Do some men who supposedly have organ-confined, Gleason 6 prostate cancer progress after first-line therapy? Yes, they do. And if one believes the Johns Hopkins data it would appear that in the cases of most of those patients a restrospective analysis of their pathology showed that they actually had a higher grade at the time of treatment. (In other series they may also not have had truly organ-confined disease.)

Do some men with true Gleason 6 disease progress? Yes they do. And based on the Johns Hopkins data it appears to be 0.4% of their patients. One wonders whether they were, in fact, truly organ-confined. Rare patients with all the indicators of organ-confined, low risk disease do progress because we find out later that they had a small micrometastasis.

Since you were only 42 at the time of treatment, is it true that you probably have 20+ more years to progress than a similar man diagnosed at age 60? Yes, obviously it is. (But you can’t progress if there are no prostate cancer cells, however long you live!)

I suppose a crucial question is, what would you do about it today if we could tell you that there was (say) a 21.3% probability that you would progress in 34 years time?

If the Johns Hopkins data are correct, you have 996 chances out of 1,000 that you will never have biochemical progression. Most men would be happy to accept those odds. If it makes you feel better, ask Hopkins to reassess your surgical pathology slides so that you can be absolutely sure there was no sign of any Gleason 4 cancer.

Actually this study says very little about the quality of biopsy data. It is entirely about the accuracy of the pathological assessment of the available tissue. If we start to do 3D mapping biopsies on everyone with an initial diagnosis of Gleason 6 disease, we will undoubtedly bankrupt Medicare nearly twice as fast as already predicted!

More needles may be better for some patients — but not for everyone.

The great unanswered question of how many men with truly organ-confined, Gleason 6 prostate cancer needed treatment at all might have been answered by 3D mapping biopsy.

Take a look at http://www.urotoday.com/index.php?option=com_content&task=view_ua&id=2224546.

Connecting the dots — more needles is better, needles accurately placed using a 5 mm grid better still.

Seems like you’d want to know the nature of the prostate cancer before choosing to treat or monitor.

This also makes you wonder if pattern 4 and Gleason scores of 7+ are the disease, and that scores less than that are a condition.