Dear Rosbif,

Don't quote me...was half-asleep when I read that.

Maybe I was jumping to conclusions because of the following:

"Similarly, small-volume Gleason 3+4 tumors probably behave like
historical Gleason 6 tumors."

I suppose it would mean that the larger volume 3+4's and any 4+3's
would stay as 7's.

However, according to a number of studies, including one by Mayo
Cinic, it has been shown that 3+4's tend to behave more like 6's,
while the 4+3's tend to behave more like 8's.  It is already
bifurcated.  So, I'm not even sure what a Gl. of 7 would mean
according to these standards.

But you're right, it did not explicitly include the 4+3's with the
8's.

Regards,

Leah

When you fully understand how the cores are harvested, you are
lucky/unlucky to get any truly valid result whatsoever, let alone
getting an overall presentation of the tumour/s G gradings.
My 4 G8s (4+4) and 3 G7s (4+3) were not upgraded, but the DRE was
upstaged from T2A to T2C without intervention.

I believe I'm doing OK for now, but the SEs of Rad & ADT have taken
their toll after 18 months:(

-Please reply to group as my email addr is fake!

-Regards CC

Dear Russ,

Please, let us straighten this out.  As Bill D. pointed out, the above
is simply not true, according to the totality of the data presented.
It is much more complicated than simply upgrading or downgrading your
Gleason score by one point.  In fact, most of the movement upward has
occurred at the lower end of the Gleason scale.  The NCI article I
read about this said that G5's are rarely encountered these days in
clinical practice, so for example, a "good" G6 would almost certainly
have been rated a G5 or lower in the past.  There also used to be
Gleasons scores of 2-4, which don't exist anymore.

I think you're right.  This is one reason why Gleason scores have gone
up, and in this case it is apparently a good thing, because they might
be better able to grade the aggressiveness of the cancer.

Anyway, here is some info on this from the Journal of the NCI.:
"What is the cause of grade inflation in prostate cancer?

A recent change in the accepted protocol for reporting of biopsy grade
may be partially responsible. Prostate cancer is usually multifocal,
with prostatectomy specimens often harboring six to eight discrete
tumors of various grades. Prostate biopsy, performed to "map" the
gland, can thus identify several different tumors.

Gleason scoring, which identifies five patterns of decreasing
differentiation and increasing aggressiveness, assigns a first number
to the predominant pattern in a biopsy core and, if there is another
pattern present, a second number to the second most common pattern
(e.g., 3 + 3).

**Increasingly, more than two patterns are identified in prostate
biopsy samples, and some clinicians have suggested reporting a
tertiary score (4). However, in recognition of the fact that the most
aggressive tumor found in a prostate biopsy, even if it is the
smallest component, may determine the prognosis of the patient's
tumor, the current recommendation for assigning Gleason grade is to
give the predominant tumor the first score and the highest grade,
among the remaining grades, the second score (5). This practice can
only lead to increased Gleason scores in some patients."

[I think they are saying the amount of high-grade ca doesn't matter.
If it's there *at all*, it will be counted as the second value.]

[FYI:  Another reason for future Gleason upgrades:]

"A second possible cause of grade inflation has been the growing
consensus that low-grade tumors should rarely (if ever) be diagnosed
(4).

This consensus, which has most likely arisen from analyses of Gleason
score changes between biopsy and prostatectomy, acknowledges that low-
grade tumors are often upgraded at prostatectomy and that the
assignment of a low grade to a tumor may lead to a false impression of
a biologically inconsequential tumor, potentially losing the
opportunity to treat an otherwise curable and lethal tumor (6)."
________________

I have been reading a response Dr. Strum wrote to a patient in the
prostate pointers doctor-to-patient mailing list
(P2P@prostatepointers.org, Bill Cambridge, 2/05/07).  This person has
a similar situation to my husband's so I have been reading it very
closely.  I have to say it is one of the most lucid, comprehensive,
informative and bold commentary I've heard about this subject in a
long time.  At one point Dr. S.  addresses the fact that a tertiary 5
tumor was found in this patient's post-op biopsy tissue, and he says
this does not bode well for the future.  He cites an article by
Hattab, et al, titled "Tertiary Gleason pattern 5 is a powerful
predictor of biochemical relapse in patients w/Gleason score 7
prostatic adenocarcinoma"  (J. Urol 175:1695-9, 2006).

Conclusion:  "Regardless of whether the primary Gleason pattern is 3
or 4, a tertiary Gleason pattern 5 is the strongest predictor of a
worse outcome in patients with Gleaon Grade 7...."

Sorry, but you asked.

I also want to mention that Dr. Strum is very passionate about the
issue that, in his opinion, there already exist a number of techniques
that can predict which cancers should be treated more aggressively and
which ca's have the highest chance of recurring.  There is also the
opportunity to prevent advanced cancers before they occur.  He does
cite good authorities for the above, although I don't know that all of
his prognosticators are accepted as Gospel truth.  But I believe a lot
of them could be useful in helping doctors formulate treatment plans
for patients.  Anyway, I think the following is right on the money.

First, he cites the old saw that, "If you don't learn from history,
you're doomed to repeat it."

I didn't get it at first, but what he seems to be saying is that we do
have records of thousands of men who have been treated with RP and RT,
and the doctors can use the data from these histories to "perform a
risk-assessment prior to any decision-making about how to treat the
PCa."  He says that not performing these calculations is "negligence"
on the part of the doctor and the patient (give me a break).   But
that appears to be the norm in practice.  At least that's how it was
in my husband's case.

[Interesting sidebar: I had posted my previous msg on Gleason score
inflation on an ML for the newly diagnosed, and I just got a letter
from a scientist who runs a company (prostatedx.com) which has
introduced a test that supposedly can predict ca recurrence.  It all
looks very prof'l.  And fortunately, he didn't say that any of the
info I passed on was goofy!)  I may just contact him re my husband.]

Anyway, allow me one more paragraph to present Dr. Strum's call to
action.

[First he says:  Not using the data we have results in less-than-
optimal outcomes which not only affect patients' quality of life but
also puts a burden on the healthcare system.  (We will all have to
deal with this issue eventually, because healthcare costs are going to
implode.)]

"This is mindless medicine and it is not something we should accept or
tolerate in today's world of supposedly sophisticated medicine.  If
there were groups of patients and their loved ones who would act in
concert to decry such stupid acts in medicine, we would see major
advances in the care of ourselves and our loved ones just by using the
technology available at the present time".

Hear Hear.

Then he lists some potentially useful procedures which are routinely
ignored.  Finally, he says:

"[s]creening tools [that] used intelligently could decrease or
eliminate the presentation of advanced ca or other medical illnesses
with tremendous reduction in the cost of life and medical expenses in
contrast to the diagnosis of the same conditions at a more advanced
stage."

Hope somebody is listening.

Best to you all.

Leah