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Gleason score question

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Posted 4/25/2014 8:29 AM (GMT -5)
As is probably true with many here, a lot of my post treatment anxiety is due to my high Gleason score.

I started out as a 4+4 and was turned into 4+5 by a respected second opinion. Even though this may have not made much difference in my choice of treatment there seem to be some differences in prognosis for 8 vs. 9. It certainly did not improve my mood in the first couple of months after diagnosis. So I have naturally been wondering about the extent of the grade 5 in my case. It was not listed in the pathology report either in the biopsy or surgery. My understanding is that the secondary grade has to be at least 5% but less than 50%. Does anyone here have a clear understanding in how the % is obtained? Is the calculation done by the pathologist somehow counting cells or is it more of a computer assisted process?

I have searched this site a bit to find out more about the Gleason score and noticed that quite often the 8s get upgraded by second opinion. Anyone have any insight into this? Besides incompetence, why would one supposedly reputable and large lab say 4+4 and another say 4+5? Are there really two different approaches when it comes to including grade 5? This seems hard to believe but I think that I saw it discussed somewhere.

Thanks,

Tom 

Posted 4/25/2014 2:29 PM (GMT -5)
Tom,

You are on the right track. My biopsy clearly identified each core with the G score, size, the percent involved, and PNI. You might re-check your biopsy and pathology reports or get the actual chart instead of a summary. Grading is not as exact a science as we would like and can vary depending on the person doing the grading. There are variations among the cells in each gleason grade, so not all 4s are identical or even clearly different than some 3s or 5s. This lack of clarity can be frustration.

I think the main thing for you is that whether you are a 4+4 or 4+5, or perhaps a third read would be 4+4 with a tertiary 5; it is high risk and the treatment needs to be appropriate to the risk.

My doctors threw out all my 3s and treated me based on the 4s, their location, the PSA, the PNI, and the tumor volume. I was high risk and they treated me aggressively. In your case my docs would look at the 5s as being more important than the 4s. In other words, my docs base the treatment on the highest grade.

Hopefully, the surgery got everything and nothing had left the gland. If so your treatment might be over. You still have to watch the PDSA for the long haul so if there is recurrance you can get all over it before it is a problem.
Posted 4/25/2014 5:23 PM (GMT -5)
I was 4+4 at Bostwick and 4+5 at Johns Hopkins both top labs. Risk and Treatment is the same for all Gleason 8-10's from what I've read so I don't think it matters whether it's 8 or 9. It's all very high risk . Secondary pathology like Node plus , EPE and SVI increase the risk somewhat but high Gleason score all by itself is the biggest risk factor for progression. It sure is better if it's contained though!
Bob
Posted 4/26/2014 12:05 PM (GMT -5)
Another phenomena is that there was been Gleason score inflation over past 20 years, possibly due to trial attorneys (my opinion, not the experts below).

In his most recent monthly newsletter Prostate Forum Volume 15 #10, Dr. Charles Snuffy Myers interviewed several experts including Dr. H Ballentine Carter of Johns Hopkins, Dr. Peter Carroll of UCSF, Dr. Timothy Wilt of U of MN, also lead author of PIVOT study, Dr Laurence Klotz Toronto Div of Urology Sunnybrook Health Services Centre.

Most of the discussion centered around Active Surveillance vs. Watchful Waiting vs. Surgery vs. Radiation for low risk PCa.

General concensus was that a G6 today 20 years ago would have been a 5, and so on.

LupronJim
Posted 4/26/2014 12:40 PM (GMT -5)
LupronJim, that's interesting, I'll get the newsletter. I have read some of the back issues and found a lot of useful information. It makes you wonder how accurate some of the long term stats are if the Gleason scores are inflating. Did they mention anything about that?

Bob and JNF I appreciate hearing about your experiences. My second opinion was from Hopkins also.

Tom
Posted 4/26/2014 6:05 PM (GMT -5)
BTom, when you get to the current article, the discussion centered around Dr. Wit's PIVOT study where men were separated into low risk, intermediate risk and high risk, but at the time this was being done long enough ago to have longer term results, it was based more on symptoms with only about 5% classified that way as a result of PSA that led to a biopsy.

Though most of it was about low risk Gleason 6 and did not apply to me, I still found it interesting.

Tey did differentiate between Active Surveillance and Watchful Waiting (do nothing) and not everybody agreed the latter is no longer applicable to people under 80.

LupronJim
Posted 4/26/2014 6:11 PM (GMT -5)

BTom said...
LupronJim, that's interesting, I'll get the newsletter. I have read some of the back issues and found a lot of useful information. It makes you wonder how accurate some of the long term stats are if the Gleason scores are inflating. Did they mention anything about that?

Bob and JNF I appreciate hearing about your experiences. My second opinion was from Hopkins also.

Tom

The other reason I sometimes question the results is that within the past few years so many new drugs like Xtandi, Zytiga, Xofigo, Provenge etc have come into play and not enough time has elapsed to cycle through all of them to get long term survival metrics.

So I tend to look at the nanograms at worst case but even there what is quoted is a median and there is so much variation on the continuum plus no two PCa's being identical still makes one wonder how far left or right of the median they happen to be.

In the end we are all a case study of one, and just try to play the hand we have been dealt the best we can since there are no redeals.

LupronJim
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