Is it or ain’t it “really” cancer?


In a new article in the Journal of Urology, researchers at Johns Hopkins Medical Center in Baltimore have again expressed their opinion that it would be inappropriate to rename low-risk Gleason 6 disease as something other than “cancer”.

This is a controversial issue that has now been under discussion for much of the past 10 years. There are those who argue that (to quote Hassan et al., the authors of the current paper):

The word cancer creates fear and contributes to the overtreatment of many indolent prostate cancers.

And then there are those who believe that it would be misleading to describe low-risk Gleason 6 prostate cancer as anything other than cancer.

Hassan et al. base their argument on a new analysis of data from just under 7,500 consecutive radical prostatectomy specimens from surgeries carried out at Johns Hopkins between 2005 and 2016, including 3,291 from men with Gleason scores of 6 and 4,202 with Gleason scores of 3 + 4 = 7.

The full text of this paper is available on line, so interested readers can study the authors’ arguments for themselves, together with the supporting data.

Basically, Hassan et al. argue that in this set of 7,493 surgical specimens, they found that:

  • Among all of the 3,291 patients who were originally diagnosed with Gleason scores of 3 + 3 = 6
    • 1/3,291 specimens (0.03 percent) exhibited a seminal vesicle invasion
    • 79/3,291 specimens (2.4 percent) exhibited non-focal extracapsular extension
    • 129/3,291 specimens (3.9 percent) exhibited focal extracapsular extension
  • Among the 1,147 patients who were originally diagnosed with Gleason scores of 3 + 4, but for whom there was < 5 percent of Gleason pattern 4 disease
    • 5/1,147 specimens (0.43 percent) exhibited a seminal vesicle invasion
    • 96/1,147 specimens (8.4 percent) exhibited non-focal extracapsular extension
    • 129/1,147 specimens (11.2 percent) exhibited focal extracapsular extension
  • Among the 3,055 patients who were originally diagnosed with Gleason scores of 3 + 4, but for whom there was > 5 percent of Gleason pattern 4 disease
    • 88/3,055 specimens (2.9 percent) exhibited a seminal vesicle invasion
    • 543/3,055 specimens (17.8 percent) exhibited non-focal extracapsular extension
    • 464/3,055 specimens (15.2 percent) exhibited focal extracapsular extension

and this leads them to conclude that

At radical prostatectomy it is not rare for pure GS6 prostate cancer to locally extend out of the prostate 3.9% focally and 2.4% nonfocally. In extremely rare cases GS6 can be associated with seminal vesicle invasion and yet not lymph node metastases. Our overall findings support the argument for continuing to use the term cancer for these tumors.

After nearly a decade of this discussion, your sitemaster is less worried about what we call such pathological findings and a great deal more concerned about how clinicians explain the risks and benefits of active surveillance as compared to the risks and benefits of immediate treatments (of which there are now nearly a dozen different types) so that patients are able to come to their own conclusions about what they want to do.

It would be a reasonable assumption that none (or almost none) of the 3,291 patients in this cohort who were diagnosed with Gleason 3 + 3 = 6 disease and a very low percentage of the 1,147 patients who had < 5 percent of Gleason pattern 4 disease and a diagnosis with Gleason 3 + 4 disease would have had metastatic prostate cancer within 15 years of follow-up — even if they had done nothing at all until there was a clear indication of need for invasive treatment.

We live in a world where any motivated patient can now gain a pretty sophisticated appreciation of the factors associated with differing types of treatment for almost every known disease. This doesn’t mean they know what a doctor knows. They don’t, if only because they haven’t had the appropriate training. But it does mean that they are in a far better position to come to their own conclusions about the risks they are willing to take to gain (or not gain) the benefits that are hypothetically available — preferably in conjunction with an empathic clinician who can offer sound guidance that is not judgemental. Such is the power of the Internet — when used with care and attention to the details.

 

3 Responses

  1. The bird has flown but in one alternative universe, the new Grade Groups start at zero, and I think a trick was missed in this one. Doc: “I’m, sorry to say that the biopsy came back positive for cancer. The good news is it is Grade Group zero”. Patient reels a minute or two but must eventually ask, and be told, what Grade Group Zero cancer really means.

  2. Low risk Gleason 6 (3 + 3) is a pseudo–cancer mislabeled as a cancer.

    In my opinion: A prostate cancer survival guide by a patient and victim. Men beware!. Read the sad truth about prostate cancer over testing and treatment dangers and exploitation for profit by predatory doctors that no one will tell you about, even after it’s too late. The man that invented the PSA test, Dr. Richard Ablin now calls it: “The Great Prostate Mistake, Hoax and a Profit-Driven Public Health Disaster”. Prostate cancer dirty secrets, lies, exaggerations, deceptions, elder abuse, outdated testing and treatments. Any man over 50, anyone concerned about cancer in general, dangers from clinical trials, injuries and deaths from medical mistakes, quality prescriptions at a huge discount from Canada, exploitation, elder abuse, HIPAA laws and privacy issues should read this document. Read “A prostate cancer survival guide by a patient and victim,” free information from a victim.

  3. Jim is entitled to his opinions … but that doesn’t mean that everyone would agree with him.

    The late Ralph Valle (who did not die of his prostate cancer) — who was a passionate advocate for the prostate cancer patient community — regularly berated me any time I even implied the possibility that any amount of Gleason pattern 3 should not be called “cancer”. And … as I have pointed out numerous times before, Dr. Albin absolutely did not “invent the PSA test”. He identified a biological molecule that subsequently became referred to as prostate-specific antigen, and the institution at which he worked at that time has made this clear on numerous occasions

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