sounds to me like compassionate care.  I'm sorry for your loss last year, but the treatments can be quite rigorous for an elderly man (diagnosed a year before his death).  I'm guessing that his care was appropriately palliative.

Regarding your own case, it is absolutely correct that most PCs are slow growing, and this is true of almost all of the known variants of PC.  There is a fast growing, but infrequently occuring variant which tends to throw off very little PSA (you didn't mention your PSA results) relative to the a high Gleason score.  This variant acts quite different than the vast majority of other PC cases.  Did the biopsy (which is just a sample) miss it, or did the G9 grow in the 4-year span, or both...impossible to tell (same response I gave BUSH in my first posting here).  Low grade PC doesn't "turn into" high grade PC (see the link Bohemond provided).  Aggressive PC needs to be treated aggressively.  What's your treatment plan?

Posted 7/10/2014 2:59 PM (GMT 0)
Gleason Grade 3 is the lowest grade deemed to be malignant. It rarely causes problems as it most always remains a G3 and it is so close to benign prostate cells that it doesn't live outside the prostate.

G4 and G5 are different animals. They are more aggressive in replicating and prone to further differentiation with successive generations. These are the cancers that can adapt to life outside the prostate, thus the metastasis, and adapt to life without testosterone, thus the hormone refractory situation where HT no longer controls the cancer. Some can get extremely aggressive and turn into small cell anaplastic and neuroendocrine cancers. Thankfully these are rare.

Generally as the cells mutate further away from the normal, the expression of PSA reduces. A G5 gives off far less PSA based on it's volume than does a G3. One of my clients fought aggressive PCa for 9 years following surgery. His skeleton was riddled with mets. he had several very large lymph node tumors and lung mets. Throughout it all his PSA stayed nearly undetectable. Quite a challenge for his oncologist. My brother's brother-in-law has been fighting hormone resistant PCa for nearly 11 years. He is G9 and has had surgery, salvage radiation, two tours of HT and now getting ready for Provenge. At diagnosis his PSA was 1 and has been consistently less than that since.

Thus, I believe you have to treat this stuff not necessarily as it currently appears, but rather on the order of what it may turn into. My docs treated the G4, which can cause some real problems. They disregarded the G3 components and there was never a discussion of G7(3+4) versus G7(4+3). They based everything on G4, 12 of 12 positive cores, and PSA of 59 (indicating a large tumor volume). In a recent discussion with my uro, he said that today he would be leaning to introducing chemo upfront with my risk profile. His practice includes me in a high risk management pool of patients that are earmarked for Provenge at the earliest point it can be used on-label. While I am cautiously confident that I will enjoy a long durable remission and perhaps even a cure, I am cognizant of my risk factors and thankful that my medical team wants to stay ahead of the risk curve.
Posted 7/10/2014 6:59 PM (GMT 0)
Thanks for that NKinney. I quite agree that compassionate care would have been appropriate for my Dad as none of us would have wanted him to suffer more or longer than he did.

I think I figured out how to put my history (including PSA levels) into a signature so I hope it appears at the bottom of this message. I do seem to fit the low PSA (8.54 at last reading) and high Gleason (9) pattern you are describing.

The present treatment plan is a combination of hormone therapy (already started on anti-androgens and LHRH analog injections), brachytherapy (I visit that specialist next week to see if it's a go) and EBRT.
Posted 7/10/2014 7:23 PM (GMT 0)
NKinney....

 

On my question I appreciate your input, and obviously you are very knowledgable on PC..

I'm sure all who have perused the thread are the wiser for doing so...

 

A final couple of points, though :

 

If I hadn't been under care of a URO my PC would probably not been discovered ( G7 w/PNI )..So,I just got lucky all around, I guess..

 

Also, what about my 790 PSA at time of BIOPSY - I'm blown away by that. Do you have any input ??

 

Finally, just a comment ( don't get me wrong ), but 51 % I'd call half/half not 'most'...

Posted 7/10/2014 8:18 PM (GMT 0)
Double check the PSA 790 report. Doesn't sound possible given the PSA history. Plus it would indicate a boatload of cancer that would not indicate being caught early. Maybe it was actually 7.90 since you had gone from 3 to 6 prompting the investigation.
Posted 7/10/2014 8:22 PM (GMT 0)

Hi BUSH.

If you'll allow me, please, to simply comment on your comment...  :-)   

(I appreciate the spirit of your reply, and this is intended in that same spirit!)

BUSH said...

Finally, just a comment ( don't get me wrong ), but 51 % I'd call half/half not 'most'...

 

Right at age 50, it would be roughly half of 50-year olds...absolutely correct.  Perhaps how it was stated in my preceding post was confusing.

But the point was more clearly stated in the post which preceded that one...what I said earlier was about the set of men over 50; specifically, "most men over 50 are walking around with ..."

A simple exercise using census (yr 2000) will help me demonstrate.  (I could probably find 2010 census data, by sex, but I found this data very quickly...)

* There were nearly 76 million alive in the US in 2000.  This is both men and women, but lets assume that the percentage of men alive in each age group is the same as the percent of men and women combined.

** 50-59 years:  30M, or 40% of the total population over age 50

** 60-69 years:  20M, or 27%

** 70-79 years:  16M, or 21%

** 80+ years:  9M, or 12%

So the weighted average for those "over 50" is approximately (age55*.4)+(age65*.27)+(age75*.21)+(age85*.12), or about age 65.5. 

So, if the typical man in the US "over 50" is age 65.5...that translates into about 65% probability of PC, which I have called "most."  So, I still contend that most men over 50 are walking around with PC.  In addition to that, most of those men with PC don't know they have it, and it will never bother most of them.

More clear?  Or did I muddy things up?

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

I'm also blown away by your 790 ng/mL PSA result at biopsy...but I didn't notice any of your other PSA results either before or after which may have been an indicator this was an anomoly, or whether (perchance) the blood was drawn AFTER the biopsy was complete (which would have been a clinical error on the part of your urologist's office staff).  Is there other PSA history?  That is, as you certainly know, an unusually high PSA.  It seems inconsistent with the rest of your case...

Post Edited (NKinney) : 7/10/2014 4:01:13 PM (GMT-6)

Posted 7/10/2014 8:39 PM (GMT 0)
Arue2011, your treatment plan appears solid. You are in the NCCN high-risk category, and are being treated accordingly.

I do not agree with the "belief" stated by JNF earlier in this thread when he said: "Thus, I believe you have to treat this stuff not necessarily as it currently appears, but rather on the order of what it may turn into."

NCCN guidelines for doctors is to treat men based on the risk category that they ARE, not what they MIGHT SOMEDAY BE.
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