NCCN Blasphemy?

[TFU589]

I found this interesting conversation on a doc/med-student blog, did not save the website, but can dig it out if anyone wants to take a look.

I had always wondered about the "% cores positive". Especially when there is a mix of grades, GG1 and GG2. Also, as Doc 2 mentions, the % of positive cores can bump you up into another risk category. I know, a little more goes into the decision making, buuuuutttt...

Would be great to hear any feedback or comments on this, or if anyone has seen any studies where they looked at this. Not sure if someone like Doc D'Amico broke it down to different GGs.

Doctor 1: I offer all my favorable intermediate risk patients AS. I steer most of the younger folks away from it do the small but non-zero risk of progression to Mets (1-10% depending on the series you look at) and very high rates of conversion to radical therapy (~50-60% at 5 years). I also get edgy with higher volumes of disease, even if it’s a 1-2 cores of GG2 in a background of 8/12 cores with GG1 (though that’s technically unfavorable IR per NCCN, which tbh I disagree with)

Incidentally I think this is the one area where focal therapy be beneficial. If you have low volume Gleason 7 disease and you can reduce their risk of progression to therapy from 60% to 20% with minimal ADRs that’s a potential benefit.

Doctor 2: I think NCCN is unclear on risk grouping based on volume of disease. There is no consideration of % cores positive for low risk. Someone can have 10/12 cores positive for GGG1 disease and anything, even AS, is ok. But now if the same person has a single core of GGG2 disease, they go all the way to unfavorable disease and need ADT if they opt for RT (and are no longer a Brachy only candidate)? Give me a break. I personally don’t count the GGG1 cores and neither do our urologists. It wouldn’t make sense.

[TFU589]

urotoday.com/video-lectures...

[RJAMSG]

I have seen some YouTube videos of Dr. Epstein the pathologist from Johns Hopkins having these types of discussions with patients, very interesting for those of us being treated or under treatments already.

[dentaltwin]

My understanding is that GG 2 is Gleason 3+4, GG 3 is 4+3. GG2 is intermediate favorable and GG3 is intermediate unfavorable.

If you're going to consider focal therapy for PC, it stands to reason you'd better be sure where your foci are. (I was intermediate risk/favorable. Though I understand SOME G3+4 patients are offered AS, I was not, and did not consider focal therapy).

[TFU589 in reply to dentaltwin]

Thank you for the response, but If I understand this correctly, and if anyone else in the group would like to jump in, it is a little more "tangled" than that.

Favorable intermediate-risk patients have 1 intermediate risk factor, Grade Group 1 or 2 cancer, and <50% of cores positive.

Unfavorable intermediate-risk patients have 2 or 3 intermediate risk factorsAnand/or Grade Group 3 prostate cancer, and/or ≥50% of biopsy cores positive.

So what doc 2 is saying is that according to guidelines, the patient he is describing does not have any grade Grade Group 3, just one core of Grade Group 2 and about 10/12 Grade Group 1 cores, which is more than 50% positive cores so that pushes the patient into the Unfavorable Intermediate risk.

And if you take a look at the hyperlink I added in an earlier post, there are some smart guys applying AI to hopefully take out the ambiguity of situations like this.

[TFU589 in reply to dentaltwin]

urotoday.com/video-lectures...