In today’s news reports we address recent publications on:
- The GEMCaP biomarkers and prediction of prostate cancer recurrence post-surgery
- Biopsy Gleason score under-staging and active surveillance
- The value of exercise during radiotherapy
- Impact of type of surgery on post-surgical continence at 1 year
Paris et al. have published data stating that the use of a set of DNA-based biomarkers termed “genomic evaluators of metastatic prostate cancer” (GEMCaP) can predict the likelihood of prostate cancer recurrence post-surgery as accurately as the Kattan pre-treatment nomogram, and may improve on the Kattan nomogram in predicting the outcomes of men with high-risk prostate cancer but negative lymph nodes.
Colliselli et al. have reported new data emphasizing the difficulty of accurately determining Gleason scores of 6 and 7 based on biopsy data alone. They address this problem with specific reference to the need to appropriately evaluate the eligibility of individual men as candidates for active surveillance and the difficulty of knowing whether and when to actually treat men on active surveillance protocols.
Kapur et al. have published data from a small, randomized clinical trial that suggests that patients who require radiotherapy for localized prostate cancer and who are asked to keep active and to adhere to a well-defined exercise schedule during their treatment appear to have a lower risk for side effects of rectal toxicity than less active patients.
Toren et al. have reported data from a retrospective series of > 250 patients at their institution suggesting that the application of nerve-sparing does not seem to affect the patient’s likelihood of being continent after radical prostatectomy. In other words, patients with similar levels of continence and urinary frequency pre-surgery who had bilateral nerve-sparing, unilateral nerve-sparing, and non-nerve-sparing forms of surgery all had comparable levels of continence at 1 year post-surgery.
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment | Tagged: active surveillance, biomarkers, continence, exercise, GEMCaP, radical prostatectomy, radiotherapy, RP, under-staging |
THE "NEW" PROSTATE CANCER INFOLINK 
Upgrading of Gleason score 6 prostate …
Although the header of this abstract and the reference in your list refer to “upgrading” of GS, the study seems more concerned with what is termed over- and under-DIAGNOSIS, with reference to PSA and staging being the main focus.
It is difficult for me to understand all the figures, but the fact that “… almost 40% of GS 6 tumors on biopsy are GS 7 or higher after surgery” must mean that more than 60% were GS 6 or lower, and since “A match between biopsy and prostatectomy GS was found in 210 patients (46.9%) …” seems to indicate that more than 23% of the biopsy GS 6 tumors were not GS 6 or higher after prostatectomy.
Since there is now no lower GS than 6, does that mean that 23% of the men would not have been diagnosed with prostate cancer if their biopsy results had reflected their correct grades?
Or do I misunderstand the position — if so, please will someone enlighten me?
Dear Terry:
(1) I think there are some linguistic infelicities in this abstract. The authors are all Italian or German (I believe), and so nuance needs to be interpreted with care!
(2) All patients who were eligible for inclusion in this analysis were Gleason 6 at the time of their original biopsy. However, the abstract does not include the range of the dates of diagnosis and treatment. But … if they were all treated after 2002, it is difficult to see how anyone could have been downgraded to a Gleason score below 6 after an RP unless there was no tumor found in the specimen. In other words, the safer interpretation of what the authors state is only that as many as 40% of Gleason 6 patients eligible for active surveillance may be upgraded — either at RP or at the time of a subsequent biopsy. This is why strict active surveillance protocols require annual biopsies. However, if the cohort included patients diagnosed and treated prior to 2002, then it is perfectly possible that some of them would have been downgraded to Gleason 5 or lower after RP.
(3) In this specific study, the only thing we can be sure of is that 46.9% of the patients who had Gleason 6 on biopsy still had Gleason 6 at RP. The implication is therefore that, in this study, 53.1% of patients did not have a Gleason score of 6 at RP. I think you’d need to get the actual paper to get any additional clarity.
The point the authors seem to me to be trying to make is that Gleason grading, in particular, as a practical element of eligibility for active surveillance protocols, needs to be viewed with some considerable caution. That was what I tried to emphasize in the summary above.
Also on the German study …
One member at HealingWell.com is touting color Doppler ultrasound for anyone considering active surveillance prior to commencing with AS. I am beginning to buy into that idea, even with it’s flaws. It is well known we lack sufficient data from needle biopsies and the new NCCN guidelines for AS will start to prove that this is prevalent. As I mentioned before, guidelines such as these will be a moving target as they are compiled with hindsight. So we enter the era of “over treatment” with well known flaws in diagnosis that prove substantial “under diagnosis” exists.