Early Treatment makes No Difference

My oncologist told me that yes, my primary care doctor was negligent to ignore my elevated PSA seven years before my eventual diagnosis, but due to my Gleason score of 10, early treatment would have made no difference. I guess she means early treatment would have given me extra years of treatment side effects, but no change in overall lifespan.

It seems that, at least for prostate cancer, most cases are so mild that they will never cause death, some are so aggressive that they will kill regardless of treatment, and the ones in the middle, for which treatment actually makes a difference, are rare. That's a really difficult concept to wrap my head around.

minnpost.com/second-opinion...

46 Replies

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  • Age matters too. From your profile photo, you look like a young man with a lot to live for. In your case, choosing an active surveillance approach "probably" gave you better years to enjoy, rather than impaired quality of life. Damn thing about all this is we'll never know if we made the "right" choice. We can only be sure that we made a choice that we can live with, no matter what the outcome.

  • Good point. I had (twin) kids one year before my prostatectomy. It would have been difficult to do that if I had already had a prostatectomy.

  • I think the earlier the treatment the better. The best thing is to be treated before it spreads outside the prostate. I don't know your case but mine had already spread by the time I found out I had prostate cancer. Take care.

  • If you know a lawyer that strongly believes that earlier treatment is always better for aggressive cancer, please have him or her contact me. I would have a case, if not for the theory that Gleason 10 always spreads, regardless of when it is caught.

  • Hello Wonderful Father of Twins!   I have just now signed on to this website.   My husband had a similar situation.   PSA went from 2.0 to 3.5 within 11 months back in 2009.   Family doctor's Physician Assistant told him not to worry, but to return in 4 months.   I knew nothing about any of this.   Insurance changed so husband had to begin with a new doctor.   His first visit to the new doctor was about 9 or 10 months later than the other doctor visit . . . and yes, my husband was foolish to let it go that long without being checked.   I still was not aware of any problem, until he came home and said his PSA was 20.4 !    Gleason turned out to be 4+5 when all of the testing began.   My greatest desire is to find out WHY the P.A. did not suggest that my husband be referred to a urologist, or at least have him return in one month to recheck his PSA.    I have been furious, to say the least.    I spoke with several attorneys, but due to my delay in getting started with a case of medical malpractice, it was too late to do anything about it.    I have so much evidence proving that the P.A. was very negligent, and so was the primary doctor for not supervising his P.A. more closely.   Sadly to say, I lost my precious husband this past October, but he put up an amazing fight for over 5 years.   He had so many different treatments, but at last the pleural effusion around his lungs from the chemo took him from me.   I pray for good success with any treatment you try or any clinical trials, and I would like to keep up with how you are doing via this website.   Thank you for being the fighter you appear to be, for the sake of your wife and twins.   God bless you.

    Susan from Atlanta

  • If your cancer had been caught at its earliest development (a Gleason Score of 3+3/6, the cancer may have been eradicated with treatment. Yet, with this insidious men's disease we can never be certain about anything. A very good plus in your case was the joy of the birth of your twins. Downside, of course, if the subsequent apparent aggressive development of your cancer to then be diagnosed with a Gleason Score 10. I do hope you are currently receiving aggressive treatment.

  • My oncologist said that an individual's Gleason score is constant. If it's a 10, it was always a 10. I would love to see a research paper saying otherwise.

    All the agressive treatments have failed, so far. I am on my third clinical trial.

  • ......look into research of RSO......rick simpson oil......medical marijuana.......MMM will cure almost any malfunction of the human body.........................

  • Have you had Proton Radiation Therapy? I had gleason 3+3/6, PSA 4.9, had 39 Proton treatments and at 3 months PSA was 1.66 and at 6 months later PSA 1.0. Have had bone scan and nothing showed up. Go back in 6 months for year check up. Am firm believer in Proton Therapy.  I was diagnosed April 2015 and started Proton Treatment in mid June and finished mid Aug. Was suggested to wait and watch which I could not do, turned 72 right before treatments started.

  • Proton therapy wasn't available nearby when I had IMRT.  The IMRT seems to have succeeded in stopping growth within the prostate bed, but radiation won't fix the metastatic part.

  • I'd get a second opinion. What studies did (s)he cite for that statement?

  • If diagnosed initially with a Gleason 10, then yes, it will always be considered a 10. But if diagnosed at its onset of development it will more likely be Gleason 6. As that development continues with the patient unaware, it can then move upward to 3+4/7, 4+3/7 4+4/8, 4+5/9, 5+4/9, and finally 5+5/10 wherein it has undoubtedly migrated beyond the gland and its periphery to metastasis to bone. You did not "suddenly" have a cancer presence of Gleason 10. Your cancer started development at extremely low grade - like the advent of anything - but with you unaware of its development, by the time you did become aware that development had progressed aggressively to your 10.

    We learning of your status would appreciate learning more of the treatment and medications you have been prescribed to date, as well as the medication in the current trial.

  • Chuck and Joel - there is a strong evidential hypothesis that Gleason grades do NOT migrate .... please see my post further down.

  • Not quite sure what you mean by "Gleason grades do NOT migrate."  I expect you mean the grades do not elevate, but if so, that makes no sense at all.  You even state a 4+5 can change to 5+4 to 5+5;  That is certainly grade elevation.  You will have to show me the evidence of which you speak that indicates that all-of-a-sudden cancer cells blow up with no beginning in a man's prostate gland with a sudden Gleason Score of, for example, 5+5/10.  That just does not occur.  A patient may not be experiencing any effects indicating he has a problem wherein there is cancer that has started development possibly several years earlier from a basic cell embryo and has continued in development wherein he finally has a PSA test and/or DRE examination that identifies cancer cell activity.  We often see men who are following their development with either Active Surveillance or even with some basic treatment wherein their Gleason Score is changing because of the continuing cancer cell proliferation (and the "differentiation" of which you refer).  As these cells proliferate and differentiate, if looked at under the microscope, they can, if not treated, "migrate" beyond the gland into seminal vesicles or adjacent lymph nodes; the reason why men are found to learn their cancer has increased in cell proliferation and tumor development that has already metastasized by the time a biopsy identifies the prostate cancer activity. 

  • P.S. - This explains the basics of how cancer develops: cancer.org/cancer/cancerbas...

  • I will explain in hopefully simpler terms -

     A cell identified as a Gleason 3 remains a Gleason 3 its entire life; similarly a 4 and a 5. Prostate cancer cells do NOT change into more aggressive cells, at least until very late in their cell cycle, and even then their gene profile may change but not their aggressiveness. That is what many highly reputable GU med oncs and urologist believe - I can list them if required.

    Read my lower post again -  you will better understand how Gleason grades for an individual man migrate; this is NOT inconsistent with Gleason grades never changing. More aggressive cells multiply at faster rates, so what is seen in the biopsy results from the number of cells viewed, and the predominance of  higher grades.

    The ACS link cited actually supports this hypothesis. Nowhere does it indicate that cells become more aggressive over time - what it does say is:

    "Some cancers grow and spread fast. Others grow more slowly"

    In other words, PCa 3 cells do not change into PCa 4 cells; PCa4 cells just grow faster ... and PCa 5 faster still. So the different cells are almost like different sub-cancers within the PCa genus. And as we know, PCa is very heterogeneous.

    Here's a simple analogy - imagine you placed rabbits and chimps in a cage. Initially the chimps would look like they dominated, but after a couple of years there would be so many more rabbits, all you would see are rabbits and no longer notice the chimps. The rabbits have not turned into chimps - they are just more dominant. So the rabbit are G5 cells, and the chimps are G3 cells!

    According to docs I have spoken to, prostate cancer differs from others cancers where the same cells  may change their character earlier in the disease.

    The links I cite below may help you understand this better. If not, please revert.

    Onward & upwards, rd

  • In two days, I will learn whether I am in arm A or arm B of

    'Enzalutamide With or Without Abiraterone and Prednisone in Treating Patients With Castration-Resistant Metastatic Prostate Cancer'

    ClinicalTrials.gov Identifier: NCT01949337

    My past history is

    Feb 2016 - PSA12, Stopped Bicalutamide, Tested negative for AR-V7.

    Dec 2015 - PSA 7.

    Aug 2015 - PSA 80, Started Goserelin and Bicalutamide.

    Jun 2015 - PSA 40, Metastases found in abdominal lymph nodes, by using Ferumoxytol enhanced MRI.

    Feb 2015 - PSA 1.2, Started radiation.

    Sep 2014 - PSA 0.7.

    Jul 2014 - PSA 50, Radical prostatectomy.

    Jun 2014 - GVAX immunotherapy.

    Apr 2014 - biopsy, Gleason 10 or 9 in all cores.

    Feb 2014 - hypospermia, PSA 15.

    July 2007 - PSA 2.0, stopped Propecia.

    2004 to present - urinary urgency and frequency.

    2000 - started Propecia (finasteride) for hair loss.

    1971 birth.

  • Hi can u pls call me asap at 714 310 5717 my name is joe I have the same thing u do let's exchange info plus I'm your age I been looking for someone like u thanks 

  • Joe - please ask T. to fill you in on our virtual support group for advanced men in which he participates and you are very welcome. Or reach out to me at pcaadvoacy@gmail.com.

  • I also was on propecia for several years before my prostate cancer diagnosis at the age of 43 in 2002. I always wonder if that was what caused the cancer to develop since I am otherwise healthy and have no cancer history in my family. Also, Propecia is known to manipulate PSA values.

  • I always heard the Psa doesnt change either. It doesn't go from a G 6 to a G 10. You treat early to prevent it spreading.

  • Bauxman, I too am a Gleason 10, I find it is fairly rare. I was diagnosed in 2006 with a psa of 148 and widespread metastatic disease at 49 years old. I am still here and Doing fine, It has meant constant treatment. Currently on xtandi. Will you have to pay for the combo xtandi and zytiga in trial?

    I hope I can be a message of hope to you being a fellow Gleason 10

  • The Xtandi manufacturer is providing that drug for free, since both arms include it, but the Zytiga manufacturer didn't like the design of the trial, so my insurance company is paying for the Zytiga, IF I get into the arm that has both.

    You ARE a message of hope! Thanks.

  • Hi Dan59, You are a true inspiration for me. I was recently diagnosed with advanced PCa with spread to my bones. I have just turned 49, I would like to hear your story. I am overwhelmed but optimistic about my future.

  • Paul, My story is that I was diagnosed in early June of 2006 with Gleason 10 , bpsa 148.6 prostate cancer that had spread to my bones and Lymph nodes, I was devastated. I began to read all I could about the disease, I found a Dr who specialized in Pca at a nearby teaching college, and He was able to work with my local Oncologist. I have been on Avodart from the get go, also zolodex, some time on nilandron , ketoconazole, estrogen , all at different times, my psa would go up a little and go down a little, my original scans showed widespread metastatic disease, I tried not to believe it, knowing I had lived a somewhat reckless life with motorcycle crashes and ski accidents, and knowing that  arthritis or degenerative bone disease shows about the same on a bone scan, I have never had a clear bone scan or a clear cat scan, I have never achieved and undetectable psa through therapy, yet through the grace of God I am still here, Currently almost 3 years on xtandi, MY expert Oncologist tells me there are new drugs in the pipeline , we just need to hang on, I still have chemo, both docetaxol and Javenta in my back pocket.

    lets stay in touch, you are not alone!

    Dan

  • Paul, In addition to the story I posted, I would like to add as a result of a long running clinical trial on the use of docetaxol up front with initial treatment of hormone therapy in advanced PCa has been shown to give increased survival. Women have been using chemo up front for years for Breast Cancer. I never did chemo when I was dxed because at the time they had no evidence, however at the time Dr. Strum in Oregon was the only one to recommend it , he a had a site called p2p patient to physician where we gave our stats and he would tell us his opinion. I think he still does in some form, and also there is a great support line at PCRI they have a free hot line you can call, PCRI is the Prostate Cancer Research Institute, it is an organization somewhere near LA started by Dr. Strum and Dr. Mark Scholtz who is IMO the best of the best . I have called and got really good response. Dr Strum has since moved to Oregon and has a private practice there.

       If you needs papers on the benefit of early chemo in PCa just Google it in Google scholar, or I am sure it is on Joels' page associated with this site.   I only asked a Dr. how long I had the first time, after that I realized he does not know, Be careful not to read to much into statistics. In that regard please read the essay about cancer statistics written by Stephen Gould who was given 6 months to live after his dx of mesothelioma and died 20 years later of something else. 

    cancerguide.org/median_not_...

     

  • Cheers Dan, I have already decided not to take any notice of the stats. I live in hope that we can all keep fighting and living until the 'crack the cure' as I think this is one disease they will certainly find a cure for one day, hopefully in time enough for us all to benefit.

  • The issue surrounding Gleason grade migration is an important topic since so many men want to do active surveillance (AS). AS requires a low Gleason Grade and a man needs some assurance that their Gleason will not morph up to a higher grade.

    What seems to be the real problem isn't that the Gleason grade morphs to a higher number, but that in some instances the biopsy misses the cancer that is already more aggressive as demonstrated by a higher Gleason grade.

    So, in Beauxman's situation his Gleason 10 was a Gleason 10 and probably did not start out earlier as a 6 or some other number.

    The question for men in his situation is more if the cancer still remained in the gland at diagnosis could earlier treatment have changed the course of the disease? Of course, with a higher and more aggressive Gleason number the changes are more significant that the cancer was out of the gland despite any negative scans.

    Joel

  • I believe Chuck is correct on a Gleason migrating from a lesser number, all it refers to is how poorly differentiated the cells look under a microscope, and as time goes by these cells become more poorly differentiated. The problem is for You as it was for Me, Men under 50 were not tested for PSA in the past, and it has shown up in much younger Men, we used to say testing should begin at age 40 and in the case of African American Men it should begin at age 35, sadly The American Cancer Society has determined in an effort to save Money there is no need to routinely test these Men, which undoubtedly will bring back the days of Men presenting with advanced disease , to save men who may never die of their prostate Cancer from going through overtreatment.

    Dan

  • With respect, Dan - I disagree that Gleasons cells migrate upwards from a lesser number; they stay the same but their number changes. Please see my post below supported by linked studies.

    As the more aggressive, undifferentiated G5 cells multiply they dominate the differentiated cells, so you see more and more 4's and 5's. A man who progresses from 4+5 to 5+4 then 5+5 is only because there are more and more G5 cells.

  • Hi,

    I just read your post and my Father also has a Gleason grade of 10, he was diagnosed in 2012 with stage 4 at the age of 60 . His doctors also told him that his Gleason was always a 10 and he probably had it for years, unfortunately his cancer had already escaped the gland and started to exhibit painful symptoms at the time of diagnosis.

    I can tell you that my Father is still with us today and very active as far as exercise.

    You are young and I think you will respond well to treatment.

    What I have learned about cancer at least Prostate if you stay physically fit and eat the right diet you will do well with less invasive treatments. The Doctors believe this is why my Father has done so well with only hormone therapy for all these years.

    Thanks,

    April

  • In my opinion, prostate cancer does not suddenly appear as a Gleason 5+5/10. It doesn't just "BAM" and suddenly appear as Gleason 10 in the prostate. Like the growth of a baby in the womb, it starts a beginning development process. If the cancer is extremely aggressive in growth and proliferation, only then could that growth be sufficiently excessive and extensive to rapidly rise to Gleason 10 and then possibly be present in the man for some period of time before the side effects of such advanced cancer become evident and the man is found with the top level of prostate cancer. It is refreshing to learn of these posts of men who have been successful in the treatment of their very advanced Gleason 10 prostate cancer at diagnosis, and does provide hope for others only recently learning of their advanced prostate cancer. I see it very good for our new friend Beauxman to learn that he is or will be in a trial testing Xtandi/enzalutamide in company with Zytiga/abiraterone acetate, or even if his arm turns out to be just Xtandi since either should play a significant role in reining in his cancer for hopeful long term management.

    Do continue to keep us posted Beauxman. We wish you the very best and will continue to be here to help address questions/concerns. In what part of our nation do you reside?

    Happy Easter to everyone!

  • You are correct, Chuck - PCa doesn't go BAM with G5 cells filling the prostate.  But is does start as one little undifferentiated G5 cell that quickly mutliplies to form a colony that grows quickly until all the pathologist can see are G5 cells, and thus a 5+5 = 10. Perhaps there were some G3's too but they were quickly overrun. And some G4 cells that grow pretty quickly; along the way this man with high grade PCa could have been a 4+5 or a 5+4.

    @Beauxman is an old buddy - we have been supporting him for a some time through The Reluctant Brotherhood. The best news for him as a young G10 with metastacised cancer is that he is AR V7 negative, so there is a much stronger likelihood either abi or enz, or maybe even both, will work for him.

  • I forgot about one, so actually, this is my fourth clinical trial.

    Thanks, maack1, for sharing your thoughts. I live near DC, so a bounce around between Johns Hopkins, Georgetown University and NIH, depending on what each has available for me at the time.

    Still hopping,

    Beauxman

  • Everyone is missing the point, in my opinion. The decision is OR SHOULD BE mine to make, not some doctor. I was in that same position and my GP did the same damn (intentional cuss!) thing for 7 years. My Gleason did not change over the years, but the extent of disease did, ending up at >>50% in all cores (one side) when finally biopsied.

    And, while GS may not "get worse" as the extent of disease becomes greater, the significance of a secondary grade may become more extensive and more easily detected. 1% of a 5% of one core is a heck of a lot different than 1% of 55% of a core.

    19 yrs later I'm still fighting the disease, albeit a GS6, but with a 3 mo PSADT. Lots of money spent on Lupron and other drugs Maybe because of one doctor's mistake.

    Herb S.

  • Don't give up.  Do research and look at all the options.  Ty Bollingers book is a good place to start to learn about alternative approaches.  There is lots of information out there.  The problem is, there is no current way, for a given patient, to know which treatment will work.  It is a bit of wheel of fortune.  I literally pray to be shown the right path.  I am doing blood ozone treatment, developed in Europe and used there for decades, but used by only a few doctors here.  A vegan diet helps, and there are lots of supportive supplements. Best wishes to you

  • (I posted this already, but somehow it got lost; if it shows up twice, forgive me!)

    As suggested by some above, there is a widely held hypothesis by many respected GU med oncs that Gleason grades do NOT migrate or change over time. Unlike in other cancers, a G3 remains a 3; a G4 a 4; and, a G5 a 5.

    The speed with which these cells multiply differs. So a man who has a tiny amount of 5 early in his disease that is not detected eventually finds that the 5 grows faster than anything else, overwhelms the gland and may break out. Eventually, all that can be seen with men who have G5 disease are undifferentiated G5 cells, even though the lesser cells are still present somewhere.

    There is research that supports this; here is a seminal study from 2013, and there are previous studies too: ncbi.nlm.nih.gov/pmc/articl...

    ........ this study was widely reported on Medscape, Cancer Network and elsewhere; here is a good commentary by Mike Scott  prostatecancerinfolink.net/... .

    This may also explain why true G3+3 disease shows a very low rate of metastasis. A Mayo study reported just 0.16% in a population of 14,000+ men.

    More recent research suggests that the genomic profile of these cells does change as the disease progresses. A mature G4 or 5 cell will eventually morph into a more resistant form and alter its genomic profile, although it will still appear as a 4 or 5. Some have suggested this happens faster with earlier exposure to multiple drugs.

    Onward & upwards, rd

  • In the papers you reference is the statement “Lavery and Droller(25) posit that Gleason patterns 3 and 4 represent separate cancer diatheses, and the faster proliferation of pattern 4 compared to 3 may explain the apparent evolution of pattern 3 to 4. Different risk factors (genetics or environmental) may lead separately to the development of Gleason grade 3 or grade 4 disease. (Please note the words “may explain the apparent evolution of pattern 3 to 4.” - again “evolution of pattern 3 to 4”).

    In fact, the entire study alludes to the fact that they cannot rule out that tumor patterns (Gleason Grades) can progress from one pattern/grade to a higher one, though they feel that even if they can, they do not do so on what could be considered a routine basis. Actually, rather than concern about grade increase from one to a higher is secondary, since the study is dealing more with the patient whose Gleason Score remains stable over time without grade increase that then enables better management of that patient’s cancer.

  • Mr. Maack - the Lavery & Droller quote you cite precisely supports my point, namely G3's and G4's are different diatheses - a fancy word for 'conditions', I believe. They don't change from one to the other, but they do grow at different rates.

    This opinion is held by many eminent urologists and GU med oncs. If you hold otherwise, as you are entitled to do, your readers should be aware that opinion is in the minority.

    Changing Gleason scores are impacted by the speed at which the cells multiply; as Lavery & Droller posit - "faster proliferation of pattern 4 compared to 3 may explain the apparent evolution of pattern 3 to 4." That is the very point I made above.

    You and I both know enough men whose Gleason score HAS changed over time ...... not because the cells changed, but because they grew at differing speeds so the pattern got altered.

    The study concludes that changing Gleason scores are not a major feature of PCa. I would agree with that - most men are stable, because most men, some 85%, do not have intermediate or advanced disease. Those that do, a significant minority, do feature changing Gleason scores.

  • I give up.  Until you name and quote the eminent physicians that may prove my pathologist - the specialist who actually reviews prostate cancer cells under the microscope - wrong, I will stick to my opinion and let readers come to their own conclusions.  I agree to disagree.

  • Not sure why you give up ..... Lavery & Droller clearly state 3 & 4 are different diatheses.

    Let's try Peter Carroll, Chuck Ryan and Eric Small for starters .... send them a note for their opinion, and share with your pathologist buddy - and with us too please.

    Like I said, you are entitled to your own opinion, even if it is in the small minority. so by all means stick with it. Just be sure your readers are aware of that.

  • My suggestion to you, ardee, since you are using their names, is that YOU contact each of those physician of whom I am well aware, and get them to confirm, specifically, that cancer cell Gleason grades do not change under the microscope from 3 to 4 etc. over time if left untreated. 

  • You asked me who I am referencing so I told you, Chuck - I have no need to contact them. I believe what they say, and know they will confirm, what I have stated

    You doubt their opinion and believe a G3 cell turns into a G4 then a G5. Many believe that does NOT happen. Cells stay the same but grow at different rates.

    So if you need confirmation, reach out. If not, just be sure to advise yours is a controversial, minority opinion.

    Btw, I am only repeating what the experts say - don't shoot the messenger old boy ... :<))!!

  • The fundamental question is, if I had gotten a biopsy in 2007, rather than 2014, is there a good chance that I currently would not be castrate resistant with bone metastases and have a far greater expectation of life?

  • Answer to that question, Beauxman, yes.

    Following on with the discussion of Gleason Grades, if cancer not treated, climbing.

    In checking with a pathologist friend the questions asked of him were:

    Me: In evaluating cancer cells under the microscope, can cells graded 3 later develop, become less differentiated, and change to grade 4 or 5?

    Pathologist: Yes, the grade can change from 3 to 4 or 5.

    Me: Put in a different manner, if a man initially received a biopsy and his prostate cancer is graded as 3+3/6, can those same cells graded 3 change as they develop to become grade 4?

    Pathologist: Yes, again.

    Me: There is discussion going on wherein some men are claiming that prostate cancer cells that are graded 3 never change from being 3. The same goes for cancer cells graded 4, or graded 5 - they always remain that grade and do not change. A doctor told a patient his Gleason Score of 10 “was always 10.”

    Pathologist: A Gleason score of 10 is the highest possible (i.e. the worst prognosis). If at diagnosis your cancer has already progressed to Gleason Score grades 5+5/10, you have that Gleason Score for the rest of your life.

    Pathologist continues: Not so simple with a score of 6; many men with a score of 6 will, over the years, experience an increase in the score (but NEVER a decrease).

    Me: My argument (and that is why I am asking your advice) is that every cancer cell, when it begins its development would likely start at grade 1, but as it continues in development - and if not suppressed from that development - it becomes less differentiated and can become grade 2, then grade 3, then grade 4, then grade 5

    Pathologist: There is at present no way to know whether all PCs start as a 1. But it is true that in some men the grade goes up over time. And it would be nice to know at the outset whether one’s 3 will become a 4. There are molecular tests being evaluated as possible predictors.

    Me: Does any of the foregoing make sense?

    Pathologist: Your questions always make sense. The use of one standardized system (Gleason) means that PC is better managed than, for example, breast cancer where you have at least four popular grading systems. Always good to hear from you.

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