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Gleason 9 Prostate Cancer Prognosis

What Are Grade Groups

What Does Gleason 9 & 10 Mean? | Ask a Prostate Expert, Mark Scholz, MD

Grade Groups are a new way to grade prostate cancer to address some of the issues with the Gleason grading system.

As noted above, currently in practice the lowest Gleason score that is given is a 6, despite the Gleason grades ranging in theory from 2 to 10. This understandably leads some patients to think that their cancer on biopsy is in the middle of the grade scale. This can compound their worry about their diagnosis and make them more likely to feel that they need to be treated right away.

Another problem with the Gleason grading system is that the Gleason scores are often divided into only 3 groups . This is not accurate, since Gleason score 7 is made up of two grades , with the latter having a much worse prognosis. Similarly, Gleason scores of 9 or 10 have a worse prognosis than Gleason score 8.

To account for these differences, the Grade Groups range from 1 to 5 :

  • Grade Group 1 = Gleason 6
  • Grade Group 2 = Gleason 3+4=7
  • Grade Group 3 = Gleason 4+3=7
  • Grade Group 4 = Gleason 8
  • Grade Group 5 = Gleason 9-10

Although eventually the Grade Group system may replace the Gleason system, the two systems are currently reported side-by-side.

How Prostate Cancer Is Diagnosed And Staged

Cancer staging helps you and your doctor understand how advanced your cancer is and how much it has spread at the time of diagnosis. Knowing your cancer stage also helps your doctor determine the best treatment options for you and estimate your chance of survival.

The most widely used staging system for cancer is the TNM system that classifies cancer from stage 1 to stage 4.

TNM stands for:

  • Tumor: the size and extent of the tumor
  • Nodes: the number or extent of nearby lymph node involvement
  • Metastasis: whether cancer has spread to distant sites in the body

The TNM scale is used for many types of cancer. When a doctor uses it to determine your prostate cancer stage, theyll consider several other factors as well, including:

How Prostate Cancer Spreads And Progresses

Prostate cancer grows within the prostate gland, often for many years. Over time, the cancer spreads outside the prostate. This happens in one of three ways:

  • It grows into nearby tissues
  • It spreads through your system of lymph nodes and lymph vessels
  • It travels to distant tissues through your blood

Prostate cancer stages describe how far the cancer has spread.

Read Also: How Is Prostate Cancer Stage Determined

What Does It Mean If In Addition To Cancer My Biopsy Report Also Says Acute Inflammation Or Chronic Inflammation

Inflammation of the prostate is called prostatitis. Most cases of prostatitis reported on a biopsy are not caused by infection and do not need to be treated. In some cases, inflammation may increase you PSA level, but it is not linked to prostate cancer. The finding of prostatitis on a biopsy of someone with cancer does not affect their prognosis or the way the cancer is treated.

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Effects Of Gp On Prognosis In The After

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To compare the prognosis between the GP 4 + 5 and the GP 5 + 4 groups in the absence of effects from other covariates, a 1:1 ratio of the PSM process was performed to generate a cohort of 5,130 patients. The baseline characteristics were well-balanced . In the matched groups, the GP 5 + 4 group had a poorer OS than the GP 4 + 5 group . The GP 5 + 4 group was also associated with a higher cumulative incidence of CSM compared with the GP 4 + 5 group .

Table 2. Univariate and multivariate Cox analyses of OS .

Table 3. Univariate and multivariate analysis for CSS using the competing risk model .

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Text Mining Algorithm Evaluation

A confusion matrix was used to compare the text mining algorithm extracted against the manually coded values . The confusion matrix consists of four values: True Positives : correctly extracting the GS, True Negatives : correctly extracting a biopsy without a GS, False Positive : falsely extracting a GS and False Negative : falsely extracting the manually coded GS . The precision and recall are calculated using these four values as follows: \ and \ respectively. Precision and recall are similar to positive predictive value and sensitivity respectively. The F-score is the harmonic mean of precision and recall and is calculated using the formula \. The manually coded values were assumed to be the gold standard, i.e. exact match. Therefore, we reported the data as Exact Match: Yes and Exact Match: No for both the predicted and manually coded values.

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What Does It Mean If In Addition To Cancer My Biopsy Report Also Mentions Acute Inflammation Or Chronic Inflammation

Inflammation of the prostate is called prostatitis. Most cases of prostatitis reported on biopsy are not caused by infection and do not need to be treated. In some cases, inflammation may increase your PSA level, but it is not linked to prostate cancer. The finding of prostatitis on a biopsy of someone with prostate cancer does not affect their prognosis or the way the cancer is treated.

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Not All Men With Gleason 8

There is a perception among a lot of patients especially when they get diagnosed that having a high Gleason score of 8, 9, or 10 is essentially a death sentence, regardless of how they get treated. This is not actually the case at all. Plenty of men with Gleason 8 to 10 disease actually do well after treatment. And it has long been assumed that this was the case in particular if they were identified and treated early while they had truly organ-confined disease.

A newly published paper by Fischer et al. has now confirmed this assumption through a careful retrospective analysis of data from > 450 men whose records could be identified in the SEARCH database, all of whom received surgical treatment for Gleason 8 to 10 prostate cancer.

Fischer and his colleagues set out to identify whether, among a large cohort of men who had pathologic Gleason scores of 8 to 10 after surgery, they could identify particular subsets who were at meaningfully greater of lesser risk for biochemical progression within 2 years of their surgery. To do this, they identified a total of 459 eligible patients within the SEARCH database and categorized these men into one of five different groups:

They then used the data from these five groups of men to compare their risks for biochemical recurrence at 2 years, showing the following findings:

  • Similar results were observed after adjustments were made to allow for variations in PSA level, age, and clinical stage.
  • The Updated Gleason Grading System Is Misleading For Patients And Physicians

    Understanding The Gleason Score | Prostate Cancer Staging Guide

    The Gleason grading system, based on five architectural patterns of a tumor, has evolved over time.4 For practical purposes, Gleason patterns 1 and 2, or scores 2 to 4 noted in the classic system, are not diagnosed on needle biopsies because of poor correlation with radical prostatectomy grade and poor reproducibility among expert pathologists.5 The Gleason system has been modified based on a 2005 consensus conference,4 whereby lesions previously referred to as Gleason scores 2 to 4 in the classic system are now assigned a higher grade in the modified system however, those previously graded as Gleason score 6 in the classic system are often graded as Gleason score 7 tumors in the modified system. Although this modification of grading could improve the prognosis of some men who have cancer-specific outcomes intermediate between the modified Gleason score 6 and the classical Gleason score 3 + 4 cancers,6 the larger effect of the 2005 modification has been to improve the perceived cancer-specific survival by 26% through the Will Rogers phenomenon.7

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    Clinical Outcomes For Patients With Gleason Score 910 Prostate Adenocarcinoma Treated With Radiotherapy Or Radical Prostatectomy: A Multi

    • Amar U. KishanCorrespondenceCorresponding author. Department of Radiation Oncology, Suite B265, 200 Medical Plaza, Los Angeles, CA 90095, USA. Tel. +1 825 9771 Fax: +1 825 7194.
    • Department of Radiation Oncology, University of California, Los Angeles, CA, USADepartment of Radiation Oncology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
    • Department of Urology, University of California, Los Angeles, CA, USADepartment of Urology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Grading After Radiation And Hormonal Therapy

    In general, the Gleason grading system should be applied only to tumor that shows no evidence of treatment effect. For radiation therapy cases, where there is no evidence or minimal evidence of therapy effect, Gleason grading may be utilized. Hormonal therapy can cause pattern alterations resembling high Gleason grades. Overall, the consensus view is that one should not report histologic grade after hormonal therapy.

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    What Can Affect My Outlook

    No one can tell you exactly what will happen. How prostate cancer affects you will depend on many things.

    • Your stage Whether your cancer is localised, locally advanced, or advanced.
    • Your Gleason score or grade group The higher your Gleason score, the more aggressive the cancer, and the more likely it is to spread.
    • Your treatment options You may be able to have treatment aimed at getting rid of the cancer. Or you may be able to have treatment to keep the cancer under control. Read more about choosing your treatment.
    • Your health If you have other health problems, you may have fewer treatment options. And you may be more likely to die from another condition, such as heart disease.
    • Your PSA level After youve been diagnosed, PSA tests are a good way of monitoring your prostate cancer and seeing how youre responding to treatment.
    • How successful your treatment is Your treatment may be successful at getting rid of your cancer or keeping it under control. But for some men, treatment may not work as well as expected.

    Outlook For Men With Localised Prostate Cancer

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    Most localised prostate cancer is slow-growing and may not need treatment or shorten a mans life. For many men who have treatment for localised prostate cancer, the treatment will get rid of the cancer. For others, treatment may be less successful and the cancer may come back. If this happens, you might need further treatment.

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    So Why Does Gleason 3+3 Mean Cancer

    Thats the question raised by Wolinsky. If we strictly interpret the original Gleason scores, a grade of 3 is given once cells that look like cancer are starting to appear, disrupting the structure of normal prostate tissue. Tucked into this score is the assumption that these early cancer cells will inevitably mutate into increasingly aggressive rogue cells.

    This assumption may very well be fake news. The facts show otherwise. According to PCa expert Dr. Laurence Klotz, who is one of the earliest proponents of the notion that Gleason 3+3 is NOT cancer, we now know that Gleason 3 and Gleason 4 are like night and day, that the molecular genetics of most Gleason 3 is normal. The metastatic potential is approximately zero.

    This means that just because it looks like a cancer cell under the microscope doesnt mean it behaves like a cancer cell. Most types of tumor cancers become more aggressive, eventually spreading to other organs and parts of the body. Klotz and others point to three cancers that are exceptions:

    • Glioblastoma, a deadly brain cancer that infiltrates throughout the brain but does not metastasize beyond the brain
    • Basal cell carcinoma, a common skin cancer that can grow but almost never metastasizes beyond itself
    • Gleason 3+3 prostate cancer, in itself, has never been proven to metastasize.

    Wolinsky quotes Dr. Scott Eggener of the University of Chicago:

    Text Mining Precision And Recall

    The first text mining algorithm output reported an F-score of 0.99 . On manual inspection of the N-grams , we identified that two different GS were reported in both the clinical history and pathological diagnosis for 16 biopsies . The algorithm was updated to report the latter GS resulting in an F-score of 1.00 . The text mining algorithm was tested on the validation dataset and reported an F-score of 0.99.

    Table 3 Performance of the text mining algorithm to automate the extraction of the Gleason score from narrative prostate biopsy narrative reports

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    What Does Gleason 6 Mean

    A Gleason score of 6 is different from other prostate cancer diagnoses because it means all the biopsy samples are grade 3 . Though the samples dont look like normal tissue, no grade 4 or 5 samples were found.

    Gleason 6 prostate tumors are:

    • Confined to the prostate
    • Not causing any symptoms

    There are changes at the cellular level, but the prostate cancer is likely slow-growing and has a low-risk of metastasizing, or spreading to other areas of the body.

    This knowledge allows your doctor to monitor you and see how your tumor changes over time.

    What Does It Mean If My Biopsy Report Mentions The Word Core

    Treating High-Risk Gleason 8: A Modern Approach | Mark Scholz, MD | PCRI

    The most common type of prostate biopsy is a core needle biopsy. For this procedure, the doctor inserts a thin, hollow needle into the prostate gland. When the needle is pulled out it removes a small cylinder of prostate tissue called a core. This is often repeated several times to sample different areas of the prostate.

    Your pathology report will list each core separately by a number assigned to it by the pathologist, with each core having its own diagnosis. If cancer or some other problem is found, it is often not in every core, so you need to look at the diagnoses for all of the cores to know what is going on with you.

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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.

    Prostate Cancer Treatment Health Professional Version

    On This Page

    The median age at diagnosis of carcinoma of the prostate is 66 years. Prostate cancer may be cured when localized, and it frequently responds to treatment when widespread. The rate of tumor growth varies from very slow to moderately rapid, and some patients may have prolonged survival even after the cancer has metastasized to distant sites, such as bone. The 5-year relative survival rate for men diagnosed in the United States from 2010 to 2016 with local or regional disease was greater than 99%, and the rate for distant disease was 30% a 98% survival rate was observed for all stages combined. The approach to treatment is influenced by age and coexisting medical problems. Side effects of various forms of treatment should be considered in selecting appropriate management.

    Many patientsespecially those with localized tumorsmay die of other illnesses without ever having suffered disability from the cancer, even if managed conservatively without an attempt at curative therapy. In part, these favorable outcomes are likely the result of widespread screening with the prostate-specific antigen test, which can identify patients with asymptomatic tumors that have little or no lethal potential. There is a large number of these clinically indolent tumors, estimated from autopsy series of men dying of causes unrelated to prostate cancer to range from 30% to 70% of men older than 60 years.

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    Stages Of Prostate Cancer

    Doctors combine the T, N, and M results with the Gleason score and PSA level in a process called stage grouping. The system uses Roman numerals from I to IV . The stage helps your doctor choose the best course of treatment for you.

    Stage I

    • The cancer is growing in your prostate but hasnât spread beyond it.
    • In most cases, the doctor canât feel the tumor during a DRE or see it in imaging tests.
    • The Gleason score is 6 or less, and the PSA level is less than 10.
    • The tumor is in half or less of one side of the prostate.

    Stage IIA

    • The cancer is growing in your prostate but hasnât spread beyond it.
    • The doctor may or may not be able to feel the tumor during a DRE or see it on an imaging test.
    • The tumor can touch more than half of one lobe of the prostate but doesnât involve both lobes.
    • The Gleason score is 7 or less, and the PSA level is less than 20.

    Stage IIB

    • The cancer is growing in your prostate but hasnât spread beyond it.
    • The doctor may or may not be able to feel the tumor during a DRE or see it on an imaging test.
    • The tumor can be in one or both lobes of the prostate.
    • The Gleason score is 7, and the PSA level is less than 20.

    Stage IIC

    • The cancer hasn’t spread beyond the prostate.
    • The doctor may or may not be able to feel the tumor during a DRE or see it on an imaging test.
    • The tumor can be in one or both lobes of the prostate.
    • The Gleason score is 7 or 8, and the PSA level is less than 20.
    • The cancer cells appear more abnormal than in stage IIB.

    Stage IIIA

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