Not much found published about Very High Risk PC

I have been doing some research as of late and came across a few articles on High risk vs Very high risk PC. Up until just recently I did not even know there was a " Very High Risk" PC classification.

Some of us fall in this "very high risk" category (comprised of patients with primary Gleason pattern 5 disease, Gleason sum 8–10 in ≥ 5 cores, or multiple high-risk factors):

I'm just wondering if anyone here has more info they can share about this?

Battle On Brothers!



The Artistic One - Mark

The actual NCCN definitions for high risk and very high risk are as follows:

High risk: The tumor has 2 or more of these characteristics:
Classified as T3a
PSA level is higher than 20 ng/mL
Gleason score is between 8 and 10

Very high risk:
The tumor is classified as T3b or T4.
The histologic grade is 5 for the main pattern of cell growth, or more than 4 biopsy cores have Gleason scores between 8 and 10.

Geez Allen, please don't tell me "it is reasonable to not pursue curative therapy".

I'm jumping thru all kinds of hoops trying to fight off this beast!

The definitions I stated came from this website:
www.cancer.net/cancer-types/prostate-cancer/stages-and-grades

Thanks for the clarification. Fortunately that's one group I am not in.

I guess I should have added a nod and a wink to my last post.

30,000 men die in the United States every year from Prostate Cancer...Most of those men began their journey's being "High Risk" or "Very High Risk"...Now they are 5 or 10 years down the road and their prognosis is "Terminal Cancer"....Actually, their prognosis was terminal cancer the moment they detected bone mets....Some guys manage to hold the grim reaper off for a long time and some not so long.... But the eventual outcome seldom changes....Everybody in the G-9 and G-10 club need to prepare ourselves for that....Yes, a small number of us achieve durable remissions and we live to die from a heart attack or a stroke like everyone else and that's what we are all hoping for......

These factors have weighed on my mind, off and on, since diagnosis. Just how possible is a durable remission in the face of a rather serious diagnosis?

I don't recall in 2013 there being the "very high risk" category. And what if someone has more than one of those factors? Mine is primary type 5 in two high-volume cores, and all 6 positive cores (out of 12) were G9. Staging was "only" cT3a, since mpMRI didn't see anything in the seminal vesicles, nor any enlarged lymph nodes.

No one in 2013 suggested adding docetaxel after the primary radiation treatment for such cases, though that's sure an option now. I would absolutely have done it if it had been offered back then. Ah well, at least progress continues and perhaps we do better for such guys newly diagnosed now.

RobLee said...
We're probably splitting hairs here, but going back to the NCCN distinction between high risk and very high, the T3a puts you in high risk unless your biopsy and/or pathology matches this 'vague' definition:
.

I'm pretty much just a cotton-headed ninnymuggins, and probably misunderstanding what you're saying.

For what it's worth, the 2.2017 version of the NCCN guidelines says Very High is: "T3b-T4 or, Primary Gleason Pattern 5/Gleason Grade Group 5 or, >4 cores with Gleason score 8-10/Gleason grade group 4 or 5".

My interpretation is those are all "or" options, hence one of them qualifies. So T3a alone, yeah, high risk. But that's not my primary concern. So primary 5? Check. >4 cores G8-10? Check. Very High risk? Sigh... check.

Therefore, in fact, multiple "very high risk" factors, when any one would be sufficient.

And yes, it's probably splitting hairs. The only difference I see specific to the Very High risk group is adding "ADT or observation for patients who are not candidates for definitive therapy". Otherwise the treatment options are the same.

Post Edited (Redwing57) : 6/19/2017 9:52:16 AM (GMT-6)

Redwing57 said...

RobLee said...
We're probably splitting hairs here, but going back to the NCCN distinction between high risk and very high, the T3a puts you in high risk unless your biopsy and/or pathology matches this 'vague' definition:

For what it's worth, the 2.2017 version of the NCCN guidelines says Very High is: "T3b-T4 or, Primary Gleason Pattern 5/Gleason Grade Group 5 or, >4 cores with Gleason score 8-10/Gleason grade group 4 or 5".

My interpretation is those are all "or" options, hence one of them qualifies. So T3a alone, yeah, high risk. But that's not my primary concern. So primary 5? Check. >4 cores G8-10? Check. Very High risk? Sigh... check.

Therefore, in fact, multiple "very high risk" factors, when any one would be sufficient.

Just so we understand each other, I DID point out that your six cores with a Gleason between 8 and 10 DOES put you into the very high category...

RobLee said...
It looks like yours is 2 cores with a main pattern of 5, BUT as you said all cores (more than 4) with G9.

If I'm reading correctly, then I think you fit into the same higher category as me, which is very high...

but in my case only because of the T3B... I had four but not more than 4 G8's

So as you said, if they are all "OR" criteria (other then the 'high risk' case which clearly states two or more) then yeah, it does look like we're in the same boat, yours for the high count of higher grade cores, and me just because of the SVI.

I still wouldn't want to be either one of us if given the choice.

Of course the prognosis is statistically worse the more risk factors you have, but the treatments are no different. So why worry about it now if the treatments are no different, and you have done all you can do anyway?

Tall Allen said...
Of course the prognosis is statistically worse the more risk factors you have, but the treatments are no different. So why worry about it now if the treatments are no different, and you have done all you can do anyway?

Exactly, I agree with this. If it doesn't affect what we plan to do, then it's not a very meaningful discussion.

RobLee, at the risk of extending a relatively meaningless discussion, and just for clarity, in the NCCN Guideline 2.2017, PROS-5 says High Risk (any of the factors listed there) can be shifted to Very High risk if there are multiple adverse factors (footnote f). It does not require multiple factors to be High Risk.

The Very High risk group on PROS-6 lists 3 items, all of which indeed are "OR" criteria. There's nowhere to go higher with multiple factors from there, so nothing is mentioned about multiple factors there.

And further for us enjoying the G9 5+4 category, it's the primary type 5 cells that present a very large risk factor, probably the most significant. I've seen a study that identified primary type 5 as a very high hazard ratio, but as usual there were so few of them they didn't bother to pursue that any further in their analysis.

Yes.......meaningless discussion....sorry to bring it up....

The fact of the matter about this discussion is about VHR PC. Not many of us fall into this category so as to be meaningless to 99% on here.

Something I find rather upsetting is having someone with low risk PC telling someone with VHR PC " TO stop worrying about it". Its not that I post hysteria on here all the time........

Sorry for the meaningless post.....

Mark

Post Edited (Artist Mark) : 6/19/2017 3:20:42 PM (GMT-6)

I get what you are saying Allen. I don't sit around worrying all day about cancer. At time's it gets to me so I vent.
I was more upset about the comment about meaningless post. Oh well... I'm over it.

My husband is VHR.

The relevance to him is that he fears his time will be shorter and he can plan accordingly, just in case. If the distinction between VHR and HR wasn't made, he might assume that all of the HR survival stats applied to him.

In Canada, my understanding is that if you are VHR, they might discuss your case at the tumour board meetings and make an exception to deviate from standard of care.

Unfortunately, my husband has been refused adjuvant chemo, so they are not willing to make an exception for him.