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What to do about a Gleason 6?

SV
Posts: 60
Joined: Sep 2010

A good friend has just been diagnosed with a Gleason (6 3+3) and he wants to know what are his best options. He is 55 and slightly overweight but very concerned about all of the conflicting advice out there as to treatments and so forth. What are the latest solutions?

Thanks

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3274
Joined: May 2012

SV,

Your question is probably the  most common at this Board. You will get a lot of differing recommendations, but all are sound and reasonable, because prostate cancer (PCa) has lots of options.  By itself, his score of "6" indicates mild, non-aggressive disease.

But all will ask for more detail to give an informed response.  Most of this will be available on his biopsy report or other medical records.  Since you are writing for someone else, be sure to not compromise his name, address, etc.  I would not even ask questions unless he has indicated that he desires you to do so.

1. His PSA history, including current PSA;

2. Whether he has been having issues with enlarged prostate (this is referred to alternatively as BEP or BPH);

3. Results of his DRE (digital rectal exam, aka "Finger poke");

4. Volume of cores postitive for PCa.  Some cores (the tiny pieces of tissue pulled out during the biopsy) will have tested positive (with cancer) or negative (no cancer). This will be expressed as a "percentage" of the overall volumn of the core.

Any and all of this will be necessary/helpful to get properly informed answers.

.

SV
Posts: 60
Joined: Sep 2010

Here's what we know now. He is Canadian but his health insurance actually covers some treatments in the US. Upon my advice he has already posted his case here a few weeks ago but unfortunately he did not receive much response/advice, probably because most guys here are not familiar with the Canadian health care treatments.

Stage t1   prostate ( 6 sites 6 cores ) needle core biopsys ( s16-3188 ) -adenocarcinoma of prostate ,nos/acinar type . Overall Gleason score, all cores 6 (3+3)-3 cores positive / 6 total cores - Carcinoma involves the following sites with corresponding linear spans - Right base 1.5mm in one core (and 5% of one core). Right mid 2mm in one core ( and 5% of one core ). Left base 1mm in one core (and 5% of one core ). -Extraprostatic extention: Not identified. -Perineural invasion: Not identified. - Lymphovascular invasion: Not identified.   Right apex and left apex of gland appear negative for invasive carcinoma. Left mid core contains an atypical small acinar proliferation.

Old Salt
Posts: 720
Joined: Aug 2014

Also encourage your friend to participate directly in the discussion to prevent misunderstandings.

Steelchuggin26
Posts: 36
Joined: Mar 2013

Hello there, your friend, while it is unfortunate that he has been diagnosed with prostate cancer,  his gleason score is quite favorable. Gleason 6 cancers are slow growing cancers that don't have to be treated right away.

Options for gleason 6 cancers include: 

Active surveillance- The Dr will do psa tests every few months to assess the PSA and note any changes, rises in PSA may warrant repeat biopsies to investigate for potential higher grade cancers.

Surgery- Radical prostatectomy removes the gland, and this gives the pathologist and the doctor the best assessment of the cancer. Usually the biopsy gets it right, but in 20% of cases gleason scores are upgraded because the pathologist found higher grade cancers that the biopsy missed.  Having surgery gives the best clinical picture. It can tell whether or not there is spread outside the gland, such as to the seminal vesicles. But as with any surgery, there is a small, but real chance of complications.(my dad development dvt and pulmonary emboli from his surgery). 

Radiation therapy- this can be done via external beam, or by brachytherapy,  which places radioactive seeds into the gland to kill the cancer. Not to worry, thetc seeds are generally not toxic to you as they emit radilation in the gland only. Your body is not affected. External beam therapy uses a focused beamy of radiation directed to the prostate, this is an outpatient procedure, and does not require hospital stay in an otherwise healthy man. Radiation too has risks of unwanted side effects, so your friend should discuss this with his dr if this is the route he goes.

Him being 55 is rather young for prostate cancer, but it's not unheard of. And with you stating he is otherwise healthy, the Dr will likely recommend surgery, but the decision is entirely your friend'should decision.

 

Side note- Surgery and radiation have similar success rates, though if surgery is done, radiation can still be used if cancer recurs. In general, if radiation is done first, most surgeons will not operate because radiation leaves scar tissue, and scar tissue is difficult to cut through, unless the physician is well experienced.

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3274
Joined: May 2012

Your last paragraph is correct per my understanding and reading also, Steel.

When I met with my Radiation Oncologist discussing RT (a guy I already knew and admired before our consultation) I asked him toward the end, "IF radiation fails, what subsequent treatments are possible second-line ?" He responded immediately, "Hormonal."   For me, that was too few words.  But he also said, "failure of IGRT on a low Gleason, low PSA disease is extremely unlikely."

I eventually chose DaVinci RP surgery, but remained ambivalent the whole time, and believe I would have been happy with radiation instead -- bless every man's choice.  But my surgeon, who has now done about 1,000 DaVincis, lists on his website that he has a subspecialty "doing post-Radiation prostate surgery."

I asked him if operating on the prostate post-surgery was rare, and he told me directly that following RT it is indeed extremely rare and tricky, but he has done it. He said following RT the gland become extremely fiberous and difficult to work around, as you noted.  Most surgeons do not attempt post-RT prostate surgery, but RT following surgical failure at cure is very common and mostly unproblematic. And also has a pretty good success rate.

Your comment about the clarity of a pathologist's report post-removal was a factor for me also....I prefer certitude when available. And my chart was changed from Stage I to Stage II, based on the patholigist's dissection and analysis.  While imaging is advancing yearly, it cannot match having the gland under a microscope in a lab.  These are just facts I have learned, not recommendations toward anyone for any thing.

max

VascodaGama's picture
VascodaGama
Posts: 2987
Joined: Nov 2010

I would add to the above replies the fact that, whatever Gleason one's cancer is rated, the treatment option is decided on the location of the cancer. For instance, contained cases (whole cancer within the gland) have high rates for cure by any type of radical treatment but localized cases (cancer existing around the gland) are susceptive to the extent of the spread and that in such cases surgery would not be practical.
Image exams are imperative when judging the clinical stage of a patient, which will influence in the final decision.

Best wishes and luck in his journey.

VGama 

Swingshiftworker
Posts: 1013
Joined: Mar 2010

Anyone whose PCa is rated Gleason 6 has all treatment options available to him and, since it is "low risk" has the time to decide which choice is best for him.  The thing for your "friend" to do now is to do the research necessary on the available options before he actually has to make the decision.  The following is my response to other men who asked for similiar advice.  It's a summary of the available treatment options and my personal opinion on the matter.   You can, of course, ignore my opinion about which treatment choice I think is best.  The overview of the choices is still valid.

 

 

The following is a duplicate of one that I posted here: http://csn.cancer.org/node/305388

. . . People here know me as an outspoken advocate for CK and against surgery of any kind.  I was treated w/CK 6 years ago (Gleason 6 and PSA less than 10).  You can troll the forum for my many comments on this point.  Here are the highlights of what you need to consider:

1)  CK (SBRT) currently is the most precise method of delivering radiation externally to treat prostate cancer.  Accuracy at the sub-mm level  in 360 degrees and can also account for organ/body movement on the fly during treatment.  Nothing is better.  Accuracy minimizes the risk of collateral tissue damage to almost nil, which means almost no risk of ED, incontinence and bleeding.  Treatment is given in 3-4 doses w/in a week time w/no need to take off time from work or other activities.

2) IMRT is the most common form of external radiation now used.  Available everythere.  Much better accuracy than before but no where near as good as CK.  So, it comes with a slightly higher risk of collateral tissue damage resulting in ED, incontienence and bleeding.  Unless things have changed, IMRT treatment generally requires 40 treatments -- 5 days a week for 8 weeks -- to be completed.  I think some treatment protocols have been reduce to only 20 but I'm not sure.  Still much longer and more disruptive to your life than CK but, if CK is not available, you may have no other choice.

3) BT (brachytherapy).  There are 2 types: high dose rate (HDR) and low dose rate (LDR).  HDR involves the temporary placement of rradioactive seeds in the prostate.  CK was modeled on HDR BT.  LDR involves the permanent placement of radioactive seens in the prostate.  1/2 life of the seeds in 1 year during which time you should not be in close contact w/pregnant women, infants and young children.  The seeds can set off metal/radiation detectors and you need to carry an ID card which explains why you've got all of the metal in your body and why you're radioactive.  Between HDR and LDR, HDR is the better choice because with LDR, the seeds can move or be expelled from the body.  Movement of the seeds can cause side effects due to excess radiation moving to where it shouldn't be causing collateral tissue damage -- ED, incontinence, bleeding, etc.   Both HDR and LDR require a precise plan for the placement of the seeds which is done manually.  If the seeds are placed improperly or move, it will reduce the effectiveness of the treatment and can cause collateral tissue damage and side effects.  An overnight stay in the hospital is required for both.  A catheter is inserted in your urethra so that you can pee.  You have to go back to have it removed and they won't let you go until you can pee on your own after it's removed.

4) Surgery -- robotic or open.   Surgery provides the same potential for cure as radiation (CK, IMRT or BT) but which MUCH GREATER risks of side effects than any method of radiation.  Temporary ED and incontinence are common for anywhere from 3-12 months BUT also sometimes permanently, which would require the implantation of an AUS (artificial urinary sphincter) to control urination and a penile implant to simulate an erection to permit penetration (but would not restore ejaculative function).  Removal of the prostate by surgery will also cause a retraction of the penile shaft about 1-2" into the body  due to the remove of the prostate which sits between the interior end of the penis and the bladder.  Doctors almost NEVER tell prospective PCa surgical patients about this.  A urologist actually had the to nerve to tell me it didn't even happen when I asked about it.   Don't trust any urologist/surgeon who tells you otherwise.  Between open and robotic, open is much better in terms of avoiding unintended tissue cutting/damage and detection of the spread of the cancer.  Robotic requires much more skill and training to perform well; the more procedures a doctor has done the better but unintended injuries can still occur and cancer can be missed because the doctor has to look thru a camera to perform the surgery which obstructs his/her field of vision.

4) You may also want to consder active surveillance (AS), which is considered a form of treatment without actually treating the cancer.  You just have to get regular PSA testing (usually quarterly) and biopsies (every 1-2 years, I believe) and keep an eye out for any acceleration in the growth of the cancer.  Hopeful and Optimistic (who has already posted above) has already mentioned this and is your best source of info on this forum about it. 

I personally could not live w/the need to constantly monitor the cancer in my body.  Like most other men, I just wanted it delt with.  Some men gravitate to surgery for this reason, thinking that the only way to be rid of it is to cut it out, but I did not like the risks presents by surgery and opted for CK, which is a choice I have NEVER regretted.  I am cancer free, there is no indication of remission, there were no side effects and my quality of life was never adversely affected.  Other men on this forum have reported similiar results.

So, for obvious reasons, I highly recommend that you consder CK as your choice of treatment.  The choice seems obvious when you consider the alternatives but you'll have to decide that for yourself.

Good luck!

 

 

Clevelandguy
Posts: 440
Joined: Jun 2015

Hi,

1+ for Steelchiggin26, good post, just the facts, no bias towards any one treatment.  Both radiation and surgery have side effects, look at both carefully and decide which one seems best for your friend.  Talk to doctors and look at the various sites for treatment options, there is a lot of info out there.

Dave 3+4

Steelchuggin26
Posts: 36
Joined: Mar 2013

Fortunately gleason 6 is a very slow growing disease, and in very many cases, never poses significant issues, especially in older men who may have significant comorbitities that are far more likely to present issues than their gleason 6 prostate cancer.

 

Just know that as mentioned above, there are many treatment options available, especially at such a young age. And if your friend wants to, he can have his biopsy slides sent to another lab for review to provide further evidence that it is indeed G 6.

Whatever hee chooses to do, I don't really think he can go wrong with any of the options available. It's just a mathere of looking at the side effects of each treatment option, weighing the pros and cons of each, and ultimately deciding based on what he is most comfortable with. Either way, I think he can expect successful treatment, if he does choose to have treatment. My dad was given time to choose what he wanted to do with his. His was clinical T1c and biopsied at G6, so all options, other than hormone therapy were presented. The Dr being a urological surgeon natural was biased towards surgery, but ultimately said the call was entirely up to dad.

 

That's the "beautiful" thing when it comes to gleason 6 disease, so many options available, and there is no rush necessary to decide one way or another.  With a higher grade, such as gleason 8, it would be a different story, and surgery would probably be the best initial option in that case. My dad could have went on AS with his being gleason 6, but he hated the idea of anything cancerous staying in his body, so I understood his feelings there in wanting to get it out.

 

Probably would have done just as well with radiation therapy, and likely would have been fine as well going on AS. Gleason 6 is such a low grade disease, and the treatments for it (or none in the case if AS) are all pretty equal in likelihood of success that you can't really go wrong either way. 

 

I do think also the fact that surgical pathology offers a bona-fide pathological picture, giving the surgeon and pathologist a whole spectrum view of what's going on is what ultimately tipped my dad to surgery. But again that was just him, and I would not try to sway other people one way or the other. Do what you feel is best for you, or we'll in this case your friend doing what he feels is best for him.

Will Doran
Posts: 207
Joined: Sep 2015

SV,

 I agree completely with everything stated above.  Your friend should get involved here and then he can ask questiosn and get the answers he wants from those of us who have been and are fighting this hard battle..  All of our situations are different and thus we can only offer our stories to help your friend make decisions.

Best wishes

Will

bsmcferron
Posts: 2
Joined: Mar 2017

Yesterday, I met with my urologist for a follow-up to get my Gleason score - 3+3 = 6  - confined to right side of prostate, area/core is 40%.  My wife went with me and I chose Active Surveillance.  Besides the blood tests, and potentially another biopsy, my doctor suggested getting a genetic profile of the removed cancerous cells.  This was kind of promising and one of the reasons I chose Active Surveillance - I will be getting another PSA in May and meet with the uro doc in September.  However, like a lot of men, I am quite concerned that "this enemy" continues to grow in my body and the psychological factor is starting already.   My choice would be brachytherapy or radiation, but I just don't know and am kind of lost.  I am 59, but have type ii diabetes as well.  This forum is now very important to me, and I share everyone's dilemma.  Does anyone have a suggestion and/or ideas?

 

hopeful and opt...
Posts: 2224
Joined: Apr 2009

bsmcferron, if you are not the friend of the original poster for this thread, please start a new thread, so we can answer your questions without hijacking this thread.

At any rate, I have been in an Active Surveillance protocol for nine years now...click my name to the left to see what I have been doing and information jermaine to active surveillance.

I will be able to answer questions that you might have and make appropriate comments on the new thread that you need to start.

bsmcferron
Posts: 2
Joined: Mar 2017

I wanted to mention that since my intial PSA and visit to the urologist, my urinary frequency has picked up - especially 4 weeks out from the biopsy.

 

thanks to all!

 

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