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MRI-Based Active Surveillance Shows Promise in GS ≤ 3 + 4 PCa
The attached article, just published in European Urology, seems to firmly place Gleason 3/4 PCa in the category for AS consideration. I present it for your review with the regular disclaimer: I am a PCa patient, not a doctor specializing in Tx of PCa. Each PCa patient's circumstance is different. Their healthcare decisions should be based on their own analysis of information, consultation with their doctors, and their life priorities. That said, those of us who are in this club should do all we can do to support each other.
I've been absent for a time while I researched topics that I felt were relevant to my decisions about addressing my prostate cancer diagnosis. I found the best way for me to digest and assimilate information is to write and save brief abstracts about articles or presentations. That enables me to catalog the information, review it, and draw conclusions. It also helps me from being overwhelmed and confused by the vast amount of information. This post begins an effort to share my process. I hope this is helpful to others.
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I solved the problem of posting PDFs: no symbols in title!
It's another datapoint.
It's an interesting article for sure....but....there are a lot of folks on here who are 3+4 after biopsy are then graded 4+3 after surgery. There's enough of a difference there in my mind to make this seem like a somewhat dangerous gamble. Grading is mostly a human process, there can be a lot of subjectivity in it.
There's also the "fight it now" mindset (mine) instead of not doing anything and worrying about it constantly. I guess that's different for everyone.
There also seems to be a lot that isn't addressed at all. It only goes out 5 years and age isn't mentioned. Among other things.
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8 ReactionsOne thing an MRI can’t tell you is exactly how much cancer is really there if you do a biopsy. If Someone was a 3+4 and their percentage of four was only five or 10% then AS makes sense. If the biopsy shows that 80% or 90% of that core is a 4 Then AS may be dangerous.
As mentioned in another reply, My 3+4 turned out to be a 4+3 after surgery. I know people who had 3+4 and ended up Gleeson nine after surgery.
The problem is the biopsy can only get to about one percent of the tissue. Even MRI directed they can’t always get the right spots.
Just issues to be aware of.
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4 ReactionsJeff and web265, first, I'm not advocating for AS. I think men need to be aware of this study and other studies that are beginning to look at 3+4s similar to the way 3+3's were re-assessed 10 to 15 years ago. I think we are moving toward a more nuanced way to address 3+4s.
Jeff, I think your spot-on. I don't think all 3+4s are the same. My 3+4 with a Decipher of .17 is different than someone else's 3+4 with a Decipher of .81.
There are several things I have to keep reminding myself as I weigh my decision about how to address my PCa dx:
1. EFFECTIVE AS HAS SPECIFIC ENTRY REQUIREMENTS. If you look at the flow chart of the UCLH Protocol for AS, it provides for at least 1 (possibly 2) biopsies with upper diagnostic limits on biopsy analysis and PSA prior to the decision to include a patient in the AS protocol.
2. EFECTIVE AS IS A STRICT PROTOCOL. It is not ‘watchful waiting’. If I don’t feel I’m someone that is very likely to follow through, I’m not a good AS candidate. There were 1050 patients in this study. No one in the study that followed through with the protocol experienced the need for more extensive treatment due to nodal involvement or distant metastasis. There were at least 10 people in the study that didn’t follow through appropriately and they did experience nodal involvement or distant metastasis.
3. AS ISN’T FOR EVERYONE As web265 very appropriately commented, for many men there is the "fight it now" mindset. I am like web265. My inclination is to fight it now. My immediate reaction to my biopsy results was to make an appointment for surgery. My surgeon at Mayo over-ruled me and told me I had the time and should take the time to educate myself before deciding what to do. Even now I have to constantly remind myself that a decision to actively treat PCa, when ever I decide, does not imply a ‘one and done’ solution. If I’m lucky to live long enough, I will probably experience the need to re-address my PCa.
4. I THINK GENETIC TESTING SHOULD BE CONSIDERED before making AS or treatment decisions. Although the European Urology article about the UCLH protocol did not mention combining genetic testing with the biopsies, that is exactly what centers of excellence are doing now. I had a Decipher at Mayo after my MRI and biopsy. I just listened to a presentation from NYU Langone where they are doing genetic testing on every PCa + biopsy. I believe genetic testing provides part of the sophisticated detail that Jeff refers to that is necessary for patients to make decisions to treat or employ AS.
5. UNDERSTAND TREATMENT OPTIONS: Finally, I felt the need to more fully understand the indications, advantages, limitations, and potential side effects of all my active treatment options before I made my decision. I’m very fortunate that I am being treated at a center of excellence (Mayo-Rochester). Even doctors at Mayo, who have always been very gracious, only have so much time they can use to educate patients. Spoiler alert: after reading the scientific literature, I realized I came away from my consults underestimating the limitations and side-effects of my treatment options. That was probably due to information overload with a side helping of anxiety. That will be the subjects of my future posts.
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3 ReactionsInteresting article. Whether a Gleason 7=3+4 PCa is firmly in the category for AS depends on a number of factors, including:
> the PSA Doubling Time (or PSA Velocity).
> the % “3” and % “4” cells in the samples.
> whether the MRI and biopsy show any cribriform pattern, extracapsular extension, seminal vesicle invasion, perineural invasion or intraductal carcinoma.
> PSMA PET scan results.
> biomarker (genomic) test results.
> genetic (germline) test results.
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Note that the study looked at “Gleason score (GS) ≤ 3 + 4,” and was over-weighted with GS 6=3+3: “64% of patients had GS 3 + 3 and 36% had GS 3 + 4;”. So, the study conclusion will likely lean towards the GS 6=3+3.
However, if all the numbers and the scans are optimal, then AS is certainly an option.
Any concern about pathological upgrading of the Gleason should note a number of studies indicating that pathological Gleason scores match initial grade or are downgraded 3x more often than they’re upgraded. (Here’s one: See the paper titled “Pathological upgrading in prostate cancer treated with surgery in the United Kingdom: trends and risk factors from the British Association of Urological Surgeons Radical Prostatectomy Registry.”)
AS often makes sense. For what other disease, illness, or injury do we cut off the offending body part “just to see” if it’s worse than we think???
(As with any other illness or injury I’ve had, I reserve radical invasive treatment to when it becomes medically-necessary. So, I was on AS for 9 years with a 6=3+3, giving me much time to get referrals to specialists, evaluate all treatment options, and eventually select and get active treatment at a time of my choosing.)
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