Dr. Scholz, can you explain to our audience what Gleason 4+4=8 means?
It's a representation of the aggressiveness and the appearance of the cancer cells under
the microscope and this is useful because the big question with all kinds of cancers
including prostate cancer is, "What's the potential for it to spread outside the gland?"
That's what makes cancer dangerous: the possibility of metastases. And the old-fashioned scaling
Gleason system, which is still in use today, it really has three grades and to keep it
confusing it starts at 3 being the lowest grade, 4 being a higher grade, and 5 being
the highest grade. Sometimes you have more than one grade and so they have two numbers
in case someone has a little bit of one and a little bit of another and so they put a
plus sign in between. 4+4 means that it's pure grade 4 which would be considered a higher
or high-grade.
So, since it's a high-grade cancer, I mean, does the patient need to act with more expediency?
Do they still need to do the second biopsy? So, I know a lot of patients when I talk to
them they hear that higher number and they think that they need to act immediately and
unfortunately, a lot of people just go straight to surgery. So, even though it's a higher-grade
Gleason score, do they still have time?
They definitely have time. They have plenty of time. When we talk about higher grade versus
lower grade, remember we're comparing prostate cancer with prostate cancer. If you look at
other types of cancers, they are all high-grade compared to prostate cancer. In fact, they're
higher grade than prostate cancer, but some types of prostate cancer are so low-grade
they don't spread, they don't really act like cancers, so the terminology sounds scary,
"high-grade," but really it's just relative to the harmless or the low-grade types that
prostate cancers that are high-grade can spread, but they grow very slowly and they're very
treatable.
What does a person do if they need to confirm that they have Gleason 8?
Well, you're probably referring to the fact that assigning a grade, looking underneath
the microscope and determining if it's a grade 3, 4, or 5 is a bit of a skill, and that can
vary. We've found it's usually helpful to have people get their glass slides from the
biopsy and send them off to a reference center—we've been using John Hopkins a lot—to confirm
that the number that was assigned was accurate because the treatment changes if the number
goes up or down. If it goes up, you get stronger treatment. If it goes down, you get milder
treatment.
So, once a person has confirmed Gleason 8 and they are now going into the conversations
with their doctor about treatment, what would you like them to keep in mind? So, there's
a lot of different treatments out there, you know, as a medical oncologist what do you
think is best? And what's really the best protocol to go about choosing a treatment?
Well, in the simplest terms, we're looking at trying to get cured without trying to cause
a lot of side effects, and historically, say 10-15 years ago, surgery was the best option
because radiation was not very precise. I think it has flip-flopped and now in 2020
we're looking at radiation being probably the best option to cure the disease and then
try and minimize the chance for incontinence and impotence and things like that. The industry
is run by surgeons and so there's still a lot of encouragement to do surgery from the
doctors that are managing it—the urologists. But I think that for the high-grade cancers
I strongly prefer some form of radiation. If we're talking about a Gleason 4+4, some
hormone treatment for 12-18 months, seed implant radiation, IMRT. These are the types of things
that we're looking at for men with high-grade prostate cancer.
So, in choosing the type of radiation for the treatment, do you have a preference for
one or the other? Or is it really based on where their cancer is? So what are the factors
that would go into that?
Well, traditional prostate cancer treatment doesn't rely on selectively treating the area
of the cancer. The whole prostate is targeted and there are newer thoughts about focal therapy.
These are still experimental; they're available and coming quickly, but traditionally the
whole prostate is targeted and with higher grade disease, studies seem to indicate fairly
convincingly that the seed implant radiation, which delivers a higher dose than the beam
radiation is capable of, making the seed implant a preferable approach or at least something
to build around. The whole idea of cancer spread, of course, has led to people wanting
to use beam radiation to treat the surrounding lymph nodes to cover the possibility that
there's spread in the lymph nodes and that may be changing with the advent of these new
PSMA/PET scans. Will we be able to skip the beam radiation or even skip the hormone therapy
if these scans are clear? This is yet to be determined.
So, when you talk about seed implants, I know in other videos we've covered this but I think
it's also very good to know now, is it really like temporary versus permanent seeds that
you've seen a better outcome for Gleason 8?
To the best of my knowledge, the outcomes are equivalent. It's far more dependent on
getting a quality skilled brachytherapist to do the seed implant. The permanent seeds
are more convenient. That's an outpatient procedure. The temporary seeds you have to
go to the hospital, it's more involved. So, the permanent seeds tend to be a lot more
popular. In people that have large cancers that are creeping up into the seminal vesicle,
the temporary seeds have a little more flexibility for treating outside the gland, and so for
really high-grade disease that's large and advanced, I tend to go with temporary seeds,
but the permanent seeds, being more convenient, there's probably 10-20 people that have a
permanent seed implant for everyone one that goes through temporary seeds.
So when it comes to, let's say, IMRT and, you know, going and doing the lower regions
so you get different lymph nodes, are there more side effects with that compared to seeds?
So, why is that we would choose brachytherapy over IMRT, and are there more benefits if
it can go in different directions?
Actually, there are very few additional side effects form treating the lymph nodes, but
it's not an either/or thing. Usually, with high-grade disease you're going to at least
get a seed implant because that provides the highest cure rates. And then, historically
and traditionally they've added IMRT on top of that to the prostate into the surrounding
lymph nodes. That policy, in all likelihood, is going to continue, so it won't be one or
the other, it will be both.
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