The Tnm System For Prostate Cancer Stages
As they do for most cancers, doctors use the TNM system to describe prostate cancer stages. The system uses three different aspects of tumor growth and spread:
- Tumor. Whatâs the size of the main area of prostate cancer?
- Nodes. Has it spread to any lymph nodes? If so, how far and how many?
- Metastasis. How far has the prostate cancer spread?
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:
- Small
- 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.
How Prostate Cancer Spreads
- The cells escape into the bloodstream, initially by invading small blood vessels around the tumor, then traveling to larger blood vessels that enable the cells to circulate around the body .
- The cells are filtered through the bodys lymph system although some are captured in lymph nodes, others may travel elsewhere in the body.
- The cells migrate along the length of a nerve, escaping from the prostate into adjacent soft tissue .
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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.
Can Adt Compensate For Dose Escalation
The Prostate Cancer Study III examined the addition of ADT to SDRT and DERT in intermediate-risk patients . The preliminary results of this trial have now been published in abstract form. A total of 600 patients were enrolled. Intermediate-risk prostate cancer was defined as T1/T2 disease, GS 6, PSA level 1020 ng/mL or T1/T2 disease, GS of 7, PSA level 20 ng/mL. Patients were randomly assigned to one of three arms: 6 months of ADT plus 70 Gy to the prostate , 6 months of ADT plus 76 Gy , or 76 Gy alone . ADT consisted of bicalutamide and goserelin for 6 months. RT was delivered using a 3D conformal technique and started 4 months after the beginning of ADT. Median follow-up was 6.75 years. Primary endpoints were biochemical failure and disease-free survival . Secondary endpoints included OS, as well as hormonal and radiation-related toxicities. Biochemical failure was defined as 2 ng/mL above the PSA nadir.
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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.
What Is The Difference Between 3+4=7 And4+3=7
Gleason Score: 3 + 4= 7
Gleason Score 3+4=7 is considered low to intermediate risk because the 1st number is Grade 3. Grade 3 is less aggressive than Grade 4, and is the most common cell pattern found in the biopsy sample.
Gleason Score: 4 + 3 = 7
Whereas, Gleason Score 4+3=7 is considered intermediate to high-risk because the 1st number is Grade 4. Grade 4 is the most common cell pattern found in the biopsy sample and is more aggressive than grade 3.
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How Is The Gleason Score Derived
The pathologist looking at the biopsy sample will assign one Gleason grade to the most predominant pattern in your biopsy and a second Gleason grade to the second most predominant pattern. For example: 3 + 4. The two grades will then be added together to determine your Gleason score. Theoretically, Gleason scores range from 2-10. However, since Dr. Gleasons original classification, pathologists almost never assign scores 2-5, and Gleason scores assigned will range from 6 to 10, with 6 being the lowest grade cancer.
How Is Prostate Cancer Diagnosed
If you have symptoms of prostate cancer, your provider will perform a digital rectal exam and a PSA blood test. If either of those two tests are abnormal, then most likely your provider will recommend that you have a prostate biopsy. A biopsy is the only way to know for sure if you have cancer, as it allows your providers to get cells that can be examined under a microscope.
The most common way that a biopsy is done is with a trans-rectal ultrasound . A trans-rectal ultrasound is a thin cylinder that puts out sound waves and monitors them when they bounce off of tissue. It is inserted into your rectum, and allows the provider performing the biopsy to view your prostate and choose where to remove the tissue for further evaluation. Any suspicious areas are biopsied. In addition, some tissue will be removed from all of the different parts of the prostate . The procedure is done while you are awake, with the help of some numbing medicine. Unfortunately, a trans-rectal ultrasound isnt a perfect tool. Even though many samples are taken, it can occasionally miss the area of the cancer. If this happens, and your PSA remains elevated, you may need to have the procedure repeated.
Your provider may order other tests including a bone scan, CT scan or MRI to see if the cancer has spread to the bones, lymph nodes or other organs.
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The Natural History And Molecular Biology Of Low Grade Prostate Cancer
Prostate cancer develops with age in the majority of men, including those from all races and regions. In Caucasians, the chance of harboring prostate cancer is approximately the same as ones age thirty percent of men in their 30s, 40% in their 40s, 80% in their 80s . Most of these are microfoci and low grade, particularly in younger men. The high prevalence of microfocal prostate cancer has been confirmed in autopsy studies of Caucasians, Asians, and other ethnic groups going back more than 50 years. A recent autopsy study in Japanese and Russian men who died of other causes showed that overall 35% of both groups had prostate cancer, and 50% of the cancers in Japanese men aged > 70 were Gleason score 7 or above .
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The Gleason Grading System
Screening for prostate cancer involves the prostate-specific antigen test and a digital rectal exam. If results are suspect, your doctor may recommend a prostate biopsythe only way to confirm the diagnosis.
During a prostate biopsy, a urologist uses a small needle to remove tissue samples from different parts of the prostate. These samplesalso called coresare then sent to a pathologist so they can review each one under a microscope.
The pathologist uses a pattern scale, developed by Donald Gleason, MD, PhD in 1966, to give each sample a grade from 1 to 5. Grade 1 cells are well-differentiated and look like normal tissue. Grade 5 cells, on the other hand, are “poorly differentiated” or even unrecognizable from normal tissue.
Your Gleason score is the sum of the two numbers that represent the most common types of tissue found in your biopsy. The first number in the equation is the most common grade present, the second number is the second most common grade. For example, if seven of your cores are grade 5 and five are grade 4, your Gleason score would be 5+4, or a Gleason 9.
Today, pathologists typically only flag tissue samples that are grade 3 or higher, making 6 the lowest Gleason score.
In 2014, a revised grading system for prostate cancercalled Grade Groupswas established. This system builds on the Gleason scoring system and breaks prostate cancer into five groups based on risk. This can help make it easier to understand the Gleason score scale.
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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.
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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Prostate Cancer Risk Groups
In addition to stage, doctors may use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Examples of these include the National Comprehensive Cancer Network risk group categories and the Cancer of the Prostate Risk Assessment risk score from University of California, San Francisco.
Information about the cancers stage and other prognostic factors will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.
Talk To Your Cancer Care Team
Your team is an important source of advice. Some men may benefit from having a low-risk tumor treated right away, even if they might have side effects. Discuss your treatment options and quality-of-life issues with your team.
This report is for you to use when talking with your health-care provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
04/2014
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Stage 1 Prostate Cancer
Stage 1 is the least advanced form of prostate cancer. Cancer in this stage is small and hasnt spread past the prostate gland. Its characterized by a PSA of less than 10 ng/mL, a grade group score of 1, and a Gleason score of 6.
Stage 1 prostate cancer has a 5-year survival rate of nearly 100 percent.
Do Prostate Cancer Disparities Differ By Grade
Compared with white men, African American men are more likely to develop prostate cancer and are twice as likely to die from the disease.
But, before Dr. Huangs study, it wasnt clear if the disparity in prostate cancer death occurred equally across all disease grades or if it occurred mainly in one grade, he said.
It was a question that we were surprised hadnt really been addressed, he added.
So, the researchers analyzed data from NCIs Surveillance, Epidemiology, and End Results program. First, they used a specialized SEER database containing information on more than 190,000 men with prostate cancer who underwent active surveillance, or watchful waiting, between 2010 and 2015. Patients were followed for a median of 3 years.
Active surveillance is one of several options for the management of localized low-grade prostate cancer, as is immediate treatment with surgery or radiation. Each individual patient and his doctor should make that decision together, Dr. Huang explained.
The specialized SEER database also includes information on socioeconomic statusa measurement of a persons income, education, and occupation. Socioeconomic differences can lead to health disparities such as access to treatment.
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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 American Joint Committee on Cancers 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:
- grade groups
Staging Of Prostate Cancer
The stage of a cancer describes its size and how far it has spread. The results of your tests help your doctors decide on the stage and plan your treatment.
We understand that waiting to know the stage and grade of your cancer can be a worrying time. We’re here if you need someone to talk to. You can:
Macmillan is also here to support you. If you would like to talk, you can:
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What Is A Gleason Score
Cancer cells donât look the same as healthy cells. The more different they appear, the more aggressive the cancer tends to be.
The Gleason system uses the numbers 1 to 5 to grade the most common and second most common patterns of cells found in a tissue sample.
- Grade 1: The tissue looks very much like normal prostate cells.
- Grades 2-4: Cells that score lower look closest to normal and represent a less aggressive cancer. Those that score higher look the furthest from normal and will probably grow faster.
- Grade 5: Most cells look very different from normal.
Doctors add your primary and secondary numbers together to form your total Gleason score. That tells you how aggressive the cancer is. The lowest score for a cancer 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.
Generally speaking, the higher your Gleason score, the more aggressive the cancer. That means itâs more likely to grow and spread to other parts of your body. Doctors use this information, along with the stage of the cancer, to choose the best treatment for you.
Movement Builds To Classify Gleason 6 Prostate Lesions As Nonmalignant
In prostate cancer, as in life, you roll the dice.
In craps, 3+3 is called a “hard six.” It’s hard because you can only win if you repeat with a combination of 3+3. Any other sixes you roll — 4+2, 5+1 — are losers.
Gleason 3+3 is a hard six in prostate cancer. It is the lowest grade cancer in the traditional Gleason scoring system. Still, to the eye of a pathologist, a Gleason 6 looks like a malignancy.
Now, a few experts are questioning whether this hard six is a cancer at all. Some urologists see a Gleason 6 as a noncancerous growth that has the potential to be invasive, but most likely will never spread to other organs or end up killing a man.
To a patient like me, who has been on active surveillance for 10 years, a Gleason 6 can create a big medical fuss lasting years with regular prostate-specific antigen blood tests, digital rectal exams , biopsies, and MRIs. It can cause “anxious surveillance” that prompts them to drop AS and undergo unnecessary radical prostatectomy, which poses a potential risk of impotence and urinary incontinence.
The Gleason 6 diagnosis can yield polar opposite recommendations from urologists. Ten years ago, I found this to be the case in the matter of a day.
On December 14, 2010, a local urologist recommended I undergo a radical prostatectomy within the week. When asked, he said he didn’t support active AS, then a relatively new approach for monitoring low-grade prostate cancer.
‘The right thing to do’
Mixed reactions
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