Outlook For Men With Advanced Prostate Cancer
While it isnt possible to cure advanced prostate cancer, treatments can help keep it under control, often for several years. Treatments will also help manage any symptoms, such as pain.
Some men may not respond well to one treatment, but may respond better to another. And when your first treatment stops working, there are other treatments available to help keep the cancer under control for longer.
Active Surveillance Testing Schedule
Medical experts offer various recommendations regarding frequency of testing and when to start treatment during active surveillance. The American Society of Clinical Oncology recommends the following periodic evaluations while under active surveillance for prostate cancer:
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PSA testing every three to six months
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A digital rectal exam at least once a year
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A prostate biopsy at least every two to five years
If test results or symptoms indicate the cancer is progressing, treatment is recommended with the intention of curing the disease.
A Gleason 6 Tumor: Is It Cancer And Should It Be Treated
The issue is not what we call a Gleason 6, but whether it has the potential to progress. Researchers currently are looking at genetic signatures that can differentiate a nonthreatening Gleason 6 from one that will progress to Gleason 7 or higher and possibly metastasize. Richard J. Ablin, PhD, DSc Tweet this quote
The diagnosis and treatment of prostate cancer have long been a source of controversy among the oncology community, the political sector, and patient advocacy groups. Most notably, the decision to biopsy a mans prostate gland rests largely on his prostate-specific antigen test numbers, the accuracy and clinical value of which have been hotly debated for decades, and still no consensus has been reached. A new controversial question has arisen in prostate cancer: Is a tumor with a Gleason 6 score a potential killer, or should it be left alone? About 180,000 American men are diagnosed with prostate cancer each year, and their clinicians need guidance on this critical question.
Is a Gleason 6 Tumor Cancer?
Herbert Lepor, MD
Dr. Lepor continued: What is unknown is whether Gleason 6 cancers on the basis of genetic instability can evolve into a higher Gleason tumor and then metastasize. So if we knew that a prostate harbored only Gleason 6 disease and over time the disease would not de-differentiate, then Gleason 6 disease would not metastasize and by definition would not be a cancer. Unfortunately, this is not so simple.
Better Selection Needed
Sharp Disagreement
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Grade Groups Of Prostate Cancer
The Grade Group is the most common system doctors use to grade prostate cancer. It is also known as the Gleason score.
The grade of a cancer tells you how much the cancer cells look like normal cells. This gives your doctor an idea of how the cancer might behave and what treatment you need.
To find out the Grade Group, a pathologist
Staging Spread And Survival Rates
As with all cancers, doctors use the term stage to describe the characteristics of the primary tumor itself, such as its size and how far prostate cancer has spread when it is found.
Staging systems are complicated. The staging system for most cancers, including prostate cancer, uses three different aspects of tumor growth and spread. Itâs called the TNM system, for tumor, nodes, and metastasis:
- T, for tumor describes the size of the main area of prostate cancer.
- N, for nodes, describes whether prostate cancer has spread to any lymph nodes, and how many and in what locations.
- M, for metastasis, means distant spread of prostate cancer, for example, to the bones or liver.
Using the TNM system, each manâs prostate cancer can be described in detail and compared to other menâs prostate cancer. Doctors use this information for studies and to decide on treatments.
As far as survival rates for prostate cancer go, however, the staging system is pretty simple. As weâve mentioned, in terms of survival rates, men with prostate cancer can be divided into two groups:
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What Is Prostate Cancer
The prostate is a gland found only in males that lies just below the bladder and in front of the rectum. Prostates in younger men are about the size of walnuts but tend to become larger as they age. It serves two main functions in the body. The first is to secrete prostate fluid and the second is to help move the seminal fluid into the urethra during ejaculation with the use of muscles.
Prostate cancer occurs when the cells in the prostate gland begin to grow rapidly and out of control. Usually, it starts out growing slowly and stays within the prostate.
There are 5 types of prostate cancers:
- Adenocarcinomas
- Transitional cell carcinomas
- Sarcomas
Chances are high that when you are diagnosed with prostate cancer, it is adenocarcinoma, which starts in the gland cells.
The other 4 types of prostate cancers are less common. Like all cancers, prostate cancer is graded to determine how aggressive and rapidly it is growing. No matter the type of cancer, all patients diagnosed are staged. This means assigning a grade that defines how aggressive the cancer is. For staging prostate cancer, the Gleason Score is the method used.
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How Do Doctors Find Out Your Grade Group
The pathologist grades each sample of prostate cancer cells from 3 to 5 based on how quickly they are likely to grow or how aggressive the cells look. You may hear this score being called the Gleason grade.
Doctors then work out an overall Gleason score by adding together the 2 most common Gleason grades. So for example, if the most common Gleason grade is 3, and the second most common is 4, then the overall Gleason score is 7. Or they might write the scores separately as 3 + 4 = 7. This combined score is now called the Grade Group.
There are 5 Grade Groups. Grade Group 1 is the least aggressive and Grade Group 5 is the most aggressive.
This is how the Gleason score and Grade Groups match up and what it means:
| Gleason score |
|---|
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What Does It Mean
A Gleason score of 6 is low grade, 7 is intermediate grade, and a score of 8 to 10 is high grade cancer.
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Its also important to know whether any cells rated at Gleason grade 5 are present, even in just a small amount, and most pathologists will report this. Having any Gleason grade 5 in your biopsy or prostate puts you at a higher risk of recurrence.
But because many prostate cancer cases are extremely slow-growing, the Gleason system didnt necessarily do a good job of communicating the risks for these cases. Patients with scores of 6 and 7 didnt have a clear picture of the nature of their particular cancer.
Why Is The Gleason Score Important
According to a study conducted by the University of Geneva, the Gleason score correlates very closely with the clinical behavior of the cancer cells. This makes is a very important indicator of how the cancer will act slowing growing versus aggressive.
It tells oncologists a great deal about the characteristics of the prostate cancer although its not the only tool used to determine whether you need to move ahead with treatment. Other factors are used and evaluated as a whole. This can include one more of the following:
- PSA blood test score
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If Treatment Does Not Work
Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.
This diagnosis is stressful, and for many people, advanced cancer may be difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.
People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment, including a hospital bed, can make staying at home a workable option for many families. Learn more about advanced cancer care planning.
After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.
Active Surveillance In Men With Gleason 3 + 4 = 7 Prostate Cancer At Diagnosis
A critical question for men with favorable intermediate-risk prostate cancer can often be, How safe would it be for me to go on active surveillance for a while after initial diagnosis?
So let us be very clear about one thing immediately.
A man with favorable intermediate-risk prostate cancer who starts on active surveillance is always going to have a higher probability of the need for later treatment if he starts on active surveillance that an otherwise identical man who has only Gleason 3 + 3 = 6 disease.
So the question about How safe it would be for such a man to start on active surveillance as opposed to having immediate treatment is really about how effective treatment will be later when it actually becomes necessary.
The abstract of a presentation by Kalapara et al., to be given at the upcoming annual meeting of the American Urological Association, provides us with some reassuring information that addresses this precise question.
The patients who started on active surveillance and then went on to have a radical prostatectomy were divided into two groups:
After patients had surgery, they were assessed as to whether their post-surgical pathology and clinical outcomes were either favorable or unfavorable. Unfavorable disease was defined as prostate cancer with a Gleason score of 4 + 3 = 7 or pathological stage T3 and biochemical failure .
Here is a summary of the study findings:
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What Tests Check For Prostate Cancer
Common tests to check for prostate cancer include:
- Digital rectal exam: Your doctor inserts a finger into your rectum and touches your prostate gland. The doctor feels the shape of the prostate gland and checks for any hard spots.
- PSA blood test: This blood test tells how much PSA is in your blood. Many men with prostate cancer have PSA levels that are higher than normal or that have gotten higher over time.
- A high PSA level does not always mean a man has prostate cancer. As men get older, their prostate gland may grow larger over time. This growth, and other health conditions, can cause a high PSA level in men who do not have prostate cancer.
If the test results are not normal, your doctor may recommend more tests, such as a biopsy. During a biopsy, the doctor uses a needle to take out a tiny piece or pieces of the prostate gland. An ultrasound probe may be used to guide the needle. Another doctor called a pathologist looks at the tissue under a microscope to check for cancer cells.
Note
How Does Gleason Scoring Work
If your doctor suspects you have prostate cancer a biopsy may be used to confirm the diagnosis and gain insight its characteristics. The two most dominant grades of cancer cells found in the biopsy are each given a score of 1 through 5.
For instance, a patient may be assigned a 4 and a 3. These two numbers are then added together to determine the Gleason Score which is a range of 2-10. In most cases, oncologists never assign a Gleason Score below 6. If we go back to our example, 4 and 3 would be added together for a sum of 7. This means 7 would the patient’s Gleason Score.
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Active Surveillance For Gleason 6 Cancer
Per the Cancer Care Ontario guideline,1 active surveillance for patients with Gleason 6 disease should include:
- PSA testing every 3 to 6 months
- Annual digital rectal exam
- 12- to 14-core confirmatory transrectal ultrasound biopsy, including anterior-directed cores, within 6 to 12 months of starting surveillance, and then a serial biopsy every 3 to 5 years thereafter
REFERENCES
1. Chen RC, Rumble RB, Loblaw DA, et al: Active surveillance for the management of localized prostate cancer : American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 32:2182-2190, 2016.
2. Cooperberg MR, Broering JM, Carroll PR: Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 28:1117-1123, 2010.
3. Loeb S, Folkvaljon Y, Curnyn C, et al: Uptake of active surveillance for very low-risk prostate cancer in Sweden. JAMA Oncol 3:1393-1398, 2016.
4. American Cancer Society: Key statistics for prostate cancer. Available at www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed June 26, 2018.
5. Morash C, Tey R, Agbassi C, et al: Active surveillance for the management of localized prostate cancer. Available at www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/2286. Accessed June 26, 2018.
6. Hamdy FC, Donovan JL, Lane JA, et al: 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 375:1415-1424, 2016.
Understanding Prostate Cancer: The Gleason Scale
Knowing the numbers
If you or a loved one has been diagnosed with prostate cancer, you may already be familiar with the Gleason scale. It was developed by physician Donald Gleason in the 1960s. It provides a score that helps predict the aggressiveness of prostate cancer.
A pathologist begins by examining tissue samples from a prostate biopsy under a microscope. To determine the Gleason score, the pathologist compares the cancer tissue pattern with normal tissue.
According to the
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Does Overdiagnosis Lead To Overtreatment Of Older Men
The widespread use of PSA screening has led to an increase in the diagnosis and treatment of early localized prostate cancer. Data from the US Cancer of the Prostate Strategic Urological Research Endeavor database suggest a significant decrease in risk in the last 2 decades in the United States, with more patients being identified with low-risk disease at diagnosis, but the role of active treatment of low- and intermediate-risk disease in elderly men remains controversial.
The median time from diagnosis to death from prostate cancer for men with nonpalpable disease is approximately 17 years., Considering that the US male life expectancy at the age of 65 years is 16 years, aggressive therapy will hardly extend life expectancy of older men with no palpable prostate cancer at the time of diagnosis. Twenty to 30% of prostate cancers detected by PSA screening programs show Gleason scores of 6 or lower and, thus, are not poorly differentiated and have volumes smaller than 0.5 cm3.
Histologic evaluation of radical prostatectomy specimens demonstrated that about 20% to 30% of cancers are small volume, show low Gleason scores, and are consequently clinically harmless., Many of these cancers pose little threat to life, especially for older men. Has PSA screening resulted in prostate cancer overdiagnosis?
When A Gleason Score Increases
If your Gleason score changes while youre on active surveillance, its time for a discussion with your urologist to better understand the situation.
You may find it helpful to ask these questions:
- In what way did my Gleason score increase? Remember that the numbers that comprise your Gleason score represent the two most common grades of tissue in your biopsy. Finding out which number increased is important to understanding how your tumor has changed. A change in your first number means that most of your tissue samples are now grade 4 . A new Gleason score of 3+4 means that grade 3 is still the most prominent type of tissue in your biopsy.
- How does this impact my risk level? Your risk level is based on the distribution of grade 3 and grade 4 samples. A Gleason 7 has a more favorable risk level than a Gleason 7 .
- Is it time to consider active treatment? It can be unsettling to find out that your prostate cancer has changed or may be getting worse. However, even if your urologist recommends staying on active surveillance, it may bring you peace of mind to better understand at what point youll need to consider other options.
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More Detail On Staging
The standardized Tumor, Node, and Metastasis system is used to stage prostate cancer. The T category is based on the extent of the tumor itself. The N category is based on whether the cancer has spread to nearby lymph nodes. The M category is based on whether the cancer has spread beyond nearby lymph nodes.
Understanding Your Pathology Report: Prostate Cancer
When your prostate was biopsied, the samples taken were studied under the microscope by a specialized doctor with many years of training called a pathologist. The pathologist sends your doctor a report that gives a diagnosis for each sample taken. Information in this report will be used to help manage your care. The questions and answers that follow are meant to help you understand medical language you might find in the pathology report from your prostate biopsy.
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