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Medical Forum / Diseases and Disorders / Prostate Cancer / April 2008Jackie Gleason Scores
Just got the pathology report back from Stanford, who reviewed the biopsies done by my uro in March. Original readings were 3+3, 3+3 and 3+4. Stanford got 3+3 across the board. Which I'm not sure I trust. Yes, I know there's some better labs here in the area, but I really didn't ask Stanford to review them. They just asked for them. I didn't say no, though. I still want to go with the surgery. This doesn't change much, except make me feel slightly less apprehensive. But, no one really knows what's going on in there. Dwight > Just got the pathology report back from Stanford, who reviewed the > biopsies done by my uro in March. [quoted text clipped - 12 lines] > > Dwight It looks like three pathologists thought it was 3+3 and one thought 3+4. Let's call it it 3 + 3.25. That sounds reasonably encouraging to me. One day a computer program will analyze the slides. Then we'll have uniform results. Alan > One day a computer program will analyze the slides. Then we'll > have uniform results. No, we'll just have more decimal points. I.P. Who can you trust? I like the smaller numbers....... The Dr.s @ Stanford need to look for themselves..... Like taking a car in to a mechanic and him telling you its the transmission, and then you go to a highly rated dealer and they say it is alignment...... I do not have the magic answer but do take time to see who is the most professional and do ask questions. How do the Dr.s make you feel @ Stanford? I know, ............you are fighting the beast, and getting close to a decision. It is very difficult, but sometime you do have to make a decision and live with it. I wish you all the best, and the best lab work, and care you can get so that you can move on with life. jloomis > Just got the pathology report back from Stanford, who reviewed the > biopsies done by my uro in March. [quoted text clipped - 12 lines] > > Dwight > Stanford got 3+3 across the board. Which I'm not sure I trust. Based on your numbers (Gleason, low PSA, no symptoms, > 10 yr life) treatment is not required. Based on your concern about ED and incontinence, you would be stupid to go for treatment. But based on your previous postings you'll have it anyway and will feel sorry later. You don't trust Stanford, because they didn't give you the bad news you hoped for. Trust or distrust should be based on factual evidence. You don't have any reason not to trust Stanford's lab. > Yes, I know there's some better labs here in the area, but I really > didn't ask Stanford to review them. They just asked for them. I > didn't say no, though. Who cares. How is it relevant for their accuracy? > I still want to go with the surgery. Because irrational fear about "the beast inside" makes it impossible for you to think straight. > This doesn't change much, except > make me feel slightly less apprehensive. But, no one really knows > what's going on in there. The doctors do. You don't. Stop being a victim and make an appointment for early July. > Dwight > ... Based on your concern about ED and incontinence, you would be stupid > to go for treatment. ... Leaving the gratuitous pejorative aside, there are objective criteria that can be used to determine whether watchful waiting is a viable alternative. Gleason score is one of them. Others include PSA and PSA velocity, and I think some others. You should look this up, but IIRC, PSA doubling time should be greater than two years for WW to be a reasonable strategy in a young man. Age is also a factor. Cancer is more likely curable when treated early. Recovery from the side effects of surgery is also said to be easier at a younger age. If you are young enough that the cancer is likely to kill you, even if it will take 15 years to do so, then an argument could be made for treating it now. What we really need to know is, what are our chances for successful treatment now, and how will they change if we wait one year, two years, five years, etc. Unfortunately, the science is not far enough advanced to answer those questions precisely. The best we can do is look at the factors mentioned above, make some reasonable estimates, and watch carefully to detect any significant change as soon as possible after it occurs. If we could say, with some assurance, that treatment is just as likely to be effective five years from now as it is now, or just as likely to be effective when the PSA rises to X (whatever X is) as it is now, then it might be most reasonable to wait. Not only could we spend some years without treatment effects, but we might find better treatment options at the end of that time. > ... You don't have any reason not to trust Stanford's lab. I would say you have three reasons to trust them (their Gleason score plus two other scorings that agree with them) and one reason not to (the pathologist who said 3+4). > ... irrational fear about "the beast inside" makes it > impossible for you to think straight. I wouldn't call it "irrational". There is a cancer inside you and, if untreated for a long enough time, it will likely lead to a rather horrible illness and death. However Safire's point that fear makes it harder for us to think straight is certainly correct. Watchful waiting requires either an equally "irrational" fear of treatment (there are men who would rather die than have surgery), or a very cool ability to make life and death decisions based on ambiguous statistics. Alan >> ... Based on your concern about ED and incontinence, you would be stupid >> to go for treatment. ... [quoted text clipped - 6 lines] > greater than two years for WW to be a reasonable strategy in a > young man. The objective criteria of the NCCN guidelines 2008 are: T1-T2a, GS 2-6, PSA < 10 ng/ml and expected life > 10 y. PSA doubling time is not considered for initial treatment, but is a determinant of cancer progression (doubling in < 3 y) as is velocity (> .75). Dwoofy's PSA was less than 2 and taking into account his age only, he should live at least 10 more years. So based on the guidelines, treatment is not required. > Age is also a factor. Cancer is more likely curable when treated > early. Recovery from the side effects of surgery is also said to [quoted text clipped - 11 lines] > watch carefully to detect any significant change as soon as > possible after it occurs. But recovery time from side effects can also not be predicted with any precision and if ED is a concern, as he has written, why would he take the gamble, if the above factors don't dictate treatment? When there is no reason to treat a cancer, there is reason not to treat that cancer - JFK. > If we could say, with some assurance, that treatment is just as > likely to be effective five years from now as it is now, or just [quoted text clipped - 8 lines] > score plus two other scorings that agree with them) and one > reason not to (the pathologist who said 3+4). Are you saying that if two people disagree, you can't trust either? If so, will you vote in November? >> ... irrational fear about "the beast inside" makes it >> impossible for you to think straight. > > I wouldn't call it "irrational". There is a cancer inside you > and, if untreated for a long enough time, it will likely lead to > a rather horrible illness and death. The only thing you should fear, is fear itself - FDR. Fear is always irrational. If you believe, as you wrote, untreated cancers "will likely lead" to horrible illness or death, you cannot agree with the objective WW criteria you referred to above. The whole point of WW is that treatment is started if cancer progression is found, but that progression is not at all assured, not even long term. > However Safire's point that fear makes it harder for us to think > straight is certainly correct. Watchful waiting requires either > an equally "irrational" fear of treatment (there are men who > would rather die than have surgery), or a very cool ability to > make life and death decisions based on ambiguous statistics. There are studies that tell you what SE risks various treatment alternatives have. Based on those you can make a rational decision to forego treatment. OTOH, there are no unambiguous studies showing treatments save lives: "A discovery of cancer through P.S.A. testing usually leads to treatment, Dr. Feldman said. ''But we don't have any conclusive evidence that surgery or other aggressive treatment make any difference in the long term in helping men live longer or better,'' he said. ''Instead, we are going completely on intuition.'' http://tinyurl.com/yrgo6y > Alan > The objective criteria of the NCCN guidelines 2008 are: T1-T2a, GS 2-6, > PSA < 10 ng/ml and expected life > 10 y. PSA doubling time is not > considered for initial treatment, but is a determinant of cancer > progression (doubling in < 3 y) as is velocity (> .75). Dwoofy's PSA was > less than 2 and taking into account his age only, he should live at least > 10 more years. So based on the guidelines, treatment is not required. But Dwight is only 55 years old. In ten years he'll be 65. Assuming he is otherwise in good health, he might reasonably expect to live to age 80 or more. Even a Gleason 6 cancer is more than likely to kill him before then. >> Age is also a factor. Cancer is more likely curable when treated >> early. Recovery from the side effects of surgery is also said to [quoted text clipped - 15 lines] > precision and if ED is a concern, as he has written, why would he take the > gamble, if the above factors don't dictate treatment? Yes, ED is a concern for Dwight. So is death. So he's got to balance the gamble concerning ED vs. the gamble concerning death. > When there is no reason to treat a cancer, there is reason not to treat > that cancer - JFK. I agree with that point. However, as I said above, Dwight is young enough that he stands an excellent chance of dying of prostate cancer. So treatment is very likely required if he doesn't want to die of PCa. The question is, is it required *now*, or should he watch it, and only get treatment when he reaches a certain PSA or has some other biomarker telling him it's time. That is the point I was making in the next paragraph. >> If we could say, with some assurance, that treatment is just as >> likely to be effective five years from now as it is now, or just [quoted text clipped - 10 lines] > > Are you saying that if two people disagree, you can't trust either? If Albert Einstein and Joe Schmo disagree about the meaning of the theory of relativity, I know exactly who to trust. On the other hand if Einstein and Niels Bohr disagree then, indeed, I've got a problem. If you say there is no reason not to trust Stanford's 3+3 scoring of Dwight's pathology slides, you are then saying you DO distrust the lab that reported 3+4. Why is that? What is your reason for distrusting them? > If so, will you vote in November? I'd like to answer that, but I don't want to get clobbered, so I'll have to pass. >>> ... irrational fear about "the beast inside" makes it >>> impossible for you to think straight. [quoted text clipped - 5 lines] > The only thing you should fear, is fear itself - FDR. > Fear is always irrational. There is a sense of the term "rationality" for which I agree with your point. There is another sense however in which we speak of "irrational" fears as being fear of something that is either very unlikely to happen, or very unlikely to pose a problem if it did, as distinct from "rational" fears as fear of something that may very well happen and will pose serious problems if it does. When you described Dwight's fear as irrational, I assumed you meant that in the second sense, which I think is the most commonly used one. However, if you meant it in the first sense, I withdraw my objection. > If you believe, as you wrote, untreated cancers "will likely lead" to > horrible illness or death, you cannot agree with the objective WW criteria > you referred to above. The whole point of WW is that treatment is started > if cancer progression is found, but that progression is not at all > assured, not even long term. I can't cite a study for it, but I seem to recall that studies show that progress is likely with the great majority of Gleason 6 cancers. IIRC, at 10 years, most Gleason 6 patients are alive. At 20, most who have not died of something else, have died of PCa. Also note that being alive is not the same thing as being symptom free. The great majority of G6 patients are alive after 10 years, but a smaller number are symptom free. At 20 years, IIRC, the majority are dead and most of the rest have symptoms. But, as I said above, I am in favor of WW if a patient has reason to believe that he will get some warning before his cancer becomes less treatable than it is now. I was agreeing with you on that point, not disagreeing. >> However Safire's point that fear makes it harder for us to think >> straight is certainly correct. Watchful waiting requires either [quoted text clipped - 15 lines] > > http://tinyurl.com/yrgo6y Yes, I know that some experts have this view, but it is a controversial one. I believe that most doctors disagree with it. I, for example, am a patient of Kaiser Permanente. They make no money by treating my cancer, and in fact, it costs them a bundle. But they did recommend and offer treatment for me. So far, four years post treatment (radiation), my PSA indicates that the cancer is controlled. Given my pre-treatment PSA doubling time, I think I would likely have a PSA in the 40's or 50's by now - which would probably indicate metastasis. I'm guessing that my PSA would be above a hundred next year, and I'd be dead well before reaching my 70th year (I'll be 62 this year). I'm sure Dr. Feldman knows a lot more about cancer than I do, but I'm not sorry I got treatment. Alan > > ... Based on your concern about ED and incontinence, you would be stupid > > to go for treatment. ... [quoted text clipped - 50 lines] > > Alan Alan, you have given an good way for making a decision. Dwight, it does seem to be what might termed as a 'pussy cat' cancer, unfortunately the current diagnosis by biopsy has limitations. If I remember correctly about 25% of the cases after surgery it was found that the extent or grade of cancer was not accurate - it could be worse or less. Have much of a gambler are you? Do YOU value your sex life that you are willing to chance the cancer growing beyond a cure? Will you be comfortable not knowing if it will become a tiger. Surviving 10 years post diagnosis for prostate cancer is easy in a majority of cases - I am doing it with a PSA of 34 and Gleason 3+4 but I can tell you that it has ruined a good part of my life and the future is definitely scary. For surgery, the difference between doctors is dramatic - some have a high incontinence rate and the good ones it is extremely rare (there can always be internal complications). For ED, if the cancer has not hit the prostate margins, then the nerves can be preserved by a good artist. If the cancer is at the margins, then you will have to live with a dead penis - better than a dead or struggling body - don't you think? Recently there is a study by Dr Klotz (and analysis by Gray & Wassersug) of one patient found very satisfying sex using a strap-on dildo for himself and his spouse - makes for interesting reading. It is a very hard decision as there will be side effects that you have to live with for the rest of your life. For an individual, statistics don't solve the case of one. Remember Mark Twain's statement "there are lies, damned lies and statistics". Good luck in your choice. Lud > Have much of a gambler are you? Do YOU value your sex life that you > are willing to chance the cancer growing beyond a cure? Will you be [quoted text clipped - 3 lines] > it has ruined a good part of my life and the future is definitely > scary. Perhaps you're responding to someone else's comments in the thread. I have already decided on surgery. The possible lower Gleason makes no difference to me. I was just reporting interesting sidelines. Dwight I don't know if you reported the size of your tumor and the relation to th size of your prostate but it is also a factor. Also most patients don' report the number of positive cores and the percentage of cancer withi the core samples. This information is about as important as Gleason an PSA in determining the success of any treatment regime. It also can be deal breaker for someone considering Active Surveillance. I understand that you have chosen surgery but this is more in response t others comments. Ron S. - Message posted using http://www.talkaboutsupport.com/group/alt.support.cancer.prostate More information at http://www.talkaboutsupport.com/faq.htm > I don't know if you reported the size of your tumor and the relation to the > size of your prostate but it is also a factor. Also most patients don't > report the number of positive cores and the percentage of cancer within > the core samples. This information is about as important as Gleason and > PSA in determining the success of any treatment regime. It also can be a > deal breaker for someone considering Active Surveillance. In review, three cores were done, on the palpable nodule. All three were positive for cancer. The doctor doing the biopsy had 12 or so sample bottles out, but said the US showed no other suspicious tissue. Yes, I know, regular US is not reliable in that way. Tumor is 1cm. Prostate is small. This nodule was not noticed 1.5 years ago. Now it is very noticeable. This does not tell me that it is slow growing, but I'm biased. My PSA is no real indication of a problem (0.8). Dwight, I wouldn't say you were biased. I'd say you probably have a bette perspective on what is going on than any of us as you have been ther throughout the process. Good luck on your surgery and let us pray for a positive outcome. Ron S - Message posted using http://www.talkaboutsupport.com/group/alt.support.cancer.prostate More information at http://www.talkaboutsupport.com/faq.htm > However Safire's point that fear makes it harder for us to think > straight is certainly correct. Watchful waiting requires either [quoted text clipped - 3 lines] > > Alan Alan, I don't pay attention to what this dude says. If you're trying to counter his "information" on my account, thanks, but you don't need to bother. If you're just trying to counter him in general, go for it. Dwight |
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