Getting the most info from a biopsy especially if considering Active Surveillane

[Guest guest]

It appears that a significant number of urologists use the information

from a biopsy as a 'yes' - 'no' flag for immediate treatment with the

idea that if any cancer is found, treatment-- surgery or radiation- is

needed. If not, then no treatment. And, some urologists apparently

feel this is all a patient needs to know. This results in patients not

being informed on the full information content from a biopsy.

For aggressive cancers this may be justified, however, there is

information in details of biopsy results that can guide decisions on

appropriate treatment for aggressive cancers. This information should

be used to estimate the 'staging' of your cancer.

For classic 'low risk' cancers it is most important to know as much as

possible about the details of a biopsy to consider whether or not

defering immediate treatment by Active Surveillance is a reasonable

option. And, for many men with the appropriate criteria, it is.

Patients should ask their urologists to provide and discuss all the

following regarding positive (cancer found) biopsy results. If not in

the first shock of learning the diagnosis, then in a followup consult.

Even better, let your doctor know BEFORE the biopsy that you will want

to discuss the following if the biopsy finds cancer. That should be an

incentive for the urologist to carefully document how the biopsy is

performed.

How many cores were positive for cancer? What percentage of the cores

taken were positive? What percentage of each positive core was cancer?

What are both the major and minor Gleason scores for each positive core?

A Gleason sum of 7 where the primary Gleason is 4 (4 +3) suggest more

aggressivenes than 3 =4. Even better is reporting the total percentage

of Gleason 4 among all the postive cores.

Where were the positive cores located? Both sides of the prostate or

one? Near the prostate walls or more within the prostate? Near the

neurovascular bundles or seminal vesicles?

What was the PSA density? This is the size of the prostate estimated

from the biopsy ultrasound divided by the 'base PSA', ie the PSA just

before the biopsy.

All these factors should be considered in thinking about Active

Surveillance, which, for many early cancers can be a viable relativly

low-risk option IF appropriate conditions are met. For more info see in

the FILES section: ActiveSurveillanceCriteria.2007.pdf.

An example of the importance of the detailed information is in the

following abstract. In this report 40% of patients fitting classic 'low

risk' criteria had their Gleason sum upgraded (most from 6 to 7) after

the prostates removed by surgery were examined. The fact that

post-surgery examination can indicate more aggressive cancer than the

initial biopsy is a factor that leads many men to opt for surgery.

However, the number of upgrades were a function of the number of

positive cores (details not given in the abstract). So, within the 'low

risk' group, knowing the full information described above would have

futher defined whether or not Active Surveillance would have been

appropriate.

With our disease, no matter what your decision may be regarding

treatment and no matter what the ultimate fate of your cancer, knowledge

is power. Insist on full disclosure and discussion of your biopsy

results. If your questions are dismissed or blown off, find another

doctor.

The Best to You and Yours!

Jon in Nevada

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Prediction of Gleason Score Upgrading in Low-Risk Prostate Cancers

Diagnosed Via Multi (>/=12)-Core Prostate Biopsy - Abstract

Tuesday, 02 December 2008

Hong SK, Han BK, Lee ST, Kim SS, Min KE, Jeong SJ, Jeong H, Byun SS, Lee

HJ, Choe G, Lee SE

Department of Urology, Seoul National University Bundang Hospital, 300,

Gumi-dong, Bundang-gu, Seongnam, Kyunggi-do, 463-707, South Korea.

A paucity of data exists on actual pathology of the contemporary

patients strictly categorized as having low-risk prostate cancer. We

tried to identify useful preoperative predictors of Gleason score

upgrading in patients who underwent radical retropubic prostatectomy

(RRP) for low-risk prostate cancer diagnosed via multi-core prostate

biopsy.

A total of 203 patients who underwent radical RRP for low-risk prostate

cancer, as defined by D'Amico et al.'s classification (clinical stage <

/=T2a, biopsy Gleason sum < /=6, and PSA < /=10 ng/ml), detected via

multi (>/=12)-core prostate biopsy were enrolled. We reviewed patients

preoperative and pathological data.

Among all subjects, 81 (39.9%) were upgraded to Gleason score >/=7 after

RRP, whereas no downgrading was observed. In multivariate analysis, only

preoperative PSA level (P = 0.024) and number of positive cores (P =

0.027) were observed to be independent predictors of Gleason score

upgrading following RRP. Also, Gleason core upgrading was observed to be

significantly associated with extraprostatic extension of tumor (P <

0.001) and positive surgical margin (P = 0.002).

A significant proportion of patients with low-risk prostate cancer as

defined by D'Amico et al.'s classification diagnosed via multi-core

prostate biopsy in contemporary period may have Gleason score upgrading

following RRP. For patients with low-risk prostate cancer, preoperative

PSA level and number of positive cores may be useful predictors of

Gleason score upgrading, which was observed to significantly associated

with other adverse pathologic features.

Reference: World J Urol. 2008 Nov 20. Epub ahead of print.

doi:10.1007/s00-3

PubMed Abstract PMID:19020885