> some 75% of all prostate cancers diagnosed are classed as favorable-risk Gleason 6 (3+3 and/or a small amount of grade 4 in a 3+4)
> GENERALLY, MOST of these favorable-risk Gleason 6 (3+3) stage T1c prostate cancers need NO treatment whether through focal therapy or whole gland treatment
> GENERALLY, MOST favorable-risk Gleason 6 (3+3) cancers do NOT PROGRESS while being monitored on ACTIVE SURVEILLANCE
> 25% or less of prostate cancers detected are the high-risk significant prostate cancers and it is these cancers which demand treatment
> NOT ALL PROSTATE CANCERS ARE EQUAL
> more people die from drug resistant infections every year than from breast cancer and prostate cancer combined
> the importance of prostate cancer is greatly overemphasized
> the preoccupation with PSA prostate cancer screening and detection, particularly for the insignificant Gleason 6 (3+3) prostate cancer, is disingenuous
WHY DO MOST MEN WITH GLEASON 6 (3+3) PROSTATE CANCER NOT NEED TREATMENT?
> MOLECULAR EVIDENCE proving the indolent, non-aggressive and generally insignificant nature of the Gleason 6 (3+3) prostate cancer with the ABSENCE of most, if not all, specific gene or protein alterations which are normally associated with significant prostate cancers.
This fundamentally important information about the insignificant Gleason 6 (3+3) has been reviewed and underscored by several physicians including Laurence Klotz MD of Toronto.
> CLINICAL EVIDENCE proving the generally INSIGNIFICANT non aggressive nature of the Gleason 6 (3+3) prostate cancer.
* the Gleason 6 (3+3) is very slow growing with a cell dividing every 475 days or so
* the Gleason 6 (3+3) from inception to a nodular growth 1 cm in diameter takes 40 years
* the Gleason 6 (3+3) is a very indolent disease
* the Gleason 6 (3+3) is commonly NOT a health risk
* the Gleason 6 (3+3) is commonly associated with the aging of the prostate
* the Gleason 6 (3+3) has essentially no spreading or metastatic potential
* the thousands upon thousands of unfortunate men who underwent the debilitating radical surgery treatment for their Gleason 6 (3+3) prostate cancer and which was associated with an essentially 0% incidence of metastases at 20 years of follow up
The gross overdiagnosis and overtreatment of this Gleason 6 (3+3) prostate cancer has been highlighted by numerous concerned physicians as well as the embarrassing USPSTF report on prostate cancer screening and the treatment of screen detected cancer.
THEREFORE, on both MOLECULAR and CLINICAL fronts, it is ABUNDANTLY CLEAR that
the Gleason 6 (3+3) prostate cancer is essentially,
> NON AGGRESSIVE
> a PSEUDO-CANCER
> a MISNOMER and should NOT be called a cancer
> grossly MISMANAGED and MISTREATED as if a significant high-risk cancer
CANCER FEAR MONGERING
This is a very common despicable practice whereby physicians will sensationalize the course and outcome of a few high-profile men with significant high-risk prostate cancer for the purpose of exploiting men made vulnerable by the common insignificant favorable-risk Gleason 6 (3+3) prostate cancer label. The Gleason 6 (3+3) prostate cancer usually does NOT require any treatment but monitoring through active surveillance.
MANAGING YOUR PROSTATE BIOPSY INFORMATION
> because of the subjectivity issues in making a prostate cancer diagnosis, all of your prostate biopsy slides should be sent to a recognized prostate pathology reference laboratory for validation. You should never rely on your local pathologist to give you a diagnosis that can set the stage for a high-risk treatment and all of its potential complications when the pathological diagnosis could be an error of judgement.
> after the initial prostate biopsy, all men diagnosed with the favorable-risk Gleason 6 (3+3) prostate cancer should undergo a repeat or CONFIRMATORY 12 core prostate biopsy some 6-12 months later to ensure that no disease with grades 4 or higher were missed at the initial biopsy. Disease with these higher grades has the potential to be significant
* the CONFIRMATORY biopsy will show STABLE disease in at least 80% of men diagnosed with the favorable-risk Gleason 6 (3+3) prostate cancer and these men do NOT need any treatment
* periodic monitoring is done through ACTIVE SURVEILLANCE with:
– 6 monthly PSAs and in particular looking for a PSA that is doubling (PSAdt) every 18 months or less (PSAs are much more reliable in monitoring progress AFTER a diagnosis of prostate cancer than when used in screening for cancer detection where it is highly unreliable). Persistent doubling of the PSA from its base level where active surveillance commenced could suggest the possibility of a missed high-risk cancer (i.e. one with grade 4s) after the second confirmatory biopsy and the need for a possible third prostate biopsy. This scenario however, is uncommon.
– annual prostate exam (digital rectal exam or DRE), looking for the development of a prostate nodule. This test also, is very subjective
– depending upon follow up clinical and laboratory data, additional prostate biopsies MAY NOT be needed for several years.
– prostates harboring high-risk (grade 4s or greater) occult cancer can be identified through careful active surveillance along with possible additional diagnostic studies
Possible additional DETECTION STUDIES to detect HIGH-RISK prostate cancer
These detection studies are valuable ONLY if they can detect reliably, significant, high-risk cancers of significant 3+4 or, 4+4, or greater
~ multiparametric 3T MRIs to identify missed significant and HIGH-RISK cancers especially for index lesion tumor volumes 1.3 ccs or greater, particularly in the apical or distal apical areas of prostates
~ new biomarkers which, once discovered and reliable enough, will allow identification of high-risk and significant prostate cancers as well as those prostate cancers at risk for progression and or, upgrading their grade 3s to a grade 4 as these prostate cancers only demand treatment
Since the very common favorable-risk Gleason 6 (3+3) prostate cancer is essentially, a pseudo-cancer and these cancers COMMONLY DO NOT REQUIRE TREATMENT, whether through focal therapy or whole gland treatment, DETECTION methods should be focused on detecting high-risk prostate cancers only.
The challenge of active surveillance is to ensure that significant grade 4 (or greater) disease has not missed.
WHICH MEN WITH Gleason 6 (3+3) PROSTATE CANCER “MAY” NEED TREATMENT?
> some 20% or less of men with Gleason 6 (3+3) MAY after the confirmatory biopsy, be diagnosed with a more significant disease (usually a grade 4) which MAY then need treatment. This fact underscores the importance of the second or confirmatory prostate biopsy.
> men with high volume (greater than 50% of the cores involved along with significant involvement of each of the cores) Gleason 6 (3+3) prostate cancer MAY need treatment because in these men there is a greater likelihood that occult grade 4s have been missed somewhere in the prostate, usually in the apical region.
> Gleason 6 (3+3) disease progression or upgrading (dedifferentiation) to a disease with grade 4s or above is uncommon but MAY occur in those men with high volume Gleason 6 (3+3) prostate cancer.
> Grade 4’s or above, in your biopsy report are an important feature (only on a validated pathology report) as these cells have the potential to be significant
> a grade 4 will result in a Gleason score of 7 at a minimum. The behaviour and risk of this particular prostate cancer depends upon whether it is a 3+4 or, 4+3
The Gleason 7 (3+4) behaves like a favorable-risk Gleason 6 (3+3) and men over 65 with low volume Gleason 7 (3+4) i.e. a small amount of grade 4, may NOT need treatment. These men with low volume Gleason 7 (3+4) may also benefit from 5 alpha reductase inhibitor medicines like proscar or avodart to forestall, possibly, disease progression during monitoring.
The Gleason 7 (4+3) behaves like a high-risk Gleason 8 (4+4) and demands treatment
> OVERTREATMENT is treatment instituted for a disease that is unnecessary and unneeded
> 75% of all prostate cancers diagnosed are the INSIGNIFICANT Gleason 6 (3+3)
> most men with Gleason 6 (3+3) prostate cancers do NOT need treatment (focal or total)
> most men diagnosed with the Gleason 6 (3+3) prostate cancer are OVERTREATED
> OVERTREATMENT of the Gleason 6 (3+3) with the toxic radical surgery/robotic prostatectomy has killed and debilitated thousands and thousands of men.
In fact, every man diagnosed with validated significant or high risk prostate cancer and considering, or advised to have, radical surgery/robotic prostatectomy should read
Dr. A. Horan’s book “The Big Scare. The business of prostate cancer” as well as reviewing the class-action lawsuits concerning the robotic prostatectomy before making the misguided decision for this ill conceived surgery. Particularly FALSE is the contention that surgery is indicated for prostate cancers in younger men, aggressive prostate cancers or, for salvage treatment (recurrent prostate cancer). Appallingly, this meritless surgery has ruined more men’s lives worldwide than any other operation, especially so for those men with the insignificant Gleason 6 (3+3) who never needed any treatment
> OVERTREATMENT is occurring more and more due to the promotion of focal therapies as having less complications. This is true but ALL treatments (whether focal or whole gland/total) are UNNECESSARY for MOST Gleason 6 (3+3) prostate cancers
> OVERTREATMENT of the Gleason 6 (3+3) prostate cancer under the guise of advanced medical care, underscores medical mismanagement, mistreatment and lack of post treatment accountability
> OVERTREATMENT of the Gleason 6 (3+3) prostate cancer results in:
* zero benefits
* complications and unnecessary after effects
* the same great survivorship and cure rates as for men who never had the Gleason 6 (3+3) prostate cancer
Which prostate cancers really need treatment?
> only some 25% of prostate cancers diagnosed are classified as high-risk
> significant or high-risk prostate cancers needing treatment are:
* men with Gleason 4+3, 4+4 and above
* men with significant volume of 4s in a Gleason 3+4