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Thread: Point & Counterpoint: Should Active Surveillance Be Used for Gleason 3+4 PCa?

  1. #1

    Point & Counterpoint: Should Active Surveillance Be Used for Gleason 3+4 PCa?

    Point: Should Active Surveillance Be Used for Gleason 3+4 Prostate Cancer? [2019, Full Text]

    https://www.cancernetwork.com/prosta...rostate-cancer

    While it remains unclear whether active surveillance in intermediate-risk patients is beneficial, it is likely that some men with intermediate-risk prostate cancer will need treatment, while others may be able to safely avoid it. The evidence suggests that those who are defined as intermediate risk based on their PSA levels, rather than stage or grade, are likely to harbor the same risk as men with low-risk prostate cancer.[9] However, the question of whether active surveillance is beneficial in men with Gleason 7 prostate cancer is more difficult. What is clear is that selection is critical. While some studies based on radical prostatectomy series have suggested that typical clinical and pathologic criteria are incapable of selecting a favorable group of intermediate-risk patients who would not be at risk for an adverse outcome when selecting active surveillance,[10] it is difficult to know whether data based on surgical patients would generalize appropriately to true active surveillance patients who are not choosing immediate radical therapy.
    ...
    At the University of Miami, we have nearly completed enrollment of 200 men who will monitor their cancer with annual MRI, prostate biopsy, and tissue genomic studies for a funded program by the National Institutes of Health/National Cancer Institute. The study allows men with up to four cores of prostate cancer, of which two can be Gleason 3+4. While most men are still in the follow-up stages of the protocol, we believe this study will provide invaluable information regarding the utility of these novel markers in men with low- and intermediate-risk cancer undergoing active surveillance. Future studies, like this one, incorporating novel risk stratification tools in the selection and monitoring of intermediate-risk patients choosing active surveillance will allow further discovery into the appropriateness of observation in these men, as well as the selection criteria that are unlikely to compromise their outcomes.

    Counterpoint: Should Active Surveillance Be Used for Gleason 3+4 Prostate Cancer? [2019, Full Text]

    https://www.cancernetwork.com/prosta...rostate-cancer

    In conclusion, men with Gleason score 3+4=7 prostate cancer represent a heterogeneous group. There are inadequate data regarding the long-term outcomes of active surveillance in these men, especially in high-risk populations such as African American men. The use of imaging and tissue-based biomarkers hold promise in helping us to find the most favorable subset of men with intermediate-risk prostate cancer for which active surveillance may be the favored initial management strategy.
    [Emphasis mine]

    See Full Texts
    69 yr at Dx, BPH x 20 yr, 9 (!) neg. Bx, PCA3-
    7-05-13 TURP for BPH (90→30 g) path neg., then 6-mo. checks
    6-06-17 Nodule on R + PSA rise on finasteride: 3.6→4.3
    6-28-17 Bx #10: 2/14 cores: G10 (5+5) 50% RB, G9 (4+5) 3% RLM
    Bone scan, CTs, X-rays: neg.
    8-7-17 Open RP, neg. frozen sections, Duke Regional
    SM EPE BNI LVI SVI LNI(5L, 11R): negative, PNI+, nerves spared
    pT2c pN0 pMX acinar adenocarcinoma G9 (4+5) 5% of prostate (4.5x5x4 cm, 64 g)
    11-10-17 Decipher 0.37 Low Risk: 5-yr met risk 2.4%, 10-yr PCa-specific mortality 3.3%
    Dry; ED OK with sildenafil
    9-16-17 (5 wk) PSA <0.1
    LabCorp uPSA, Roche ECLIA:
    11-28-17 (3 m ) 0.010
    02-26-18 (6 m ) 0.009
    05-30-18 (9 m ) 0.007
    08-27-18 (1 yr.) 0.018 (?)
    09-26-18 (13 m) 0.013 (30-day retest)
    11-26-18 (15 m) 0.012
    02-25-19 (18 m) 0.015
    05-22-19 (21 m) 0.015
    08-28-19 (2 yr. ) 0.016
    Avg. = 0.013

  2. #2
    Top User
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    Aug 2016
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    My brother chose RP with this criteria: 3 samples at G3+3; 1 at G3+4. Age 61. Had 3 positive margins at the site of the G3+4 adjacent to his rectum and a failed surgery with a post PSA of 0.03. Presurgery PSA of 7. Not much cancer, but a little bit of the bad stuff in a bad spot on the surface.

    I'm a sceptic when it comes to G4 in young men.
    Last edited by Another; 06-24-2019 at 03:45 PM.

  3. #3
    Quote Originally Posted by Another View Post
    My brother chose RP with this criteria. Age 61. Had 3 positive margins at the site of the G3+4 adjacent to his rectum and a failed surgery with a post PSA of 0.03. Presurgery PSA of 7.

    I'm a sceptic when it comes to G4 in young men.
    Pattern 4 (Gleason 7) should make anyone skeptical. However, I believe the question has become Can genomics select out those men who can be managed with AS? I think it's good that researchers are asking the question and are willing to test the hypothesis in a clinical trial.

  4. #4
    This kind of question really depends on the age and co-morbidities of the individual patient. I don't think genomic tests and imaging technology have progressed to the point where many medical doctors would advise AS for someone who is younger and better health and Gleason 7 cancer at this point in time.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  5. #5
    We need a new study. Every time a doctor is named in an AS study they should be followed to see if they are diagnosed with PCa in the future and if they elect AS.
    YOB 1957

    DX 12/18, GS 8, 4+4 6/12 cores, LL Apex 100%, LM Apex 60%, LL Mid 50%, LMM 40%, LL Base 5%, LM <5%, Right side negative.

    3/6/19. Pathology - Grade Group 4 Intraductal Carcinoma
    T3aNO, 1 mm EPE, GS8, 21 mm uni-focal tumor involved 10% of prostate.

    7 Nodes, SV, SM, PNI, and BNI were negative.

    LVI and Cribriform pattern present.

    Decipher .86 High Risk.

    Post Surgery PSA
    3/25/19 .03. (<1 month)
    4/25/19 <.03. (2 months)
    5/25/19 <.02. (3 months)
    9/10/2019. <.02. (6 months)
    11/27/2019. <.02. T<3. (9 months)

    3 Part Modality Treatment

    2/25/19 Robotic Laparoendoscopic Single Site Surgery outpatient Cleveland Clinic,

    ADT - started 6/19, end date 6/21.

    ART - Completed 9/26/19. (78 Gy, yes, I glow in the dark)

  6. #6
    An AS Case Study (NYU) aided by genomics (G6):

    Active Surveillance for Prostate Cancer [2018, Full Text]

    A 65-year-old healthy man presented for management of low-risk prostate cancer. He was diagnosed a year prior, when his prostate-specific antigen (PSA) increased from 3 ng/mL to 5.6 ng/mL (free PSA 18%). A multiparametric MRI revealed a 47-cc prostate with a PI-RADS 2 lesion in the left anterior apex. Biopsy results indicated Gleason 6 in two systematic cores (80% left lateral mid, <5% left medial apex) and benign tissue with chronic inflammation in the targeted cores. The patient chose active surveillance (AS) and presented to our clinic a year later for evaluation.

    ...

    In the current case, the patient had volume reclassification but remained in the low-risk category. Follow-up data from the Prostate Cancer Research International Active Surveillance study showed that an increase in the number of positive cores with Gleason 6 cancer did not predict a higher risk of adverse pathology at radical prostatectomy.14 As a result, such an increase is now used as a trigger for further investigation for the presence of higher-grade disease rather than an immediate switch to treatment. In our patient, further investigation has failed to identify the presence of higher-grade disease. The patient’s preference is to avoid radical therapy if possible, and the presence of concordant Oncotype DX results led to greater confidence in his decision to remain on AS

    (See the Full Text for the Evaluation and Discussion)
    Last edited by DjinTonic; 06-24-2019 at 06:50 PM.

  7. #7
    Quote Originally Posted by Duck2 View Post
    We need a new study. Every time a doctor is named in an AS study they should be followed to see if they are diagnosed with PCa in the future and if they elect AS.

    Most surgeons are cool with being operated on themselves, when its definitely called for or when its an option .

    This definitely makes sense. Surgery is their vocation and livelihood, they really believe in it and that the therapy is beneficial to patients.

    As well it should be, BTW. I'd hate to have any surgeon who didn't really believe in the specialty and only chose surgery because they like to cut people.
    Nov 2013 PSA 4.2 Biopsy Jan 2014- 1 core positive, 20% Gleason 6, doctor highly reco'ed robotic RP - 2nd opinion at UPMC April 2014, put on active surveillance. 2nd biopsy Feb 2015, results negative. PSA test Feb 2016, 3.5. 3rd Biopsy Feb 2016. 3 positive cores less than 5%, Gleason 6. Octotype DX done April 2016, GPS Score of 24--rated "Low risk". PSA test 8/2016, 3.2. PSA test 1/2018 2.2 (after 7 months of proscar) PSA test 7/2018 2.3, PSA test 7/2019 2.0


    DOB 1956, in Pittsburgh, USA

  8. #8
    Thanks, Djin,

    This question of the G 3+4 guys is always a major topic for AS groups. What we know is that AS is probably safe for 80-85 percent of them. But, that is significantly more adverse than G 6 men.

    Research has so far failed to determine a precise marker or threshold for selecting G7 men into AS programs. Like so many other questions about PCa, we will know someday...not not.
    DOB: May 1944
    In Active Surveillance program at Johns Hopkins
    Strict protocol of tests, including PHI, DRE, MRI, and biopsy.
    Six biopsies from 2009 to 2019. Numbers 1, 2, and 5 were negative. Numbers 3,4, and 6 were positive with 5% Gleason(3+3) found. Last one was Precision Point transperineal.
    PSA has varied up and down from 3 to 10 over the years. Is 4.0 as of September 2019.
    Hopefully, I can remain untreated. So far, so good.

  9. #9
    Quote Originally Posted by ASAdvocate View Post
    Thanks, Djin,

    This question of the G 3+4 guys is always a major topic for AS groups. What we know is that AS is probably safe for 80-85 percent of them. But, that is significantly more adverse than G 6 men.

    Research has so far failed to determine a precise marker or threshold for selecting G7 men into AS programs. Like so many other questions about PCa, we will know someday...not not.
    Yes, so far the standard selection parameters have failed to produce a razor-sharp criteria that will exclude those who need treatment. But I applaud the clinical trial that sees how well we can do with genomics added in. The flip side of the coin is that 80-85% of 3+4 men are probably being overtreated.

  10. #10
    Top User
    Join Date
    Aug 2016
    Posts
    1,937
    "Overtreated" is a very strong statement for a cancer forum. Many men will use that as reason to do nothing.

    We are still dealing with the mythology that PC is nothing to worry about and you will die of something else.

    Better safe than sorry is another view.

 

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