“Stop inappropriate, expensive & perhaps even unethical radical therapies for a condition that by itself does not kill”

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That’s an excerpt from a recent commentary in the British Journal of Urology International (BJUI) by authors from urology departments in Canada and the UK asking, “Should we really consider Gleason 6 prostate cancer?” (subscription required for full access).

The National Cancer Institute defines the Gleason score as:

A system of grading prostate cancer tissue based on how it looks under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer tissue is similar to normal prostate tissue and the tumor is less likely to spread; a high Gleason score means the cancer tissue is very different from normal and the tumor is more likely to spread.

But on that spectrum of 2 to 10, different doctors draw different cut-off points for decision-making.  The BJUI commentary stated:

“There is no doubt that prostate cancer kills, but only a minority of men who are given this diagnosis, die from prostate cancer. In the developed world we are now overdiagnosing and, more importantly, overtreating prostate cancer, a fact for which we will be criticized in generations to come. As well-intentioned urologists, we should have no trouble in justifying our radical therapy for pathologically moderate to high grade, Gleason 7 – 10 cancers. Despite the opinions of some urological luddites, careful active surveillance is slowly becoming the standard for Gleason 6, particularly for those with low volume disease associated with low serum PSA values, however, many patients with Gleason 6 still receive radical treatment. We (and others) would like to hypothesize, at least for the sake of discussion, that Gleason 6 pattern prostate pathology is not in itself a lethal prostate cancer, but rather can be associated with a higher risk of potentially lethal prostate cancer (e.g. Gleason 7 or higher) or, alternatively, is a precursor to such prostate cancer. This change in thinking would mean that patients with Gleason 6 scores would not be labelled with a ‘ lethal ‘ cancer diagnosis and would be less anxious about the appropriate treatment plan of active surveillance. Many patients drop out of active surveillance and pursue radical treatment, not because of rising PSA levels, biopsy results or other forms of disease progression, but because of anxiety. There may be less morbidity (and cost) if patients were not given the ‘cancer-label ‘ until they had Gleason 7 disease.

Whether Gleason 6 is really a cancer or not is a mute (sic) point, one that can only be debated, at this time. We continue to over-diagnose and subsequently over-treat unfortunate men who are labelled with a ‘lethal’ cancer, when in fact they will probably never die from it. It is a fact, however, that some men continue to die from prostate cancer, so we must try and direct our therapies to those men, a task that will only be possible through enlightened discussion coupled with basic and clinical research. We need to change our paradigm when dealing with Gleason 6 pattern diagnosis, whether it is a low-risk cancer, a benign disease associated with a high risk of developing real potentially lethal cancer, or a true prostate cancer precursor. Let ‘s find a way to treat only those men who are destined to die from this serious cancer and relieve some of the psychological burden and significant morbidity from those men who should never have been labelled ashaving a lethal cancer in the first place. Let us make the case and put in the effort to develop improved prostate cancer screening for the higher grade prostate cancers,while at the same time relegating low volume Gleason 6 to the status of no more than a significant risk factor. Let us decide as a profession to stop the push for inappropriate, expensive, inopportune and perhaps even unethical radical therapies for a condition that by itself does not kill our patients.”

What to call certain abnormal cellular findings is increasingly becoming an issue for doctors.

In breast cancer, there’s been some discussion of re-naming ductal carcinoma in situ and removing the “carcinoma” from the diagnosis.

In cervical cancer, there are ASCUS cells – or “atypical squamous cells of unknown significance.”

Gleason 6 cells in the prostate cancer field have been called “adenosis.”  They’ve been called IDLE – indolent lesions of epithelial origin.

Whatever these cells are called, one practical goal for now is to educate men about the harms of overdiagnosis and overtreatment and offer active surveillance as a treatment option.

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