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

  1. #11
    Senior User
    Join Date
    Nov 2018
    Posts
    249
    I think would agree with Another. Look at my signature. GS 3+4 with 3 positive cores none above 50% and 1 at 5% even though was in base and mid. Biopsy looked pretty good for a cure and even though final pathology remained GS 3+4 and only where found on the biopsy it still had gotten into the left seminal vessel. Don't know how that will turn out but sure couldn't have waited any longer. Also when referred to Urologist my psa was only 4.05
    DOB 1955
    63 at dx
    3/2018 PSA 4.05 DRE normal refer to URO small town
    10/2018 PSA 6.28 DRE normal
    Bx 11/2018 12 cores 3 pos 1 - 5% left mid 2 - 50% left base
    GS 3+4=7 T1c
    Appt Mayo Clinic Phoenix Az 1/4/2019
    Dr. Paul Andrews recommend
    MRI 2/27/2019 Mayo AZ
    RALP 2/28/2019 Mayo AZ Dr. Paul Andrews
    Path: GS 3+4=7, Tertiary Gleason Pattern none, Grade Group 2
    Tumor presents moderate to extensive volume mainly posterior
    portion of prostate. Largest tumor nodule measures 8 mm
    Prostate: 21g 3.5 x 3 x 3 cm
    EPE: Neg
    Bladder Neck Invasion: Neg
    Seminal Vesicle Invasion: Pos (left seminal vesicle)
    Margins: Pos left lateral base & central base 2mm focus each
    Lymph Nodes involved: 0
    Lymph Nodes Ex: 16
    Nerves spared right side only
    Path Staging (AJCC 8th Edition)
    Primary Tumor pT3b
    Regional lymph nodes: pNO
    Distant Metastasis: Mx
    Continence 99% 9 wks
    ED Present
    PSA 4/17/2019 <.10
    PSA 5/2/2019 <.007
    PSA 6/10/2019 <.10
    PSA 8/1/2019 <.007
    PSA 9/16/2019 <.10

  2. #12
    Quote Originally Posted by nmguy View Post
    I think would agree with Another. Look at my signature. GS 3+4 with 3 positive cores none above 50% and 1 at 5% even though was in base and mid. Biopsy looked pretty good for a cure and even though final pathology remained GS 3+4 and only where found on the biopsy it still had gotten into the left seminal vessel. Don't know how that will turn out but sure couldn't have waited any longer. Also when referred to Urologist my psa was only 4.05
    nmguy, that's the point. We don't know for certainty which 3+4 men need treatment! The odds aren't good to bet your life. And we do know some 3+3 need it as well.

    But in your case if more than 2 of your biopsy cores were 3+4 you wouldn't have qualified for the U. of Miami study to begin with. Perhaps biopsy genomics would have made the SVI+ less of a surprise (not that I think it's essential for a 3+4 opting for treatment, although I personally would want it after RP with any G score from 6 up if I were SVI+).

    And overtreatment is what happens with many men who get treatment for BCR. But who wants to risk going without?

    And yes, I agree overtreatment is a bad PR term, although it's the correct one used in the medical literature, and the way I meant it.

    Examples:

    A new predictor is comparable to the updated nomogram in predicting the intermediate- and high-risk prostate cancer but outperforms nomogram in reducing the overtreatment for the low-risk Pca [2019, Full Text]

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500873/

    Cost implications and complications of overtreatment of low-risk prostate cancer in the United States [2019]

    https://www.ncbi.nlm.nih.gov/pubmed/25583770

    The ability to avoid treating the 80% of men with low-grade disease who will never die of prostate cancer would save $1.32 billion per year nationally.
    Just because we currently can't say which (if any) intermediate-risk men can safely start out on AS doesn't mean we should stop looking for it. I think both sides in the above Point/Counterpoint agree on that.
    Last edited by DjinTonic; 06-25-2019 at 11:50 AM.

  3. #13
    I will agree with the intent of Another’s post.

    While overtreatment is an accepted term, as Djin points out, there is way too much laxity among low risk men who are not active about their surveillance. This has been shown repeatedly. There are even forums where men discuss their own AS plans, and question further protocol testing, especially biopsies, and MRI’s with contrast.

    This is heresy to me, as much as my insistence on scheduled testing and following my specialists’ advice is anathema to them.

    So, IMHO, while AS testing gets more accurate, the unwillingness of many patients to follow directions, remains an unsolved problem.
    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.

  4. #14
    Quote Originally Posted by ASAdvocate View Post
    I will agree with the intent of Another’s post.

    While overtreatment is an accepted term, as Djin points out, there is way too much laxity among low risk men who are not active about their surveillance. This has been shown repeatedly. There are even forums where men discuss their own AS plans, and question further protocol testing, especially biopsies, and MRI’s with contrast.

    This is heresy to me, as much as my insistence on scheduled testing and following my specialists’ advice is anathema to them.

    So, IMHO, while AS testing gets more accurate, the unwillingness of many patients to follow directions, remains an unsolved problem.
    Hey, as a guy who nonchalantly walked into his umteenth biopsy and got a Gleason 10 surprise that wiped the smile of his face, I say and have advocated that whenever a trustworthy uro wants a biopsy, get one!* And knowing what I do now, if I had had a low-risk diagnosis, I would want my uro to convince me not only that I could do AS, but that AS was my best choice (and he better have my genomics test result to back him up).

    Men going into AS programs need to be made aware that a big chunk of them (30-40%?) will be advised to have treatment at some point.

    We are willing to shell out a couple of dollars for a 1 in tens or hundreds of millions chance of winning a lottery, but who wants to risk even a 1 in 10 chance of ignoring a PCa situation that could kill you, whether that's before or after primary treatment?

    Unfortunately, some, but not, all overtreatment is (necessarily) baked into the treatment cake. And I agree with Another that "Better safe than sorry" beats "Don't be one of The Overtreated!" as a better philosophy and ad campaign.
    _________________
    *Full disclosure: I fibbed for dramatic effect: my uro had felt a new nodule, which prompted the last biopsy. There was no smile going into the biopsy.
    Last edited by DjinTonic; 06-25-2019 at 12:51 PM.
    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(16): 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 check)
    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

  5. #15
    I decided on active treatment even with a very low G4. I was relatively young and the idea of AS with any G4 was enough to for me to pull the trigger and have RP. And it turns out that the biopsy missed the majority of the G4. I am very glad I was aggressive.

  6. #16
    For those interested, here is a study on the use/integration of a genomics test (Decipher, in this case) with current thinking about evaluation tools (like CAPRA) and accepted AS criteria:

    Validation of the Decipher Test for predicting adverse pathology in candidates for prostate cancer active surveillance [2018, Full Text]

    The underutilization of AS is due, in part, to concerns about misclassifying disease risk when using standard clinical parameters [7, 8]. This concern is highlighted by the observation that ~36% of low grade cancers based on biopsy have high grade disease following prostatectomy [9]. Patel et al. reported that 25% of patients with low volume GS 3 + 4 on biopsy harbor adverse pathology (AP), defined as GS at least 4+3, advanced local stage (pT3b or greater) or lymph node involvement (LNI), upon radical prostatectomy (RP) [7].

  7. #17
    Regular User
    Join Date
    Jul 2017
    Posts
    25
    I too had too many positive cores. It was my lymph nodes that lit up that caught my attention. They turned out to be be benign, but G5 was found on pathology.
    PSA 1/2013 was 3.6, DRE normal.
    PSA 8/2014 was 5.5, DRE normal.
    Open RP 11/20/2014. Age 55.
    Pathology from surgery:
    Gleason 3+4=7, Tertiary Pattern 5 (15%)
    Tumor size: 30x 24x 12 mm
    Extraprostatic extension present nonfocal (established, extensive) right and left posterior
    Seminal vesicles, bilateral +
    Positive margins, multifocal, Apical, Postero-lateral
    Perineural invasion +
    19 Lymph nodes, Negative, Tumor t3b
    Adjuvant RT, 1/16
    PSA 7/19, <0.01

  8. #18
    Djin, Thanks for this article. It referenced a researcher named Rahul Parikh. I googled him and found more of his research on AS.

    Just one nit about his articles. He states that only 14 percent of low risk men are choosing AS. I checked and see that he was using data from 2010-2013. The rate as of 2016 is 42 percent choosing AS according to SEER, and that number is probably close to 50 now.

    The more information and data, the more questions....
    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. #19
    Quote Originally Posted by ASAdvocate View Post
    Djin, Thanks for this article. It referenced a researcher named Rahul Parikh. I googled him and found more of his research on AS.

    Just one nit about his articles. He states that only 14 percent of low risk men are choosing AS. I checked and see that he was using data from 2010-2013. .
    When I was diagnosed in January 2014, I was told that 90% of men choose treatment with 70% of all men choosing surgery. So that would be close to the numbers Parikh is citing
    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

  10. #20
    Top User
    Join Date
    Aug 2016
    Posts
    1,768
    A question, what are the percentages of the general category of genomic testing "low risk" of adverse conditions being discovered or realized? It is my understanding they can range as high as 10%.
    Born 1953
    family w/PCa; grandfather, 3 brothers
    07-12-04 PSA 1.90
    07-10-06 PSA 2.02
    08-30-07 PSA 3.20
    12-01-11 PSA 5.69 Internist recommends urologist, I say no
    05-16-12 PSA 4.76 manipulate w/diet & supplements
    12-11-12 PSA 5.20, Health system changes to 3 years on testing
    03-07-16 PSA 7.20 Internist adamant on urologist
    DRE smooth, enlarged
    03-14-16 TRUS biopsy-prostatic adenocarcinoma 1%-60% across 8 of 12 samples, Gleason 3+3=6
    03-31-16 MRI pelvis w/o dye
    05-04-16 DaVinci prostatectomy, nerve sparing, Dr. Kent Adkins - recommend
    Final Path; weight 65g, lymph nodes, seminal vesicles, capsule, margin all negative, Gleason 3+4=7, Tumor volume 35%, +pT2c
    Catheter out - 16 days
    Incontinence at 6mos is minimal – no pad
    Cialis 3x/wk & Viagra on occasion
    Begin self-injection needle therapy for erections, stop after 6 due to onset of Peyronie’s
    Erections 100% - 14 months
    5-21-19 PSA <0.02, Zero Club 3.5 years

 

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