From “The Decision”
Think apples to apples, prostates to prostates.
A little knowledge – Don’t get too cute with what you’ve learned from your research; there is no reason to “go it alone” in making your decision. Don’t be clever by half.
On one particular occasion, however it has happened countless times, I had just told a patient that his biopsy showed cancer. I began to lay out an overview of the options and happened to start with surgery. Before I could continue, the patient told me, “My brother has a friend who has prostate cancer, and he did radiation because his doctor told him that if he had surgery he’d be impotent and that surgery lets air get to the prostate and will make it spread.” Now, normally I will take a deep breath and slowly explain the pros and cons of both radiation and surgery and the concept of apples to apples, but sometimes I have a little fun showcasing the folly of how some patients will place so much credence on something someone has told them. On this occasion I said, “Mr. Jones, thank you for sharing that with me. Based on what you have told me, this is what I’d recommend for your cancer. My advice to you would be for you to do what your brother said his friend was told by his doctor about your brother’s friend’s cancer.” “Do you have any other questions for me?”
- Prostate cancers differ by the Gleason’s score. A score of 6 is considered moderate, it is the most common score and usually associated with favorable outcome regardless of the treatment.
- The Gleason score tells you the grade or the differentiation of the cancer. A higher grade, or higher Gleason’s score is poorly differentiated (looks less like normal cells) and is associated with a more aggressive cancer.
- A Gleason’s 7 is a little more aggressive than 6. Gleason’s 8-10 is considered unfavorable parameters. In general the closer the score gets to 10 the more aggressively the cancer behaves.
- The pathologist determines the score by grading the two most aggressive areas of a positive biopsy 1 to 5 and then adds the two. The the predominant score is listed first, i.e. a (3+4) is a Gleason’s 7 and is better than a Gleason’s 7 that is (4+3).
- When you read that doctors don’t which prostate cancers are aggressive and require treatment and which are benign acting and may be followed with active surveillance, this is partially true. I can tell you that Gleason’s 8 and up behave badly.
- Low volume of disease on the biopsy is better than high volume of disease on the biopsy, i.e. you had 12 cores and 8 are positive. That is worse than only one being positive.
- Location of the positive biopsy core is important. If all the positive cores are at the base then seminal vesicle extension might be an issue. If it is at the apex, or laterally then extension to the margin of the gland is a possibility.
- So location, Gleason’s score, and volume make each biopsy and each cancer different. One also must factor in the pre-biospy PSA to assess the nature of “your” cancer.
- The Partin tables are very helpful in your determining the aggressiveness of your cancer. You should understand the concept of that table.
If you have had a biopsy and it’s shows cancer feel free to speak to friends and family about what they did with their cancer. But to do what they did blindly without the knowledge of the specifics of the biopsy and all the other issues that go into the decision-making process ( Who are you factors) borders on foolhardy.
So no, all prostate cancers are not all the same. We need to better define this disease particularly which favorable biopsies are better suited for active surveillance versus curative treatment. On the other end of the spectrum, you can count on the Gleason’s 8 being a bad actor and you need to make your decisions accordingly.