Six, Not a Bad Score

Gleason 6 prostate cancer may sound like a dangerous type of prostate cancer. Luckily that is not the case, Gleason 6 prostate cancer does not spread. This means men with Gleason 6 can be safely monitored through active surveillance and avoid the side effects that come with treatment. Active surveillance is not synonymous with watchful waiting, and it no longer means periodic random biopsy. Learn the active surveillance protocol and discover a Gleason 6 lifestyle.

Dr. Scholz:  [00:03] Welcome to PROSTATE PROS podcast. We're guiding you to treatment success and avoiding prostate cancer pitfalls. I'm your host, Dr. Mark Scholz here with my cohost Liz Graves.

Liz:  [00:13] Gleason 6 prostate cancer may sound like a scary diagnosis, especially if you're thinking of rating on a one to ten scale with ten being the worst. But that is not the case. Gleason 6 is actually a good score.

Dr. Scholz:  [00:28] The scoring system is so confusing that Dr. Jonathan Epstein at Johns Hopkins has developed a new scoring system. It doesn't change what they see under the microscope, but by assigning realistic numbers, people have a better sense of where they stand. So under Epstein's system, what they call a Gleason 6 is a one, on a one to five scale. So it's the lowest number possible. Gleason 6 is actually a type of condition that can't spread.

Liz:  [00:59] So, how did a Gleason 6 ever get called cancer?

Dr. Scholz:  [01:03] So 30, 40 years ago when the system was developed, it was thought that Gleason 6 could spread, and that of course, defines any cancer. What we call metastasis is what makes these conditions dangerous. But it turns out, after much research that Gleason 6 never spreads; therefore, it's actually not even a cancer. And this has been discussed thoroughly in different circles about changing it to a different name besides cancer. Those discussions are ongoing. But, in the meantime we have to live with this incorrect terminology, calling Gleason 6 a cancer.

Liz:   [01:42] So if Gleason 6 isn't a cancer, then why do you need to watch it?

Dr. Scholz:   [01:46] It turns out when you do biopsies of the prostate, it's sometimes possible to get multiple different types of prostate cancer in the same individual. Another problem is that as men are being monitored over time, it is possible for them to get a brand new cancer that has a higher score. The watching, therefore, is done for two reasons: to make sure, (one) that some higher grade cancer isn't lurking in a corner that was missed, and (two) that a new cancer doesn't come along and create a problem and without appropriate surveillance is allowed to spread and doesn't get treated in a timely fashion.

Liz:  [02:28] So you're saying that Gleason 6 prostate cancer can be watched and that's a type of treatment called active surveillance.

Dr. Scholz:  [02:37] Exactly. The idea of monitoring rather than treating was very revolutionary ten years ago, but as of 2019, throughout academia, it's universally agreed that Gleason 6 prostate cancer should be monitored. There unfortunately are still pockets of resistance where, mostly in perhaps small towns and whatnot, doctors are still recommending treatment for Gleason 6. This is a holdover from a time when we thought that it could spread. We now know that that's improper therapy and that active surveillance is the right way to treat it.

Liz:  [03:17] What’s your protocol of active surveillance?

Dr. Scholz:  [03:21] Yeah, there is quite a bit of variety because until good imaging came along, the only way to evaluate prostates on an ongoing basis was to do a random 12 core biopsy. Regular biopsies every couple, three years, is still considered standard at most urology centers to this day. Personally, I don't ascribe to that belief because imaging has been shown in well-designed studies to be more accurate. Imaging, I’m specifically referring to multiparametric MRI. Our policy is to do MRI scans once a year and only do targeted biopsies if there's an abnormality or if a previously noted area of concern has changed or grown.

Liz:  [04:07] This is one reason it's really important to have a doctor that's familiar with active surveillance. As we've talked about, random biopsies aren't always accurate and if you miss a higher stage cancer in a random biopsy, the cancer can spread and then Gleason 6 seems like it might be more dangerous.

Dr. Scholz:  [04:27] Yeah, there is confusion. One of the reasons I thought Gleason 6 could potentially spread was because of hidden areas of higher grade tumor that were in another part of the prostate that was missed on the random biopsy. We now know in cases where pure Gleason 6 is present, it won't spread. This is why it's important for people to have careful scanning to make sure that nothing is being missed.

Liz:  [04:52] So you combine PSA testing with MRI scans. How often do you test for PSA and how often should men be getting scanned?

Dr. Scholz: [05:03] Typically men are on an annual basis for their scans. If there's something suspicious in exceptional cases, we'll get a scan every six months. PSA testing initially could be every three to four months, but over time people realize that nothing is changing and twice a year PSA testing is usually adequate.

Liz:  [05:24] I've also heard the term watchful waiting. Is this the same thing as active surveillance?

Dr. Scholz:  [05:30] Watchful waiting is an older methodology that's been around for many decades. This is tipping our hat to the realization that as men get older, even bad prostate cancers take a long time to spread. The policy then if men had what appeared to be localized disease, perhaps detected on a digital rectal exam, was to simply do nothing. These men were advised that if the cancer spread and their bones started to hurt, that they could then go on a hormonal treatment that would put them back in remission. This type of approach is not that unreasonable for men that are in their eighties but watchful waiting really isn't practiced that much in my opinion. Because if men do have localized disease, the treatments are becoming so much more tolerable and simply treating the disease rather than giving it a chance to spread is often a more sensible approach.

Liz:  [06:27] So in that context, when you say localized disease, you're not necessarily talking about a Gleason 6. That could be a Gleason 7 that has potential to spread.

Dr. Scholz:  [06:38] Absolutely. Higher grade prostate cancer is only higher grade compared to Gleason 6. These Gleason 7s, 8s, 9s, and even 10s actually grow quite a bit more slowly than most other types of cancers like pancreas cancer, lung cancer, bone cancer. Even higher grade cancers that are coming from the prostate are relatively slow growing compared to most cancers.

Liz:  [07:07] Because of prostate cancer’s slow growing nature, if someone is on active surveillance and they're preserving their urinary function and sexual function, they can actually delay treatment for 10 to 15 years. In that time they're likely to benefit from technology that has yet to be invented.

Dr. Scholz:  [07:28] Absolutely. There’s a rapid progress ongoing in the prostate cancer world and new treatments are being developed all the time. One of the major advantages of active surveillance is postponing irreversible therapy because down the line a less damaging type of treatment may be invented.

Liz:  [07:47] So it sounds like active surveillance has a lot going for it, but a ton of men are still getting radical treatment. Why is that?

Dr. Scholz:  [07:55] I think it's that word cancer. People tended to fall to a belief that it's a deadly illness and the doctors that are involved in treating prostate cancer, the urologist are men of action. They are trained in surgery and may not be comfortable watching a condition. Trying to explain that to a patient, why cancer isn't being treated, is a somewhat difficult proposition. There's a whole history behind it and the urological community is sometimes not up to speed in terms of how safe Gleason 6 really is.

Liz:  [08:33] What age group of men is eligible for active surveillance?

Dr. Scholz:  [08:38] All ages are eligible. This is one thing that we really want to emphasize because watchful waiting was always reserved for the elderly. As I mentioned before, we're not doing much watchful waiting anymore, but the men that really benefit from active surveillance are the ones that are still sexually active. Treatment for prostate cancer has gotten better and better, but the one thing that is very difficult to avoid is erectile dysfunction, which is occurring in as many as 50% of men that have surgery or radiation.

Liz:  [09:10] Young men and old men can both be on active surveillance safely if it has been established that they do have a cancer that won't spread. So how long can men stay on active surveillance?

Dr. Scholz:  [09:23] Decades. We’ve had patients on active surveillance for over 15 years now and the assumption that the cancer is going to get worse or devolve into a higher grade, is just not correct. The problem was with the random biopsies which were missing higher grade cancers 20% of the time and then with repeat biopsies they would finally find it. Now with our modern imaging techniques, we're picking up the higher grade cancers from the get-go and the men that are going on to active surveillance are much more likely to have pure grade six and the men that have pure grade six, almost all of them remain on active surveillance for many, many years and will probably remain on active surveillance for the rest of their lives. Liz:  [10:07] One of your patients is an actor, director and he wrote an autobiography, Bill Duke: My 40-Year Career on Screen and Behind the Camera.

Dr. Scholz:  [10:17] Bill came to see me back in the late 1990s. He’s a very intelligent and innovative guy and he was determined to not go through prostate surgery. We had information from Europe back then about this watchful waiting stuff that we talked about that possibly some types of cancer could be safely watched. Bill had immense courage and decided that he was going to do active surveillance. He's been doing that now for 20 years. He's never required any therapy. His PSA has not gone excessively high and he's profoundly pleased that he decided to not have surgery. He’s of course had to face that question constantly throughout the years and had wondered if he's making a mistake. But thankfully now, 20 years later he's still doing well.

Liz:  [11:09] What if someone isn't as brave and they believe it will change and they really, really want treatment?

Dr. Scholz:  [11:17] Well, we certainly encounter that. People that are really nervous and frightened; our first step is always to try and reassure them and tell them that the science is really strong and that there are thousands of men that are successfully pursuing this type of an approach. But that's their choice of course, ultimately. In cases like that, we would want to try and steer them towards as minimal treatment as possible. Perhaps some sort of a focal therapy where just a section of the prostate is radiated, or frozen, or destroyed with high intensity focused ultrasound, and other men have picked short courses of hormonal therapy just to shrivel up the cancer and then stop treatment. The more rigorous treatments are really a shame, because these less invasive treatments are certainly effective and have a lot fewer side effects than the more traditional surgical approach.

Liz:  [12:13] We've talked about Proscar and Avodart and I read that sometimes these are also used for men on active surveillance.

Dr. Scholz:  [12:22] These medicines lower PSA. A high PSA is one of the things that makes people nervous, doctors, and patients alike. So in that sense, Proscar and Avodart are attractive. The impact on stopping high-grade cancers, should one be lurking in a corner, is not notable. It will impede grade six but is that really necessary? These are pretty harmless, so we don't typically use those medicines on a routine basis, but they can be considered and as we've stated before, we always need to advise people that there is a potential negative impact on libido.

Liz:  [13:07] Here's an update on the recent news and developments in prostate cancer. Duke University published a study about how prostate cancer cells mimic bone cells when they metastasize. This is called osteomimicry. The study finds that osteomimicry may contribute to the uptake of radium-223, also known as Xofigo, and enhance its benefit in treating bone mets. The FDA recently approved another of Bayer’s drugs, darolutamide, trade name, Nubeqa for non-metastatic castration resistant prostate cancer. Nubeqa shows fewer side effects than other similar drugs, namely less incidence of severe fatigue. The University of North Carolina found that out of 350 men, only 15% followed the recommended active surveillance guidelines. The study did not hypothesize why men were not following guidelines. How this affects survival rates is unknown at this time. A study published in Molecular Cancer Research may have found a link between the increased rates of prostate cancer among September 11th responders and exposure to the dust from the attack. In regards to diet and overall health, The World Cancer Research Fund associated higher body mass index and waist circumference with an increased risk of advanced prostate cancer. Thigh and visceral fat in high concentrations also increases the odds of fatal, aggressive prostate cancer by 30-40%. That’s the news update at this time.

Liz:  [14:52] Gleason 6, not a bad score. What are the signs someone should be taken off active surveillance and start getting treated?

Dr. Scholz:  [15:01] In the case of monitoring men with multiparametric MRI, if there's enlargement in the previously noted lesion that's been under surveillance, or if it looks like it's changing to become a little more aggressive, or if a new spot shows up, all these things would lead to a targeted biopsy. If a higher Gleason score is detected, those men will need treatment that’s appropriate for their stage.

Liz:  [15:28] Active surveillance is different than watchful waiting. You're actively monitoring the prostate cancer, so at the earliest sign of something changing, you can catch it right away and begin treatment.

Dr. Scholz:  [15:39] So this has been really good to cover a very common problem. About half the men with prostate cancer have Gleason 6. This is not a rare occurrence. The other half of men are going to need some type of treatment. In the future we're going to cover the TEAL stage of prostate cancer, otherwise known as Intermediate-Risk and there are a variety of effective relatively minimalistic therapies that need to be considered and we'll be covering that in the future.

Liz:  [16:08] If you don’t yet know your stage, you can take the staging quiz at keytopc.com. I just wanted to remind you that September is prostate cancer awareness month. Do your job and remind friends and families to get their PSAs tested. With one in nine men being diagnosed with prostate cancer in their lifetime, a simple PSA test can really make a difference. We're also going to be doing a book giveaway this month, so you can find the link on our website, podcast.prostateoncology.com. Also, if you're at the PCRI conference this weekend, September 6th through 9th, Dr. Scholz and I will both be there. So come say hi. Please help us out by rating and reviewing and subscribing to PROSTATE PROS on Apple Podcasts. We'd really love to hear from you, meet you, and talk about prostate cancer.

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