Gerald Chodak, MD

The Prostate Cancer Doc

News you need to know from a pro

Posted in: Prostate Cancer

Doctor, Do I Have Prostate Cancer or Not?

A new idea being tossed around by several doctors is whether a man with a Gleason score of 3+3 on a biopsy really has prostate cancer. According to the National Cancer Institute, cancer is defined as a disease in which abnormal cells divide without control and can invade other tissues and spread to other organs. After nearly 16 years of screening for this disease, doctors are finally accepting that a large percentage of the prostate cancers that have been detected and treated would never have been life threatening if left alone. For that reason, the idea of doing active surveillance has gained in popularity. This term is applied to men that are followed and not treated until there is clear evidence the cancer is becoming more dangerous. The problem, however, in telling a man he has cancer but does not need treatment is that it can be a hard pill to swallow for either the patient, his significant other, or both. Because of this, these doctors are suggesting that we no longer tell a man with Gleason 3+3 disease that he has cancer. That way, he should have little trouble refraining from getting treatment.

Is this a good idea? Many will argue it is not for several reasons. First, although the evidence is pretty strong that the risk from Gleason 3+3 disease is low, it is not a zero risk. Some small percentage of these men still will get into trouble. Basal cell cancer of the skin has some similarities. It too has a very low chance of spreading and leading to death, but that risk is not zero. However, no one is suggesting that basal cell cancer should be called something other than cancer. Some people still do get in trouble. With Gleason 3+3 prostate cancer, doctors cannot say at this time that there is NO chance the cancer will progress, only that the risk appears to be very small. Can you imagine the number of lawsuits that will result if a man is told he really doesn’t have cancer, and then his Gleason 3+3 actually does progress?

A second problem is that at present there is no way to be sure that a man with Gleason 3+3 cancer cells on a biopsy doesn’t have more aggressive cancer cells somewhere else in his prostate that were not detected. At present, MRI, ultrasound, and CT are not able to reliably detect a small area of cancer that might contain these more dangerous cells, and a biopsy only samples a portion of the entire gland.

Another problem is that the interpretation on a biopsy is subjective. Studies have shown that some doctors underestimate the Gleason score. Without a way to standardize the interpretation, there is a substantial risk that some men assigned to this “no cancer” diagnosis will be assigned improperly and then fail to get the treatment they really need.

Lastly, doctors are still not sure that Gleason 3+3 will never change to a higher Gleason score. For that reason, continued follow-up is necessary.

The bottom line is that many men diagnosed with prostate cancer following a screening PSA test are not in danger and may never need treatment. Rather than change the name and call it something other than cancer, patients would be better served by more intense education about the low risk it poses and the extremely small benefit offered by aggressive treatment.

Last Updated: 1/26/2014
Posted in: Prostate Cancer

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