Gleason 6 prostate cancer | Why we should rename it (and why we can't)!

Is grade group 1 (Gleason 6 in old money) really prostate cancer? Wouldn't life be a little easier for patients (and the rest of the world) if we could somehow remove the label "cancer" from this relatively indolent condition??
Well this decade-old discussion seems to have developed a lot of momentum in the past year, driven by urologists like Dr Scott Eggener (University of Chicago) and Dr Matt Cooperberg (University of California San Francisco), who with others have written some nice articles to argue the case for "re-branding" grade group 1 as a non-cancer. This would certainly deal with the lingering issue of over-treatment of low-risk prostate cancer which persists to a variable extent around the world.
Alas, it's not so simple. Expert GU pathologists like Dr Eva Comperat (University of Vienna) point out that this is cancer. Period. If the clinical community have an issue with over-treatment, then we should deal with this another ways, rather than ask for the impossible.
Today we thrash this out with Scott, Matt and Eva. A great listen/watch. And maybe a way forward...
Also available as an audio-only podcast in all the usual places, or directly here www.buzzsprout.com/904063/118...

[@derekgb3780]

At present, the problem is that only biopsies determine the grade of cancer but biopsy sampling is still somewhat of a "finding a needle in a haystack" exercise. I speak from personal experience.

[@gu_cast]

Hi Derek. Sorry to hear of your personal experience of having your "haystack" biopsied. One of the big advances of the last ten years for patients in my experience is the use of MRI pre-biopsy. If the MRI is normal, we usually don't do a biopsy, and this often means that we "miss" some low grade insignificant prostate cancer. No big deal. Whereas if the MRI is abnormal, then we do a targeted biopsy, i.e. we have something to aim for in the haystack. Therefore for most patients (at least here in Australia), we are usually not just looking for needles in the haystack. Definitely a step forward. Good luck! Declan

[@robtowle1580]

As a 63 yr old who’s just received a pathology report with a single core finding of Gleason 3+3=6(grade group 1) with a 1 of 1 core (0.5mm: 5%) I’m feeling like the “wimpy” cancer poster boy! I can’t describe how helpful it is to have listened to your discussion. I’m meeting in a couple days with my Urologist and will listen to what he has to say.

[@gu_cast]

Thanks for the feedback Rob, we love hearing that these discussions are helpful to patients as well as healthcare professionals. I hope that your cancer will do very well with surveillance. Declan

[@iamric23]

you should count your blessings.

[@ikhideomo7407]

Any way to book an appointment with Dr Scott Eggener?

[@themightysquid]

I strongly agree with Dr. Comperat. You can live in denial or accept the facts, while keeping active surveillance. The truth may hurt but better to have the facts so you can monitor the progression than to be blindsided when it becomes necessary to take action. This is from my own experience after 5 years of observation and prostate growth I had to make that decision to take action when my mri showed 3 lesions and the biopsy showed 9/18 samples positive at 3+4 and one at 3+3 with a pirad 3. The year prior the mri showed one small but inconspicuous lesion with a pirad 2. Monitoring the progression along the way gave a proper perspective to our active surveillance.

[@cristiandiaz6333]

I agree in that men in group one should be minimally informed without using the word "cancer" to the extent of not worrying them which might cause mental stress. However, Urologists and physicians in general should educate men about prevention and recommend more frequent PSA testing and occasional MRIs.

[@michealolsen1344]

No harm in active monitoring.

[@EmranAskari]

We need to hear more from patients whose prostate pathology is reported as "wimpy cancer". There should be greater emphasis on the hardships they may face, such as repeated blood tests, mpMRI scans, and most importantly, re-biopsies or possibly subsequent surgery. Recently, the American Thyroid Association has also made efforts to recruit patients with the "Cadillac of cancers" and amplified their voices regarding their experience with DTC.

[@michealolsen1344]

If the random biopsy didn't miss a Gleason 3/4 or 4/3.

[@d.r.martin6301]

That patient is right that hearing the word "cancer," even if it's a "not so bad" cancer, galvanizes the adrenaline. I would be curious to know how many Gleason 6 patients ever have something nastier lurking that is unseen and unbiopsied-later getting loose. Also, what should a patient with a "high risk" genomics test like Decipher do?

[@catfish24]

I just had a Biopsy the Urologist done this in the hospital and I was completely knocked out when I woke up in the recovery room the Urologist said he took 21 core samples instead of the 12 he was at first going to do. He wanted me to see him in his office in 30 days and when I saw him then he told me 2 of the core samples came back positive for cancer he said my Gleason score was 6 my psa was 3.7 he said it was a low grade cancer and wants to do active surveillance meaning do a psa test every 3 months. I have to get up 5 to 8 times a night to pee if things keep going like they are I will probably have to have some kind of surgery to open up the urethra to be able to pee. I am thinking about going ahead and having the prostate completely removed that way it will solve all the problems. I am just dreading the surgery still haven't completely decided what to do. Man life comes at you hard when you get older . 6-2023

[@gu_cast]

Sorry to hear all of this David, but quite a relief that you don't have a significant cancer. And good to hear that your urologist recommending active surveillance. Patients in this situation can usually have their urinary symptoms managed with the usual range of options for BPH (benign prostatic hyperplasia). I'm sure that your uro will look after you well. Good luck! Declan

[@spitfirekid1]

Fellow cancer patient here. Originally Gleason six, now, Gleason 9 with metastasis. I just underwent a robotic radical prostatectomy. What did you choose to do and how are you doing?

[@DjDmt]

I got diagnosed with this 6 months ago, gleeson 6, im not sure the grade actually. My Psa was like 2 or something. I was offered active surveillance, but I have a strong family history with it, my dad passed away at 63 fighting it for 10 years as it was quite aggressive. So they have given me two options, active surveillance, or get it out, might be a over treatment, but for my age, I'm not sure, as I don't want to end up like my old man. Decisions decisions. BTW, I'm constantly going to the toilet, to the point where I have to plan bathroom trips if I'm out lol, very annoying

[@iamric23]

You need treatment, but surgery seems to be a 2nd option from what I am seeing out there.

[@hugomcclean8483]

Thanks for a great discussion, but would like to have heard more about how good quality, multiparametric MRI scanning and reporting can reliabily predict not needing biopsy, perhaps from an expert prostate radiologist. Also, more on biopsy quality - number of cores, core length and tumour involvement, glandular tissue involvement etc. Also, the expression tumour 'volume' is used several times - does this mean the percentage length of core made up of tumour? This seems to be important since a man with Gleason 6 with, say, 6 out of 18 cores with, say, 3 cores with more than 50% tumour, may more likely be offered radical prostatectomy than a man with only 2 cores with some Gleason 6. I agree that current Urology practice in some countries is harming men by giving a cancer label and overtreatment, and that this, in turn harmfully puts off the Primary Care community from offering PSA tests!

[@gu_cast]

All great comments Hugo. We have some good episodes in our back catalogue which cover some of this (links below). Tumour volume is reported inconsistently around the world. My preference is for the number and length of core to be reported, and then the length (in mm) of any cancer involvement. Very easy then to distinguish between a 0.5mm core of grade group 1, versus a 12mm core of grade group 3. Reporting just "% core involvement" can vary hugely depending on the core length. But we will definitely re-visit this and have taken note of your comments. Thansk again. Declan

[@hugomcclean8483]

@@gu_cast Thank you for responding, much appreciated. I'll look at the other threads. Best Wishes, Hugo.

[@gu_cast]

@@hugomcclean8483 kzbin.info/www/bejne/jWGupXSIbalsjtk kzbin.info/www/bejne/hnTPqnmJe5WlfK8

[@michealolsen1344]

More good than harm, unless you're a patient they misdiagnose.

[@tomjgrant]

With a "clean 3T MRI but ISO PSA 6.7 and ExoDx of 41.7 and PSA of 8.7 is a biopsy recommended? I am 76 y.o. with a prostate of 78 grams.

[@gu_cast]

Hi Tom. Apologies that we cannot give specific advice in this type of forum. But I can tell you that in my practice, in a patient like you with no family history and a normal examination, and a PSA density of 0.09, the vast majority of men will not opt for a biopsy. Good luck! Declan

[@MyFrank71]

Iam Gleason 6 is there any need for another biopsy

[@gu_cast]

Apologies white doves but we cannot give specific advice like this. But in general terms, in men in good health suitable for curative treatment if needed, then pretty much all active surveillance protocols will recommend a further biopsy at some stage. Good luck! Declan

[@davidbouchierhayes]

I think this discussion demonstrates a failure on behalf of urologists in not explaining this condition better, and not absolutely insisting in active surveillance but tailoring it for the specific patient.

[@monarc78]

and definitely..do not enact the ENACT trial...inmh

[@onthemove301]

Sorry, but as a Gleason 6 with evidence of perineural invasion I found this discussion quite lightweight, with very little in the way of statistical support for either approach. The two younger males in the US are clearly trying to make a name for themselves. They would not be successful in that endeavour if they stuck with the orthodox approach.