Several reports have clearly shown that biochemical recurrence (a rising PSA) after first-line treatment is more common among men with a Gleason score of 4 + 3 = 7 than it is in men with a Gleason score of 3 + 4 = 7. However, there has been no confirmation of an association between these Gleason scores and risk for prostate cancer-specific death.
Wright et al. have now published a retrospective analysis of data from 753 men aged between 40 and 64 years of age who were diagnosed with prostate cancer between 1993 and 1996 in King County, Washington. Prostate cancer recurrence and/or progression was determined by using a follow-up survey and medical record review. Mortality and cause of death were obtained from the Seattle-Puget Sound Surveillance, Epidemiology and End Results (SEER) registry.
The study showed that:
- 65/753 patients (8.6 percent) actually died of prostate cancer during a median follow-up of 13.2 years.
- The 10-year prostate cancer-specific survival rate categorized by Gleason score was as follows:
- Gleason score 6 or less — 98.4 percent
- Gleason score 3 + 4 = 7 — 92.1 percent
- Gleason score 4 + 3 = 7 — 76.5 percent
- Gleason score 8-10 – 69.9 percent
- Compared to patients with Gleason 3 + 4 disease, those with Gleason 4 + 3 tumors were at significantly increased risk for prostate cancer-specific mortality.
- Compared to patients with Gleason 3 + 4 disease undergoing curative therapy with radical prostatectomy or radiation therapy, those with Gleason 4 + 3 tumors had an increased risk for recurrence and/or progression and prostate cancer-specific mortality.
- There was no observable difference in prostate cancer specific-mortality between patients with Gleason 4 + 3 tumors and those with Gleason 8-10 tumors.
The authors conclude that (in men diagnosed with localized prostate cancer between 40 and 64 years of age) tumors with Gleason scores of 3 + 4 and 4 + 3 tend to have different impact on prostate cancer specific mortality, and that these data “provide important information for counseling patients with Gleason 7 prostate cancer on the natural history of the disease.”
While The “New” Prostate Cancer InfoLink would like to see these data confirmed through analysis of data from another population-based series of patients, we feel that this is an important analysis which does certainly confirm that Gleason 4 + 3 = 7 tumors behave more like Gleason 8-10 tumors, even with respect to the potential impact on prostate cancer-specific mortality. On the other hand, we would also emphasize that, based on the same set of data, the 10-year prostate cancer-specific survival rate of even the patients with Gleason scores of 8-10 was only fractionally under 70 percent.
It should also be noted that men diagnosed with clinically localized prostate cancer between 1993 and 1996 were probably at significantly greater risk for pathologically non-localized disease than men being diagnosed with clinically localized disease today. This suggests that men being diagnosed with Gleason 4 + 3 or Gleason 8-10 disease today may have a significantly greater probability of 10-year prostate cancer-specific survival than comparable men being diagnosed in the mid-1990s.
Filed under: Living with Prostate Cancer Tagged: | Gleason score, prostate cancer-specific survival
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Does anyone know, did they also report on how many of the men died during those first 10 years of “other causes”? That issue looms higher and higher on my radar screen as I experience the long-term side effects of having and being treated for this miserable disease.
Dear Mr. Arnold:
As far as I can tell, the complete paper does not contain definitive information about the number of patients who died of non-prostate cancer-specific causes at 10+ years of follow-up.
One can infer from data provided in the paper that about 80 patients might have died of “other causes.” However, this is not explicitly stated anywhere in the paper.
If you want to get a precise answer to this question, my suggestion would be that you e-mail the primary author, Dr. Jonathan Wright, and see if he is able to give you this information.
As I understand this new study from Seattle, involving men aged between 40 to 64 years, it showed, in a median follow up of 13.2 years, a 10-year prostate cancer specific survival rate for men with a
• Gleason score of 6 or less as 98.4% (1.6% disease specific mortality rate)
• Gleason score of 3 + 4 as 92.1% (7.9% disease specific mortality rate)
• Gleason score of 4 + 3 as 76.5% (23.5% disease specific mortality rate)
• Gleason score of 8-10 as 69.9% (30.1% disease specific mortality rate)
I wondered how these figures compared with the Albertsen study (JAMA 1998 Sep 16;280(11):975-80) which was intended to be a competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer.
The men in that study were either not treated or treated with immediate or delayed hormonal therapy, and they had the following estimated chance of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis:
• Gleason scores of 2 to 4 — 4 to 7% (96 – 93% disease specific survival rate)
• Gleason score of 5 — 6 to 11% (94 – 89% disease specific survival rate)
• Gleason score of 6 — 18 to 30% (82 – 70% disease specific survival rate)
• Gleason score of 7 — 42 to 70% (58 – 30% disease specific survival rate)
• Gleason score of 8 to 10 — 60 to 87% (40 – 23% disease specific survival rate)
I know this is not a direct comparison, but feel it is not quite chalk and cheese. I felt that the following points might be relevant and account for some of the apparent anomalies:
1. The new study makes no mention of tumors with Gleason scores of 5 or less. This seems to be because such ‘tumors’ are no longer classified as prostate cancer.
2. There has been a significant “migration” of Gleason scores in the last 10 years or so, by a point or two. This would mean that, for example an Gleason 5 in the Albertsen study might be a Gleason 6 or even a Gleason 3 + 4 in the later study.
3. The men in the Albertsen study were within an older range –- 10 years older –- and therefore were closer to the median age for prostate cancer deaths (which has stayed at about 83 years of age (i.e., half the men who die from PCa are older than 83 when they die)
Given these, and no doubt, other considerations, there does not seem to be a great deal of difference between the outcomes in the two studies and what difference there is may well be due to the better medical care available now.
My dad has prostate cancer. His PSA level is 121. Is this possible?
Dear Roberto:
Yes, it is perfectly possible for someone to be diagnosed with prostate cancer with a PSA of over 100 ng/ml. In fact, back in the early 1990s — before widespread PSA testing was available — this was very common.
The problem with a diagnosis in which the PSA is this high is that that cancer is almost certainly no longer limited to the prostate — but hormone therapy can still be extremely effective at getting your Dad’s PSA level back down to very low levels so that biochemical progression of the disease is delayed.
Mi padre tiene un PSA o Gleason de 7.9. ¿Es muy elevado?, despues de un resonancia le han mandado una prueba de huesos. ¿Eso significa que hay metastasis?
Gracias
Un valor de PSA de 7,9 no es muy alta. Es sólo un poco por encima de los niveles medios. Esto puede ocurrir por muchas razones. El cáncer de próstata es sólo una de estas razones.
Sería muy raro que un hombre con un PSA de 7,9 para tener cáncer de próstata metastásico.
Hi, my husband’s PSA was 1060 ! prior to beginning Lupron. After six weeks, it was 10. The prostate cancer is also in the groin lymph node. A CAT scan will be done in the pelvic area to see what’s going on. He had planned on having proton beam therapy at Loma Linda University Medical Center. Is it possible for the cancer cells in the lymph node not show up after 3 months of Lupron therapy? In order to have the treatment at LLUMC, the cancer cells must be confined to the prostate. Help. Our urologist has been remiss in giving us information.
Dear Brenda:
Something doesn’t “smell right” here. A man who has a PSA of 1,060 ng/ml at diagnosis should have been given a bone scan to look for signs of metastatic prostate cancer as soon as he was diagnosed. Did you husband get such a scan? If so, what waS the result?
It is almost inevitable than a man who is initially diagnosed with a PSA of 1,060 ng/ml has disseminated proistate cancer (i.e., it is not confined to his prostate). Proton beam radiation seems most unlikley to be appropriate.
On the other hand, the good news is that your husband seems to be responding extremely well to the hormone therapy. You might want to get a second opinion from a medical oncologist (as opposed to a urologist).
My husband is 55 years old; PSA 850; biopsy Gleason score 10; 6 of 12 left side only cores positive 95%, 75%, and 50%; bone scan clear; CT scan everything clear; treated with Lupron and Casodex; PSA down to 0.2 in 3 months; added radiation; PSA now 0 after 8 months; still on Lupron; everything is too such extremes; can’t find any literature for a comparison.
Dear Shannon:
The form of prostate cancer you describe is much more like the way prostate tended to be diagnosed 20 years ago than the current situation.
The good news is that despite the high PSA level and the high Gleason score, your husband still has no sign of metastasis and he has responded really well to the hormone therapy. So long as this continues to be the case, he could do very well. However, you do need to understand that he is at very high risk for progression at almost any time, and he needs to make sure he is getting his PSA monitored every 3 months — like clockwork. There is no known curative therapy for men like your husband at this time … but survival times for men like this still can be many years.
The other piece of good news is that — by comparison with the situation 20 years ago — there are now many therapeutic options even when primary hormone therapy does stop having the effect it is currently providing … and there are even more such products in clinical development.
The literature I have read on laser ablation treatment seems very promising. How long before it goes “mainstream”?
This is a complete guess, but I would figure it is going to be at least another 10 years and maybe never.
For laser-based radical prostatectomy to start to go “mainstream,” most urology residency programs would need to have the relevant equipment, an expert skilled enough to teach the technique, and enough data to demonstrate that it was at least as effective and easy to carry out as “standard” robot-assisted laparoscopic prostatectomy. Just to give you an example, it took about 20 years for laser-based transurethral resection of the prostate to become commonplace.
My dad was diagnosed with prostate cancer in 2004 His PSA was 19.3, Gleason score 3 + 4 = 7. He was scheduled for a radical prostatectomy but declined at the last moment. Now, 7 years later, his PSA is 121. I’m so afraid and almost certain that the cancer has metastasized beyond the prostate. He is scheduled for a CT next week.
Am I close to being correct and — if metastasis has occurred — what treatment will be best, if any?
Denia
Dear Denia:
First the bad news … Yes, there is a very high likelihood that a man with a PSA > 100 ng/ml has at least micrometastatic and potentially metastatic disease — especially after a diagnosis of localized prostate cancer 7 years ago. (In the former — micrometastatic — case, the cancer has spread outside the prostate but extraprostatic tumors are not yet visible on a CT scan or a bone scan. In the latter — metastatic — case, there will be clear evidence of metastatic tumors on a bone scan or a CT scan.)
Now the good news … The vast majority of such patients respond very well to hormone therapy, and may do so for a considerable period of time — 15+ years is not unknown. There are some side effects to this type of therapy, but ideally the hormone therapy will drop his PSA level back down to near to zero, and he will be able to adapt to the side effects.
Denia,
My website incorporates the experiences of over 1,000 men diagnosed with prostate cancer. (You can click here to find the index to all the personal stories on the Yananow web site.) As the SiteMaster says, there is no doubt that your Dad’s situation is high risk, and on the Yananow site there are the stories of men who have passed on after having such diagnoses, BUT … there are also stories of hope, of men who had even worse diagnoses who have survived for years, and are still there to help with advice on how to manage this awful disease.
Hi. My Dad (68 years old) has a PSA of 74 and got a biopsy with a Gleason score of 3 + 4 = 7. His pathology report says adenocarcinoma of the prostate and presence of perineural invasion with mild inflammation. Total linear amount of carcinoma is 99 mm. The proportion of total issue involved by tumor is 72%. What do you think and advise? What should be best therapy? What should be the survival rate? Any precautions? … THANKS!
Dear B:
The important question here is whether your father already has metastatic disease … which is very possible with a PSA of 74 ng/ml and so much cancer in his prostate on biopsy. Your father needs to get a bone scan to see if there is evidence of metastatic disease. However, it is also possible that he has so-called micrometastatic disease (in which the disease has already spread far outside his prostate, but only in very small foci that would not be evident on a bone scan).
Until you can get some idea of whether your father’s cancer has metastasized or not, it is quite impossible to know what the most appropriate type opf treatment might be.
Thanks for quick response. His bone test was clear. No sign of spread. How to find out micrometastatic disease?
There is no easy way to know whether cancer has micrometastasized. You could ask about having a laparoscopic lymph node dissection prior to any actual treatment to see if there was cancer in the lymph nodes. You could also ask about having a bone marrow biopsy to see if cancer is already present in the bone marrow. However, what you really need to do first is have a serious discussion with the doctors about the risk that the cancer has already micrometastasized, and if so what sort of treatment they would recommend. It seems likely to me that you father may need some form of combination therapy (e.g., radiation + hormone therapy), but your father’s doctors may have additional insights that need to be considered.
What is the best route to go with …
Surgery > Radiation > Hormone therapy
Hormone therapy > Radiation > Surgery
Dear B.
You really should join our social network, where you can get opinions from lots of different people what have already had treatment for prostate cancer.
No one should get surgery after hormone therapy + radiation except as an absolute last resort. If surgery is appropriate, it is always best applied as a first line of treatment.
Thanks for your response … Do you know if there is any article on this treatment option …
Dear B.
There are literally hundreds of articles on the management of men like your father. However, there is no consensus on “the right” way to treat men like him because there are too many unknown variables.
Unless you father’s doctors are able to give you some clear understanding of the degree of risk that your father is at for micrometastatic prostate cancer, no one can tell you what “the right way” is for him to get treated.
Some physicians would tell you that if you take his prostate out and then give him hormone therapy, you may be able to delay progression of his cancer for years … and that is true. Others will tell you to radiate his prostate and give him hormone therapy … which is also a valid option (but if that doesn’t work, I wouldn’t suggest surgery afterwards). A third group of physicians would tell you to just give him hormone therapy because neither surgery nor radiation is going to have any meaningful effect.
I find it difficult to believe that your father wouldn’t have at least positive lymph nodes with a PSA of 74 ng/ml, but he could have extensive micrometastatic disease, into his bone marrow. If the latter is the case, then there is not a lot of point in either surgery or local radiation to the prostate, because the disease has effectively spread extensively through his body. We just can’t image it yet. First-line hormone therapy would probably be the most appropriate treatment in such a circumstance.
Hey, Sitemaster.
I’m 60 years old and I had my prostate removed in 2008. My Gleason score was 4 + 5 = 9 in 6 out of 12 biopsy cores. My PSA started going back up 2009 and in August I did Calypso-guided radiation therapy. By March of 2010 my PSA was up again and when I went to M D Anderson they found prostate cancer in my lymph nodes. I started hormone therapy injections every 4 months and also take a hormone pill every day. The PSA still on the rise. I go back to M D next week for a CT scan and a bone scan. For all veteran’s of the Vietnam War and Agent Orange, Get your prostate check!
I just came across this site and would like an opinion. (I will speak to my surgeon/urologist.) My report on the pathology came back with BOTH 4 + 3 = 7 and 3 + 4 = 7 Gleason scores. There is a significant difference in the mortality rates. What is the significance of having two scores? I will be undergoing cryoablation in a few weeks. Thanks for any information you might be able to offer.
Louis:
(1) The only Gleason score that is important is the highest one … in your case, 4 + 3 = 7. Any lower Gleason core is irrelevamt.
(2) Whole-gland prostate cryoablation is associated with a very high rate of post-treatment erectile dysfunction. Focal cryoablation is a different story if that is what you are referring to.
(3) We strongly recommend you join our social network to get addition input on your clinical options before you commit to any specific form of treatment.
Hi.
My 49-year-old brother was just told he has prostate cancer with a Gleason score of 8 (4 + 4) He is going to have a bone scan soon. If I am reading the information correctly the he has a 69.9% chance of beating or living with it with treatment? We do not have his PSA numbers as they just did it today.
After 29 years of employment he lost his job last year and his insurance in June. Now he has no insurance. What is he going to do?
Rich’s sis
Dear Tammy:
(1) I very strongly suggest that you and/or your brother join our social network and post all the available information you have there. Someone will get back to you quickly to offer assistance.
(2) It is impossible to be able to accurately assess your brother’s risk profile without knowing his PSA level, but it is high because of the presence of Gleason 8 disease. We can’t answer the 69% question without a PSA level.
(3) Are you telling us that he was diagnosed without ever being given a PSA test? That would be unusual today, and would suggest that he may have had clear symptoms suggestive of prostate cancer as well as a positive digital rectal examination. Is it possible that his primary care doctor got an original PSA and that the urologist is now repeating it? You need to check on this please.
(4) With respect to treatment, there are a variety of options, and some of those will depend on exactly where your brother lives.
My 72-year-old husband was diagnosed with T1c prostate cancer after a biopsy. Only 25% of one sample out of 12 came up positive. His PSA is 5.3. However, we were told his Gleason score was 4 + 4 = 8.
We are presently getting a second opinion of the biopsy as well as a bone scan and MRI of the pelvic/abdomen area. Radiation therapy has been recommended as opposed to surgery. We are going to see a radiation oncologist next week. What would his life expectancy be if he underwent radiation therapy?
Dear Nancy:
If your husband is otherwise reasonably healthy, his normal life expectancy as a man who has lived to 72 years is about another 12 years.
Based on the information you have provided, high-dose external beam radiation therapy carried out by a skilled clinical team using modern technology (i.e., image-guided and intensity-modulated radiation), perhaps with a short course of neoadjuvant hormone therapy for 4 or 6 months, really ought to be curative, and so he ought to be able to live out his normal life expectancy or more. Of course one cannot make any form of guarantee for an individual patient.