prostate cancer, discordance, upstaging….iceberg-feinberg…its all the same to me

What you see in the picture above is my most beautiful lab trying to enhale a slip weight. A popular way to catch largemouth bass in the South and I imagine everywhere is by using what is referred to as a “Texas rig.” My brother Rushton, you will hear about him soon as I am making a humorous prostate movie using his song Heartache and Hemorrhoids, showed me how to fish a “plastic worm.” In the picture you see the slip weight, it’s triangular, but you dont see the worm. Penelope will bite at it and prevent me from fishing and at the same time “mess up” the water. She has swallowed the worm on many occasion and I think that is what has happened here. This rig, buries the hook in the worm so it is possible to have the worm in one’s mouth but not get hooked by it. You have to “set the hook violently” to get the hook to come through the worm and into the fish’s lip. Luckily in the picture and in other occasions, I have not hooked the Pepsimiester. Doesn’t she make a beautiful profile. I lovvvvvvvvvvvve her. Now… about upstaging, referred to in this article as…discordance…sounds like a domestic dispute to me.

Discordance or upstaging is a situation where the biopsy is a lower Gleason’s score and possibly less volume of disease than the final pathology report after the prostate is removed. So…the biopsy shows Gleason’s six and two cores positive, which is are very favorable parameters, but when the entire gland is evaluated after surgery there is more volume and a higher Gleason’s score. For the person that chose surgery because he felt that removing the gland was the most aggressive thing he could do to treat the cancer there is little relevance. It is what it is. It means to him that he has a slightly higher chance of recurrence. (See post, The prostate is removed so I am cured, right?)

Now however, If you did a less aggressive treatment based on the biopsy, but in reality your parameters are much more aggressive, then you made a decision regarding treatment on bogus information. It is not that the biopsy report is wrong or read wrong, it is that the pathologist only gets a small sampling of your prostate.  The significance of the article that follows and why I chose to share it with you is that if you are choosing a less aggressive therapy based on your biopsy report, you maybe making the wrong decision. It is something to aware of, particularly in the patient that I refer to as the ” I want my cake and eat it too” type. In your head you have to prioritize and decide what is most important to you. Continence, cure, or potency, or all. And which treatment will do that. This article and the concept of upstaging suggests that if you are a “cure type” you need to be thinking in terms of what you feel has the best chance of ridding you of your cancer. You only know about upstaging if you choose surgery because no other treatment makes available the prostate for pathological review.  As my doctor friend who had prostate cancer and came to my house with a bottle of wine and two legal pads of questions said, ” John, I just did not know how complicated this would be.”

‘Substantial’ discordance between Gleason score at prostate biopsy and surgeryBy Sarah Guy06 May 2010Urol Oncol 2010; 28: 302–307MedWire News: More than a third of men diagnosed with Gleason score (GS) 6 at prostate biopsy will be upgraded to a score of 7 at radical prostatectomy, show US study results.

Furthermore, men whose GS is upgraded from 6 to 7 are more likely to experience biochemical recurrence after treatment, than men with GS 6 concordance at biopsy and surgery.

“This discordance has potential clinical significance in predicting oncologic outcomes,” write Javier Hernandez (Brooke Army Medical Center, Houston, Texas) and colleagues, who speculate that patients who choose less aggressive treatment after a GS 6 biopsy may be undertreated.

To investigate further, the team determined the frequency of GS discordance at biopsy and surgery in a group of 2771 prostatectomy patients, then evaluated associations with clinical parameters and the likelihood of biochemical recurrence after surgery. In all 67% of men had a GS 6 on biopsy, and 33% had GS 7.

Among men with GS 7 at biopsy, 66% had concordance at surgery, while 55% of men with GS 6 had concordance, and 37% were upgraded to GS 7 at surgery.

Patients who upgraded from GS 6 to 7 had statistically higher prostate-specific antigen (PSA) levels at diagnosis than those with concordant GS 6 scores, and, although not clinically relevant, were older. Additionally, more men with a prostate volume of less than 20 cm3 were upgraded from GS 6 to 7 compared with men whose prostates were 60 cm3 or more, at 34% versus 17%.

Hernandez and team also observed an association between the percent of positive biopsy cores and GS upgrade. The risk for upgrading was 1.9 times higher in men with more than 50% positive biopsy cores compared with men with less than 30% positivity.

Furthermore, men who upgraded from GS 6 at biopsy to GS 7 at surgery had a significantly shorter time to biochemical recurrence (defined as a PSA of 0.2 ng/ml or more at 2 months or more after surgery), compared with those whose GS remained 6 at surgery.

“The occurrence of positive surgical margins, capsular invasion, seminal vesicle invasion, and increased pT stage were all significantly increased in patients who were upgraded,” note the researchers in the journal Urologic Oncology.

“Patients who are upgraded are a unique group and have cancers that behave more like those of patients who are initially diagnosed with GS 7,” they conclude.

MedWire (www.medwire-news.md) is an independent clinical news service provided by Current Medicine Group, a trading division of Springer Healthcare Limited. © Springer Healthcare Ltd; 2010