How Important Is The Gleason Score
The Gleason score is very important in predicting the behavior of a prostate cancer and determining the best treatment options. Still, other factors are also important, such as:
- The blood PSA level
- How much of each core is made up of cancer
- The number of cores that contain cancer
- Whether cancer was found in both sides of the prostate
- Whether the cancer has spread outside the prostate
Tests To Identify Prostate Cancer Stage
After a prostate cancer diagnosis, your doctor will do tests to see how far the cancer has spread. Not all men need every test. It depends on the results of your biopsy, a test that checks tissue from your prostate gland for cancer. Tests that help your doctor figure out the stage of your prostate cancer include:
- CT scan of the abdomen and pelvis to see if the cancer has spread
- Nuclear medicine bone scan to see if the cancer has spread to your bones
- Surgery to check the lymph nodes in your pelvis for prostate cancer spread
Treatment Option Overview For Prostate Cancer
Local treatment modalities are associated with prolonged disease-free survival for many patients with localized prostate cancer but are rarely curative in patients with locally extensive tumors. Because of clinical understaging using current diagnostic techniques, even when the cancer appears clinically localized to the prostate gland, some patients develop disseminated tumors after local therapy with surgery or radiation.
Treatment options for each stage of prostate cancer are presented in Table 6.
| Stage | Standard Treatment Options |
|---|---|
| EBRT = external-beam radiation therapy LH-RH = luteinizing hormone-releasing hormone PARP = poly polymerase TURP = transurethral resection of the prostate. | |
| Stage I Prostate Cancer | |
| PARP inhibitors for men with prostate cancer and BRCA1, BRCA2, and/or ATM mutations |
Side effects of each of the treatment approaches are covered in the relevant sections below. Patient-reported adverse effects differ substantially across the options for management of clinically localized disease, with few direct comparisons, and include watchful waiting/active surveillance/active monitoring, radical prostatectomy, and radiation therapy. The differences in adverse effects can play an important role in patient choice among treatment options. Detailed comparisons of these effects have been reported in population-based cohort studies, albeit with relatively short follow-up times of 2 to 3 years.
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Table 1 Why A Low Psa Does Not Mean You Are Cancer
The Prostate Cancer Prevention Trial included a provision that men randomized to receive placebo undergo a prostate biopsy at the end of the study, even if they had normal PSA levels and digital rectal exams. To their surprise, investigators found that many of these men had prostate cancer in some cases, high-grade prostate cancer.
PSA level 13 *Note: A PSA level over 4.0 ng/ml traditionally triggers a biopsy. Adapted with permission from I.M. Thompson, et al. Prevalence of Prostate Cancer Among Men with a Prostate-Specific Antigen Level 4.0 ng per Milliliter. New England Journal of Medicine, May 27, 2004, Table 2.
This study inadvertently provided evidence not only that prostate cancer occurs more often than once believed, but also that PSA levels may not be a reliable indicator of which cancers are most aggressive. Both findings add weight to the growing consensus that many prostate tumors currently being detected may not need to have been diagnosed or treated in the first place.
Treatment Options Under Clinical Evaluation
Treatment options under clinical evaluation for patients with prostate cancer include the following:
Cryosurgery
Cryosurgery, or cryotherapy, is under evaluation for the treatment of localized prostate cancer. It is a surgical technique that involves destruction of prostate cancer cells by intermittent freezing of the prostate with cryoprobes, followed by thawing. There is limited evidence regarding its efficacy and safety compared with standard prostatectomy and radiation therapy, and the technique is evolving in an attempt to reduce local toxicity and normal tissue damage. The quality of evidence on efficacy is low, currently limited to case series of relatively small size, short follow-up, and surrogate outcomes of efficacy.
Serious toxic effects associated with cryosurgery include bladder outlet injury, urinary incontinence, sexual impotence, and rectal injury. Impotence is common, ranging from about 47% to 100%.
The frequency of other side effects and the probability of cancer control at 5 years’ follow-up have varied among reporting centers, and series are small compared with surgery and radiation therapy. Other major complications include urethral sloughing, urinary fistula or stricture, and bladder neck obstruction.
Proton-beam therapy
Vascular-targeted photodynamic therapy using a photosensitizing agent has been tested in men with low-risk prostate cancer.
Neoadjuvant hormonal therapy
The role of neoadjuvant hormonal therapy is not established.
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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.
What Does It Mean When There Are Different Core Samples With Different Gleason Scores
Cores may be samples from different areas of the same tumor or different tumors in the prostate. Because the grade may vary within the same tumor or between different tumors, different samples taken from your prostate may have different Gleason scores. Typically, the highest Gleason score will be the one used by your doctor for predicting your prognosis and deciding on treatment options.
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Personal Stories About Having A Prostatectomy Or Radiation Therapy
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
My doctor told me I have prostate cancer. After I got over the shock, we talked about my treatment choices. My doctor told me the cancer is small, so I have taken some time to think about it. I could have surgery to remove my prostate or use radiation to try to kill the cancer. Except for this cancer, I am in good health and hope to live a good long while, so I have decided on a radical prostatectomy. I realize the surgery may cause problems with holding my urine or getting an erection, but I do not like the idea of cancer slowly growing in my prostate. I want to get rid of it and not just try to kill it with radiation.
Sam, age 50
My doctor told me after my last checkup that I have prostate cancer. I’ve got some heart problems that may make surgery more risky for me. So I’m choosing to have radiation therapy. We are also talking about using hormone therapy to try to increase the effectiveness of the treatment. I’m not concerned about the side effects. I just want to enjoy a little more time with my family.
David, age 62
Steven, age 72
Gleason Prostate Cancer Score
1960s as a way to measure how aggressive your prostate cancer may be.
A pathologist determines your Gleason score by looking at a biopsy of your prostate tissue under a microscope. They grade the cells in the biopsy on a scale of 1 to 5. Grade 1 cells are healthy prostate, whereas grade 5 cells are highly mutated and dont resemble healthy cells at all.
The pathologist will calculate your Gleason score by adding together the number of the most prevalent type of cell in the sample and the second most prevalent type of cell.
For example, if the most common cell grade in your sample is 4 and the second most common is 4, you would have a score of 8.
A Gleason score of 6 is considered low-grade cancer, 7 is intermediate, and 8 to 10 is high-grade cancer.
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What Are The Stages Of Prostate Cancer
Cancer staging is first described using what is called a TNM system. The “T” refers to a description of the size or extent of the primary, or original, tumor. “N” describes the presence or absence of, and extent of spread of the cancer to lymph nodes that may be nearby or further from the original tumor. “M” describes the presence or absence of metastases — usually distant areas elsewhere in the body other than regional lymph nodes to which the cancer has spread. Cancers with specific TNM characteristics are then grouped into stages, and the stages are then assigned Roman numerals with the numerals used in increasing order as the extent of the cancer being staged increases or the cancer prognosis worsens. Prognosis is finally reflected by considering the patient’s PSA score at presentation as well as their Gleason score in assigning a final stage designation.
The American Joint Commission on Cancer system for prostate cancer staging is as follows:
Traditionally, advanced prostate cancer was defined as disease that had widely metastasized beyond the prostate, the surrounding tissue, and the pelvic lymph nodes and was incurable. However, a more contemporary definition includes patients with lower grade disease with an increased risk of progression and/or death from prostate cancer in addition to those with widely metastatic disease.
The National Cancer Institute and the National Comprehensive Cancer Network guidelines on prostate cancer version 2.2017 indicate the following:
When Is Brachytherapy Alone The Right Choice
For a patient with disease that is confined to the prostate and not too aggressive, brachytherapy alone is a good option. With the use of sophisticated real-time computer-based planning, we can use brachytherapy to deliver radiation in an extraordinarily precise way, with minimal exposure to the surrounding normal tissues. It is also convenient for the patient as it is done in an outpatient setting and most people are able to get back to work the next day.
But brachytherapy is not right for everyone. For some patients with less-aggressive disease, a watch-and-wait approach would also be very reasonable. At MSK, our philosophy is that when the disease is caught very early meaning a low PSA level, or nonaggressive disease as reflected by a Gleason score of 6 with evidence of cancer in only a few of the biopsy samples and no evidence from the MRI of a significant amount of disease then it would be very appropriate to do active surveillance and hold off on treatment.
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The Most Common Symptoms Of Stage 3 Mesothelioma Include:
- Shortness of breath
- Fluid buildup
- Weight loss
As the tumors continue to grow and spread throughout the chest, symptoms will become more problematic. Stage 3 symptoms vary from patient to patient depending on where the cancer is spreading and if the tumor mass damages vital organs. Some patients may experience referred pain felt in the neck, back or shoulders.
A tumor invading the chest wall may cause increased chest pain, while tumors forming around the lung may lead to increased breathing difficulties. Pleural mesothelioma tumors also cause increased pleural fluid, which puts pressure on the lungs. Symptoms and characteristics of stage 3 mesothelioma vary based primarily on cancer type.
Connect with a Top Mesothelioma Specialist
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What Are The Treatments For Localized Prostate Cancer
- Surgery takes out the prostate and any nearby tissue that may contain cancer, including lymph nodes. This surgery is called a radical prostatectomy . A doctor can do it as open surgery by making a cut, or incision, in your belly or groin. Or he or she can do laparoscopic surgery by putting a lighted tube, or scope, and other surgical tools through much smaller cuts in your belly or groin. The doctor is able to see your prostate and other organs with the scope. In some places, robot-assisted laparoscopic prostatectomy may be done. In this type of surgery, the surgeon controls the robotic arms that hold the tools and scope.
- Radiation uses X-rays and other types of radiation to kill the cancer cells. This may be done with:
- External-beam radiation, in which a machine aims high-energy rays at the cancer.
- Brachytherapy , in which tiny pellets of radioactive material are injected into or near the cancer.
- Both kinds of radiation.
Radiation and surgery are treatments that destroy or remove localized prostate cancer. Both treatments also have long-term side effects, like bladder, bowel, and erection problems.
In the first 2 to 5 years after treatment, the chance of having erection or bladder problems is higher with surgery. And the chance of having bowel problems, such as an urgent need to move your bowels, is higher with radiation. But at 15 years, the chance of erection, bladder, or bowel problems is about the same with either treatment.footnote 3
Follow-up treatment
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What Are The Risks Of Radiation Treatment
Radiation treatment for prostate cancer may increase a man’s risk for having another cancer later in life, such as bladder or rectal cancer.
Some radiation side effects, like urinary problems, are usually short-term problems that go away with time. But a radiation side effect can become a long-term problem. Common side effects from radiation treatment include:
- Bowel problems, such as rectal pain, diarrhea, blood in your stool, and rectal leakage.
- In one study, 67 out of 100 men had erections firm enough for intercourse before they had radiation. Six years later, 27 out of 100 men who had radiation had erections firm enough for intercourse.footnote 4
For men with intermediate-risk or high-risk prostate cancer, radiation treatment may be given along with hormone therapy. Hormone therapy has side effects, such as the loss of bone density and muscle mass. It can also increase the risk for bone fractures, diabetes, and heart disease.
Your doctor might advise you to have surgery if:
- You are healthy enough to have major surgery.
- Radiation therapy isn’t a good option for you because you have had previous radiation therapy to your pelvic area or you have a serious bowel disease such as ulcerative colitis.
Your doctor might advise you to have radiation if:
- You want to avoid the side effects of surgery, such as leaking urine and erection problems.
- You have other health problems that make surgery too risky.
What Does It Mean To Have A Gleason Score Of 6 Or 7 Or 8
The lowest Gleason Score of a cancer found on a prostate biopsy is 6. These cancers may be called well-differentiated or low-grade and are likely to be less aggressive they tend to grow and spread slowly.
Cancers with Gleason Scores of 8 to 10 may be called poorly differentiated or high grade. These cancers tend to be aggressive, meaning they are likely to grow and spread more quickly.
Cancers with a Gleason Score of 7 may be called moderately differentiated or intermediate grade. The rate at which they grow and spread tends to be in between the other 2.
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Gleason Score For Grading Prostate Cancer
Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.
The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 3 to 5 from 2 different locations. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the pathologist determines the main pattern of cell growth, which is the area where the cancer is most obvious, and then looks for another area of growth. The doctor then gives each area a score from 3 to 5. The scores are added together to come up with an overall score between 6 and 10.
Gleason scores of 5 or lower are not used. The lowest Gleason score is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.
What Is Advanced Prostate Cancer
When prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer.
Prostate cancer is often grouped into four stages.
- Stages I & II: The tumor has not spread beyond the prostate. This is often called early stage or localized prostate cancer.
- Stage III: Cancer has spread outside the prostate, but only to nearby tissues. This is often called locally advanced prostate cancer.
- Stage IV: Cancer has spread outside the prostate to other parts such as the lymph nodes, bones, liver or lungs. This stage is often called advanced prostate cancer.
When an early stage prostate cancer is found, it may be treated or placed on surveillance . If prostate cancer spreads beyond the prostate or returns after treatment, it is often called advanced prostate cancer. Stage IV prostate cancer is not curable, but there are many ways to control it. Treatment can stop advanced prostate cancer from growing and causing symptoms.
There are several types of advanced prostate cancer, including:
Biochemical Recurrence
If your Prostate Specific Antigen level has risen after the first treatment but you have no other signs of cancer, you have “biochemical recurrence.”
Castration-Resistant Prostate Cancer
Non-Metastatic Castration-Resistant Prostate Cancer
Metastatic Prostate Cancer
- Lymph nodes outside the pelvis
- Bones
- Other organs
Metastatic Hormone-Sensitive Prostate Cancer
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