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As I await my prostate biopsy results, I have two questions in dire need of answers!

Question 1: There are two widely-asserted facts that seem to contradict one another, at least upon further investigation. Fact One: we hear that most prostate cancer is 'indolent', i.e. slow-growing and not inclined to metastasize, and so not really a threat to the patient's life. Fact Two: we're told that, these days, men with prostate cancer are not given Gleason scores of less than 6. But (in the only study I could find that gave Gleason scores by percentage) only 35.4 % were in Category 6. But if Fact One is true, wouldn't all those men with indolent cancers-- who, logic says, would be given a Gleason score of 6-- mean that those with Gleason score 6 would comprise a much higher percentage of the total than 35.4? Perhaps closer to 60%? Please help me resolve this seeming paradox.

Question 2: I have had a CT scan of the pelvis/abdomen, with and without contrast, and an MRI of the prostate, also with and without contrast. Both showed nothing even hinting at the presence of cancer in the bones, lymph nodes, the organs adjacent to the prostate, etc.: in short, nothing beyond whatever is going on in the prostate. So, in that context, what would the meaning be of a biopsy report with a high Gleason score, should I be unfortunate enough to get one? Ought I be grateful that, though my prostate cancer may be an aggressive SOB, fortunately it hasn't yet gotten around to doing me harm, and if I act fast, maybe I can keep it that way? Or is a more pessimistic interpretation of my situation warranted-- that perhaps CT scans and even MRIs are less precise than is commonly believed?

  1. Not sure how to address your first question as a Gleason 6 score is very controversial score. Depending on what pathologist you research. Further, studies suggest MRI of the prostate have just as much diagnostic value as the Biopsy. But all studies are used to make a more precise direction of care. I'm not a fan of Biopsy as there can be some risks but seems to be the one test Urologist want to push. I myself am in a similar dilemma, as PSAs have been creeping up in the past two years and sitting a 4.17. Both MRIs neg for any cancer/risks. Sitting on the fence presently. Hope thats not a mistake. lol/ Also, consider researching Biopsy's risks and percentage of biopsy getting the the problem area. SC

    1. The frustration is .... there are no apparent right or wrong answers I suspect. All of a sudden you find yourself in a place where solutions are not clearly defined. I just tried to remain calm (not an easy task) did some meditation and after 2 weeks followed my heart vs my brain. I did the surgery and 5 years later did the same when the cancer returned and I needed radiation. So far that approach has worked for me. Dennis( TEAM).

  2. Hi, scox59! Believe me, I understand your reluctance to undergo a prostate biopsy-- among my first posts on this website was one that concerned an article I read in the January 2020 issue of Clinical Chemistry about the likelihood that the prostate biopsy actually CAUSED some cases of metastatic prostate cancer that would not have occurred in the absence of the biopsy, with the mechanism of causation being the unusually repetitious puncturing of the prostate by the needle (often more than a dozen times in a prostate biopsy, which greatly exceeds what happens in the typical biopsy of an organ). That puncturing-- it was conjectured by the authors of the article-- would cause prostate cancer cells to detach from the prostate and go into the circulating blood, eventually landing God knows where in the body. This wasn't idle speculation: medical science now has a way of determining if cells are detached and put into circulation, and the men (30% of the total) who the test demonstrated had had detached cells had triple the rate of prostate metastases compared to the men in the group who the test showed did not have cells get put into the blood (70% of the total).

    1. Jazj says, " So it's the biopsy that eventually kills you years down the road? I thought I heard it all."

      I appreciate your humorous take on the subject-- I too initially reacted with amused skepticism when I first grasped what was being alleged by the researchers. But if you actually read the article you'll see that the study was done in a way that would satisfy the most demanding of critics.

      They focused on all those shown by the biopsy to have prostate cancer for Circulating Tumor Cells (CTC) both before and after the biopsy. There is a semi-automated test for these cells that has been approved. To express the results in this post in a nutshell (for the entire tree, read the article): among those who showed no increase in CTC after the biopsy, there was a 15% rate of metastasis in the years of follow-up; among those who DID show an increase in CTC following the biopsy, there was a 45% incidence of progressive disease on follow-up. Quite a damning (and, more importantly, statistically significant) difference!

      Now, is that absolute proof that a prostate biopsy of an organ that harbors cancer will CAUSE a greatly increased rate of metastasis? Not necessarily, because there's an alternative explanation that must be considered: namely, that prostate tumors that are inclined towards metastases are different from those that are not, in that their cells adhere to one another less well, and thus are more likely to be detached into circulation by the force of the biopsy needle-- but they would have detached spontaneously in any case because of this lesser adhesion.

      So in order to prove that it was the biopsy that actually caused the metastases, you'd have to do an experiment that I believe is unethical to carry out in humans but could be done in animals, assuming they too get prostate cancer. You'd take a large number of animals with likely PC based on non-invasive scans, divide them into two groups, give one group biopsies and the other not, and observe if the group that had biopsies developed metastases at a significantly higher rate.

      As for your comment about insurance companies only paying for treatment of PC proved by biopsy, I agree that that currently is the case. That's why I got a biopsy.

      But I very recently learned about a PSMA Pet/Ct scan detection system using a radioactive isotope that affixes to prostate cancer and doesn't show positive results for benign tissue or other cancers. That may be exactly what's needed to end the reign of the prostate biopsy.

    2. There comes a point in life I believe where there are too many "what If's" combined with too many conflicting points of view. For me at least the constant emotional jousting between unknown alternatives as they applied in my particular medical case needed to end.

      At one point on my PCa journey the importance of the quality of life for me and my loved ones came into focus. It was at that point I made a decision to move forward and have never looked back

  3. Investigations and interventions are just means at the disposal of doctors to reduce the probability of disease progression. I too had been under “Active Surveillance” based on findings of two PSMA-PET Ga68 scans, a first biopsy grading of 3+3 about 4 ½ years ago, a steadily declining post-biopsy PSA trend over the same 4 ½ years and under guidance of a “very low risk” score of Oncotype DX GPS. However the PSA suddenly spiked and the latest PSMA-PET scan and PET-CT guided biopsy show disease progression. I am, right now, getting ready to visit the OPD to find out what the future holds.

    There have to be better means for risk assessment and more focal treatments for indolent and prostate-confined tumours so that Prostate Cancer does not wreak havoc in lives as it sometimes can.

    But a positive frame of mind combined with trust in medical advice specific to each individual case appear to be the best options.

    1. peekaafighter, I guess I'm still the rawest of rookies on the prostate cancer scene, because I had never heard of Oncotype DX GPS, but I just watched their video after seeing your mention of it. And now I'm a little surprised: if you had a very low risk score but now are experiencing disease progression, isn't that something of a refutation of the efficacy of Oncotype's methodology? Perhaps we have another example of entrepreneurs invoking the charisma of genes and DNA to sell a product even if it's still very premature to do so. (There's a weight-loss company in my area that promotes a DNA-guided plan, where the customer's particular low-calorie diet is determined by their DNA. A look at the science behind it says there is none!)

      Well, at least you must have already been somewhat skeptical of Oncotype's pronouncements because you appear to have avoided complacency and maintained a properly vigilant eye on your prostate. Good for you!

      1. Richard says, "The question then became did the Grade really increase of [or] did the sampling simply not find the higher grade?" Richard, there is a third possibility: did a new focus of more virulent, higher grade cancer DEVELOP, which could not have been found on the earlier sampling because it didn't yet exist! Just to clarify, that third possibility is distinct from the case of the Grade of the original cancer increasing over time, which is certainly possible too. I didn't simply invent this third possibility-- the article you linked to mentioned it, albeit briefly.

      2. Hi . Absolutely, a new growth is a possibility. In fact, I find it a very interesting question whether new growths in a particular individual are likely to be of the same grade and if it might be a higher grade, just how often this happens. This would be a great piece of information to have when it comes to informing decisions on such things as surveillance and rate of follow-up. Thanks for bring this up. Best, Richard ( Team)

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