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Does Prostate Cancer turn agressive at some point in time

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

I have been reading as much as I can about prostate cancer including Dr. Walsh’s book and haven’t run across the answer to a question I have so I thought I would see if anyone else has seen the answer. The question is “does aggressive cancer start out that way or can it start out not aggressive and turn aggressive at some point in time?” The reason I am asking is I started on Active Surveillance in 1999 which had “a single focus of adenocarcinoma – too few glands to Gleason Score” and in my last biopsy (12 years later) it was 2 cores positive, one with <5% involvement and one with 50% involvement. Both were Gleason 7 (3+4). To me that development over 12 years wouldn’t be termed aggressive. Any thoughts?

Thanks

David

Samsungtech1
Posts: 350
Joined: Jan 2011

David,
I believe everyone is different. That is what makes it so bad. Mine was considered agressive, but now it seems to have slowed down. It might start again tomorrow. Are you eating right? Exercising? These are critical. Your body is strong, but can only handle so much. I am heading to the Pacific coast of Mexico for about five weeks, and if it works then go back down for rest of winter. Suppose to go yesterday but they cancelled all flights. Anyhow this is a remote fishing village. Basically I will be eating shellfish, I love them, and fish, snapper plentiful. We all do the best we can. My idea is to go for the gusto just in case Dr. Got it wrong.

Cancer can do whatever it wants. I believe you should treat whatever is going on and see where you end up. Everyone here is divided on treatment, etc. if I had low grade cancer I would do the IMRT or something similar, if it gets to that. Watchful waiting is not bad, but do not know your age, and this really makes a difference on treatment. Do not obsesse over this. S happens and it is good to know everything before you make a decision.

Good luck,

Mike

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

Mike,
I have to be honest - I eat fairly well. I do eat a lot of red meat. I don't excercise at all. I only weigh 145 pounds. I think if I exercised I would weigh less plus I just hate it. I had the whole time I was in the service and hated it.

Oh, and I am 62. Was diagnosed when I was 59 just before deploying to Egypt. My wife loved that.

I made a couple lists the past few days and that seemed to help. One list was "the things I am scared of" (related to the cancer; another was kind of plan of what to do next - see my urologist, get a second opinion, choose a treatment (the list includes waiting); and execute the plan. I also made a list of things I want to discuss with the 2nd opinion doc.

After I posted that question I hit myself in the head and asked why didn't I google that. I did and got a couple hits. One study said in about 40% of the men their cancer turned agresive. Another one said it was unlikely that it would turn agressive after 10 years of AS but it could.

Thanks for you thoughts!!

David

Samsungtech1
Posts: 350
Joined: Jan 2011

David,
I literally scared myself to death with web searches. Ask your doc and he will tell you not to go there. According to my web searches I should be dead now. The VA gave me 2.88 years, most on line searches said 1 in five go the first year, most die within 2-3 years and no one gets past 5 years. This was for my particular cancer, metastic prostate cancer. Been fighting it now for 2.5 years and feel ok. Can not worry about downmthe road. Whatever happens is beyond my control. I do the best I can and plan on going forward. It is all good. Everyday is a gift to be lived. We forget that sometimes.

Mike

Kongo's picture
Kongo
Posts: 1167
Joined: Mar 2010

David,

There are more than 20 different types of prostate cancer. Some of these start out aggressive and get worse. Others are indolent and never do much at all and will not pose a threat to men and do not require treatment.

The most common type of cancer is adenocarcinoma which just means that it is a cancer of the gland. (adeno = gland, carcinoma = cancer). The prostate is a gland that produces secretions (PSA) necessary for the reproductive cycle.

I would query your doctor about his opinion on the evolution of prostate cancer but from what I have read, prostate cancer (like all other cancers) starts off with a single cell. The mechanism for the start of cancer could be a lot of things such as chemicals in our environment (or food like red meat produced from large slaughter houses), genetics, or just the normal course of life.

Prostate cancer is usually (but not always) very slow growing, taking over 50 years to go from a single cell to (if left untreated) killing us. As prostate cancer cells evolve through dividing they get more primitive and act less and less like normal prostate cells. This state of this progression is what the pathologist categorizes when he assigns a Gleason score to our biopsy sample. Men with higher Gleason scores have more advanced cancers. If you were to look at the cells under a microscope you would see that advanced cancer cells look nothing at all like the cancer cells of earlier, less advanced stages. As these cells grow by dividing over the years they sometimes evolve into this advanced state. Some cancers are indolent, in other words they don't progress to advanced stages.

Men harboring advanced cancers often see very little PSA because the cancer cells in this stage cease producing this enzyme. (Remember, as they advance they act less and less like a normal prostate cell so they produce less PSA). These cells can also grow without testosterone which means that hormone therapy is no longer effective in curbing their growth.

It's hard to predict what our cancers will grow up to be. We can help keep it in check through a healthy lifestyle that includes exercise, significantly reduced intake of red meat, processed foods, and dairy products, and avoiding as much as possible contaminants in the environment.

Hope this helps but please discuss it with your physician.

Best to you.

K

caseyh
Posts: 63
Joined: May 2002

I asked my doctor this very question when I was diagnosed 12 years ago. H e said that if it was aggressive, it was so from the start.

VascodaGama's picture
VascodaGama
Posts: 1574
Joined: Nov 2010

David

I think that your question refers to a progressive status of the cancerous cells not to the status of the disease. While there are many theories on both matters, doctors have different opinions and there is no prove to the contrary. As they say; "it is difficult to separate the wheat from the chaff".

One thing they all agree is that Cancer begins from a deformation of the prostate stem cells. Some scientists believe that prostate cancer is derived from a luminal cell progenitor that has acquired self-renewal activity through mutation. This equals to the progressive theory.

In folks language it is to say that from PIN it develops into well then poorly differentiated (Gleason grades from 1 to 5). However this action takes time to be accomplished and one may find equal types of cells (same Gr) being constantly produced (doubling) and causing a tumor formed with the same DNA characteristics.
In other words, if at initiation the Pca is formed by say only two types, these will progress without altering their aggressivity. Late metastases (after a treatment) have been found to be of the same grade.

In any case, there have been proved that cells may alter their grade after treatments that affect or damage their DNA (such as radiation and chemo). Hormonal treatment cases with 5-ARI (Avodart, etc.) become controversial after comments that doctors found a more aggressive grade of cancer after years on the drugs.
My take on the matter is that 5-ARI drugs “clean” the serum from low grade cells (killing them) and such leave behind the aggressive ones (that usually are not hormonal dependent) which will increase the initial findings (Gleason scale from 3+3 to 4+3 or 4+5). This is also seen as a progression of the disease.
Equally, in treatments one will try to catch the “bandit” with radicals and at each failure we have accomplished a “clean up” of many cancerous cells that could be composed of the higher aggressive ones. Such would lead to a continuous grade supporting the theory that “cancer does not turn aggressive at some point in time”.

In this detailed article researches say this;

“……..Interestingly, several aspects of this disease are remarkably similar to CML. CML is most frequently diagnosed in adults and the elderly and first presents as a chronic myelogenous hyperplasia that eventually progresses to acute immature blast crisis following the accumulation of genetic and epigenetic alterations in addition to BCR-ABL. Prostate cancer is similarly a disease of aging that is thought to begin with the chronic accumulation of prostatic intraepithelial neoplasia (PIN) lesions that may eventually develop into adenocarcinoma, although no experimental evidence for this has yet been provided. Many adenocarcinomas also progress to a poorly differentiated, hormone-refractory prostate cancer (HRPC) consisting mostly of immature blast-like cells. Arul Chinnaiyan and colleagues have recently identified a class of translocations that, like BCR-ABL, are present in the majority of prostate cancers (16). These translocations result in fusion of the androgen-regulated promoter for TMPRSS2 with the coding regions of ETS family TFs that are associated with Ewing sarcoma and several types of human leukemia (17, 18). In light of these findings, a major goal of our laboratory is application of the fundamental concepts learned about stem cells in CML to elucidate prostate cancer etiology. This Review will focus on current concepts of stem cells in prostate cancer initiation and progression as well as the implication of these concepts in prostate cancer research and therapeutic development. We hope that understanding the cellular basis of prostate cancer will yield insight critical for the development of more efficacious therapeutics to fight the disease.”

Here is the full text;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934594/

I believe that the Gleason of tumours at diagnosis will kept it status along our journey. You should care in having due pathological analysis at the beginning to make it sure that the highest grade is found and not left occult in the tissues.

I admire your confidence in AS. The twelve years living with the bandit is worring you but the results of your last tests does not support the theory of "progressive aggressivity of cells". The disease may be expected to progress because cancer do not "die" but multiply. Your type though is sort of indolent.
The grade 4 is the baddy but you could get a DNA profile to verify if such cells are prone to become androgen independent. That could cause trouble in future metastases.

Regards.
VGama

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

VGamma,
Thanks for the comments. The past 12 years hasn't really been difficult. In fact I really never worried about it. What I am more concerned with now is the progression in the next 12 or more years. If it were just me I know absolutley what I would do and that is continue with the AS. However I am married and love my wife dearly and she is not convinced AS is the best course of action. I have to take her feelings into consideration. I think a lot will depend on my PSA in January and what a 2nd opinion doc says.

Thanks again for the commenst and web sites.

David

caseyh
Posts: 63
Joined: May 2002

VG
Your disease history is very much like mine with the exception of my 4+3. My disease is also nowhere to be seen although my PSA is almost the same as it was in January. I am also a former MSK patient. Dr. Michael Morris treated me immediately after my recurrence.

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

Thanks for the input. I am trying to be openminded about this whole thing and really appreciate other people's opinions and help.

David

laserlight's picture
laserlight
Posts: 165
Joined: May 2012

From my understanding so far with this monster is that the cancer can do whatever. It can grow or go into remission.

Having your wife on your side is a good thing, mine has helped me quite a bit with this.
The one item that she did was to let me make the decision for the MOST part on treatment.

The one thing she wanted was for me to get treatment and not ignore, I tend to put things off at times. This time I glad I listened to her

My doctor informed me when I was diagnosed that I had agressive cancer, he was not going over board or holding back.

The other thing with PC is that it is a waiting game, always waiting on PSA tests and the results.

The past 20 months has been a different journey for me

I hope this helps, take care

Kurt

dwhite1031
Posts: 26
Joined: Jul 2012

I'll share my experience with you.

I had an elevated PSA & subsequent biopsy in July 2011 that came back with no signs of cancer in any of the 12 cores taken. Had another PSA in May 2012 that was 8.1 and a digital exam that showed enlargement and nothing he could feel so he put on 3 weeks of antibiotics in case it may have been due to prostatitis. Went back in June after the antiobiotics & had another PSA with a result of 9.2
Had biopsy in July that came back with positive cores on right side of prostate a Gleason score of 9. My local urologist said I had a very "angry" and aggressive cancer to go from no signs to a Gleason 9 in a year.

Exactly one month to the day of my diagnosis we were at my first appointment aft MD Anderson. They drew labs for another PSA and it was now 12. Had an endorectal MRI on day 4 that showed cancer in the right as expected and in the left side as well. I started my treatment on day 5.

So in my experience prostate cancer can be quite aggressive.

jerseyguy891
Posts: 18
Joined: May 2012

David, Based on my observations from internet research and being on a few forums it seems every individuals case is unique and no one should base their treatment on anyone else's. I was diagnosed in March, 1 core (23%) out of 12, Gleason 6. Had 2nd biopsy in October (New Dr.) all cores negative. I am following AS. How old were you when you were first diagnosed? You noted you have been on AS for 12 years. My thinking is if one has their PSA checked and a DRE every 3 months and a Biopsy every couple of years you should be able to determine how the cancer is progressing.

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

Hi,
Thanks for the input. I was diagnosed in 1999 when I was 49. At that time it was "a single focus of cancer - too few cells to Gleason Score". Now it is two cores positive - one <5% and one 50&. Gleason score was 7 (3+4). Stage is T1c. I am really leaning toward continuing on AS.

Thanks

David

VascodaGama's picture
VascodaGama
Posts: 1574
Joined: Nov 2010

David

I was diagnosed at the age of 50 in 2000. I am now 63 and probably of the same age as you. My cancer was diagnosed as being a well differentiated type (Gleason 2+3) which tends to be indolent. However, my wife and I decided to get rid of it the soonest because of the high PSA of 22.4 ng/ml.

The difference in our cases after 12 years is that you did "nothing" and I did it all (RP+RT+HT). Interestingly we both did not manage to get "free" from the bandit, but I have been affected by the side effects from treatments whether you have not.

You probably have realized on the advancements done in medicines to combat PCa since 1999. Newer drugs have come out and others are on the drawing board (trials), particularly in the field of genetic "engineering". Improvements in image studies and treatments have also had a big step forward and they are now friendlier of the patient.

Consideration on Quality over Quantity may help you guys in confronting a decision.

Wishing you continuous "normal" way of living.

VGama

cchqnetman's picture
cchqnetman
Posts: 97
Joined: Sep 2012

VGama,
Thanks!! I have to see my doc in Jan and have another PSA test. I will see where I go from there.

Thanks again for you thoughts!!

David

jerseyguy891
Posts: 18
Joined: May 2012

VGama,
Do you think your PCa was more aggressive then a Gleason 5 at diagnosis 13 years ago. Was there a post RP biopsy? One would think with a gleason 5 and after a RP you would have been rid of the cancer. How many years after your RP did you have RT and then HT. What factors led you these treatments. Your treatment sounds as if it was a Gleason 8 or 9.

caseyh
Posts: 63
Joined: May 2002

VG
Your PCa history points out how complex and individualized this disease can be. With a Gleason 2+3, by current thinking, you should have walked away from PCa after your surgery. The fact that micro metastasis had already taken place suggests to me that regardless of the Gleason score, your cancer was anything but indolent. That raises the question, “Where would you be today had you not taken a very aggressive approach to the disease?” I suspect that the the odds are pretty good that you would not be here. In hindsight, AS was probably not an option. Your already high PSA most likely would have continued to rise and within a short time required aggressive treatment. Who knows how much your cancer would have progressed while on AS? There is a lesson here for all of us. Seek the BEST medical care that you can afford. This is definitely not a one size fits all disease.

VascodaGama's picture
VascodaGama
Posts: 1574
Joined: Nov 2010

Casey
You are right. My cancer was not indolent. It was active and still is.
Gleason 5 though is thought to be low aggressive and that may have been my shining star to allow me of being here today after 12 years.
Amazingly, the doubling time has been decreasing at each treatment taken. Before surgery I had PSADT equivalent of 24 months which decreased to 14.5 months after surgery and again to 9.5 months after radiation.

If such fuse about PSADT is correct regarding indolence, the cancer before surgery was the one that would have given me more time of living.
But, after all, we are different and so it is each case. Ironically I had several opinions on my case from different doctors at reknown institutions at the initial diagnosis and continuing recurrences, and none managed to get it right. The most touching the truth is exactly the diagnosis of micrometastases pointed out by the surgeon, and again by Mario Eisenberger in a second opinion.

Even though I “recognise” its presence, I never had an “encounter” with the bandit. It never shown its face (on image studies) or ever caused a symptom. Its progressive presence was noticed only though PSAs.
Susan Slovin at MSKCC suggested allowing “him” to grow big enough so that one could localize it and target it with focal radiation. However, after six years on WW and an increasing PSA from 0.12 to 3.8, none were in doubt that I was confronting a systemic micrometastases status.

To Jerseyguy;
The Gleason score attributed to my cancer was subjected to four pathologist’s analyses. I got a second opinion on the biopsy cores and the prostate specimens were analysed at JH for a second opinion. They all confirmed the patterns of 2 and 3. Doctors were curious about my Gleason 2 which seemed to be rare at those times.
I trust the veracity of the Gleason as the probable reason for the extended time on the run.

Please note that Low Gleason do not equalize to success in treatments as you pointed out in your post. Cure can only be achieved if one manages to cut the “infested” tissue and strip it out totally, or manages to hit the whole cancer with enough radiation to destroy its DNA, whether it is a Gleason 5 or 9 or 10.

In my case each treatment was ruled due to recurrence. The PSA has been the marker to set the timing for starting and the thresholds were defined by each specialist treating me. The trigger threshold for HT was PSA= 1.0 ng/ml because of the characteristics of my cancer. It happen 4 years after RT.

Overall, Quality of Life was important and taken into consideration by all my doctors. In fact, it seems that “debulking” was the routine chosen so that I did not get “cured” but I did not get nasty side effects.

I am now on an Off-Drugs “vacation” of the intermittent HT protocol.
You can see my story here;
http://csn.cancer.org/node/244938

Best.
VGama

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