Prostate cancer decision making based on a biopsy…a potential pitfall for surveillance therapy.

yeah lycopene prevents prostate cancer and bla bla bla bla….
Summer is a good time to be a urologist in Georgia.  Here’s how it goes.
An older patient comes in and has a tan. I ask, ” How is your garden this year?”
The response, ” The tomatoes are just coming in.”
I say,” I’ll do half the work. You grow them and I’ll help you eat em.”
A week later the patient stops by with some homegrown tomatoes like the ones pictured above.
I need to learn how to can them. I have asked a thousand times and in fact one time bought the jars but never got around to “canning them.”
Lycopene and tomatoes are supposed  to prevent cancer. Well…I have eaten a thousand and I got prostate cancer. Go figure.
Last week I took out a prostate of a 50-year-old man whose biopsy of his prostate was very favorable one core of 12 positive at only 10% and it was Gleason 6. The psa had been about 5 or so and he had a normal rectal exam. So I encouraged him to think about surveillance.
His remark was that he did not want to be dealing with prostate cancer years from now and that he wanted to be done with it now while he was healthy enough to deal with the surgery. I made the point about “killing a fly with a hand grenade” but he had made up his mind.
The path of the prostatectomy came back bilateral disease, an area of 1.2 cm nodule of cancer and elements of Gleason 7 (3+4).
The point? I don’t think I would recommend surveillance in a 50-year-old if I had known the “true path.” So…you guys out there with a favorable path report on biopsy at least have to be aware that “what you see ain’t what you get” when it comes to the accurate appraisal of you cancer on biopsy. Think 12 hair sized specimens from a lemon. Not telling you what to do, not against surveillance, I’m just saying.
BJU Int. 2002 Nov;90(7):694-8; discussion 698-9.

Gleason score on biopsy: is it reliable for predicting the final grade on pathology?


Department of Urology, Centre Hospitalier de l’Université de Montréal, Université de Montréal, Montreal, Canada.



To assess the correlation of the Gleason score on biopsy and the final pathology after radical prostatectomy (RP) for prostate adenocarcinoma.


In a retrospective analysis within a tertiary-care centre, the charts of 537 patients who had undergone radical prostatectomy from April 1989 to November 2000 were reviewed. The RPs were undertaken in one institution; 167 biopsies were taken and interpreted in the referring centres, and 355 were taken and interpreted in the authors’ institution by up to 15 pathologists. All the final pathology specimens were interpreted by the same group of pathologists. The main outcome measures were: the pathological report of the biopsy including the primary and secondary Gleason grade; the final pathological grade (primary and secondary); the margin status; and the identification of the pathologist for the biopsy and final pathology.


In all, 390 patients had inclusion criteria (the Gleason grade before and after RP) available. For the individual scores 38.2% of tumours were undergraded, 32.6% overgraded and only 29.2% had identical grading in preoperative biopsies and final specimens. When grouped into more meaningful categories (Gleason 2-4, 5-6, 7 and 8-10) the correlation improved, with 48.5% of patients remaining in the same group after RP. For 39 patients the same pathologist assessed the biopsy and final specimen; in these cases individual scores were identical in 49% and group scores were identical in 64%.


Gleason grading of the prostate biopsy remains a poor predictor of pathological outcome. Assessment by the same pathologist reduces the discrepancy but over half the patients are under- or overgraded on final pathology. Clinicians should be aware of these limitations when using the biopsy Gleason grade in decision making.

2 Replies to “Prostate cancer decision making based on a biopsy…a potential pitfall for surveillance therapy.”

  1. Your story is the same that happened to me. Yet I have a friend with a PSA of 10 and increasing ever so slightly yearly, dealing with a watching approach. It is a personal decision. Yes, for every intervention there are consequences. I am glad of the path that I chose. No looking back.


  2. Dr John and Mark L thank you for your findings and your honesty. I am confused my husband’s case. He went through Hodgkins CA last year – chemo and radiation – had check up’s with PET SCANS that say he’s clear of CA – then at his urologist he suggested since his PSA was 12.9 he should have 36 biopsies each 18 on each side which came back non-cancer (total 54 biopsies in the last 5 years) then 2 months ago his PSA was 10.8 dropping but then I read a CAT SCAN report and it said his prostrate was enlarged I asked him about it and it oh yeah, (I’ve only been married for about 2 years 10/22/10) and have known him for a year before – so his doctor checked his testoerone and it was 219 – low and now he is on Androgel. My big question is – Is he in the safe zone or inside the cancer zone again – after reading all the posts and comments (and thank you Dr John for this free information on the net) should I just give it to God or keep looking and asking my husband questions – you know the ?’s – Do you hurt down there, dribble, have a hard time peeing etc. Even when he went thru chemo and radiation – he lost all his hair and lost 75 pounds and with the biopsies on his prostate never bleed or had pain – the only problem is -Is he has not had an erection since our wedding week back in October of 2010? Any advice Dr John? anyone
    Thank you so much doris


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