So, Dr. Scholz, I have a question
regarding staging for prostate cancer. This person's looking to do active surveillance and
they have a PIRADS-5 lesion. Can you explain what PIRADS is before I go into the question?
Well, MRI is one of the best ways to find out what's going on inside the prostate,
and other methods are ultrasound, biopsies, and now we have PSMA PET scans as well. MRIs,
if they see what we call a lesion (but you could just call it a shadow or a spot or
a bump) inside the prostate, the big question is, "is it cancer?" and if it is cancer, is it
a type of prostate cancer that does need treatment or is it a type of cancer that can be watched?
And the MRI can't give you 100% certainty as to what a shadow or a lesion is, but it can give
you an idea based on how they score it called the PIRADS system, one through five. 5's mean that if
you stick a needle in, it's about 80% likely to be a Gleason 7 or higher prostate cancer, a type of
prostate cancer that you're going to want to treat, in general, and then PIRADS-4 I think
is around 40% to 50% risk, PIRADS-3 maybe 20% risk that it'll be an actionable type
of prostate cancer; PIRADS-1 and -2, it's just background noise; it doesn't signify anything
at all. So, it just gives you an indication in advance—if there's a spot there—is it likely to
be something that is cancerous, and is it likely to be a type of cancer that needs treatment.
So, this patient had a targeted biopsy and one core came back with some 4,
and it was like 5% Gleason 4. So, they have 3+4 and they're wondering— they've read that
when there is a possibility of less than 10% in the core of Gleason 4 that it could be
a misfire, that maybe it's picking up an artifact from a previous biopsy or something like that.
So, they're wondering how often does this happen? And they have plans to go get the
biopsy specimen read again, but they're kind of wondering how often do you see this happening?
Quite a bit. So, our general policy is if someone has 3+4, you want to know what percentage of the
cancer is 4, and the if it's 3 plus 4, it has to be 49% or less otherwise it'd be called 4+3, but
there's a big difference between a cancer that's 5% grade 4 and one that's 49% percent grade 4, and
this has been shown— that the larger the amount of 4, the greater the risk of something spreading
outside the prostate, and that's the thing we can are concerned about when we're watching prostate
cancer— what is the risk of it spreading? It turns out that people that have 5% or less grade 4,
you know, ascertained at a center of excellence where they know how to do this sort of thing,
that they have the same risk of cancer spreading outside the prostate is someone has 3+3; so, it
behaves like three 3+3, and then as the percentage of grade 4 starts to creep up—10%, 15%, 20%, 20%,
25%—then there's going to be a an increasing risk of spread outside the prostate. These are not big
numbers; if you look at say someone that has a 10% to 20% amount of grade 4 in their biopsy specimen,
the risk of it spreading in the next 10 years may be only 10 to 15 percent, but each individual
doesn't know if they're going to be in the 10 to 15 percent group or in the 80 to 90 percent group,
and so as a precaution, many people undergo therapy, but other people, as they get older,
or those that are, you know, profoundly concerned about the risk of erectile dysfunction, they may
decide to take a small risk of it spreading and watch it even with 3+4's that have 10%,
15% or 20% percent grade 4. So, it's all calculated risk and to refine that risk
oftentimes in these patients we'll order a genetic test called Oncotype and this actually reads out
a percentage risk of spread at ten years based on databases that they have in genetic profiling. So,
they look at hundreds and hundreds of patients that have a genetic profile that is similar to the
individual who's being tested, and this testing is done on the biopsy specimen that's already been,
you know, already been taken out. I really like that type of testing because you can just present
the numbers to the patient and then they can sort of weigh what concerns them most— the
risk of immediate erectile dysfunction from some sort of treatment or
the possibility of spread outside the prostate over the next 10 years, and then I think it's
a personal decision that each patient can make based on which seems to be more risky to them.
So, in a 3+4 patient—you know, we have 3+3, then we have 3+4—so there's different monitoring
processes all around the country it seems, you know, if you talk to one person they're getting
a random biopsy, the next person is getting a targeted biopsy and MRI. In our videos we always
talk about that we should rely more heavily on MRIs for patients on active surveillance rather
than getting random biopsies every year. What would be the optimal monitoring process for a 3+3
versus a 3+4, or is it the same? And if it's not the same, what would be the difference?
Yeah, we lost interest in doing random biopsies a number of years ago when studies showed that the
well-performed MRIs are more accurate than the random biopsies in finding high-grade disease.
Some purists have argued, "well, if that's the case then let's do both MRIs plus random
biopsies." Which seems kind of ridiculous considering we know that we've overtreated
prostate cancer for the last 30 years. So, we've tried to use reputable centers that do
MRI well and then only stick needles in people if there's a change on imaging that suggests that the
cancer may be growing or changing, and then we would do a targeted biopsy, not a random biopsy,
just, you know, sampling the area that's changing, not doing these global biopsies that
are so popular. So, I don't have a different policy for 3+4 patients and 3+3 patients;
we we treat them the same, we get an annual MRI, sometimes we'll do a color doppler as well,
monitor their PSAs a couple times a year, and if something is changing, historically, then we would
get another targeted biopsy of the area that's changing.
How does the monitoring process look in year one versus year two, three, four, and
so on? Is the first year of active surveillance more intense as far as monitoring goes?
Rarely, but I mean maybe we will check PSA a little more frequently. These days,
if someone's had stable PSAs, we'll check their PSA twice a year, but for the first
year we might check it every three months just to make sure they don't have some very rare variant
of prostate cancer that's changing quickly. So, it's pretty much continuous the same policy that
of annual scans and biannual blood tests.
As far as duration goes, how often or how long do you see patients on active surveillance,
be able to stay on active surveillance, until something else progresses?
Oh, we've had patients that have been under surveillance for more than 20 years
and really with no indication that they're ever going to need treatment. Active surveillance is
a very logical sensible choice for people with 3+3 and with select patients that have select 3+4's.
So, besides PSA, MRI, targeted biopsies if there's anything changing, the Oncotype test,
I've also heard about Decipher, I've heard 4k in the background for anybody diagnosed with
prostate cancer, what type of genetic versus genomic test do you suggest patients get?
Is there anything on top of it? Do they need to test for BRCA? What does that look like?
Well, OPCO 4k is more for patients that haven't been diagnosed. I haven't been as pleased with
the Decipher and Prolaris tests as i have with the Oncotype. All of these genetic tests just
give you a percentage, and so it's not like, you know, a directive from god; it just gives
you another sense of what the risk— where the risk may lie. I tend to limit the genetic testing with
Oncotype to those patients that have 3+4. The— all the early research in active surveillance was
was with 3+3 and they didn't have any genetic tests and they showed that it's very safe to
monitor people with 3+3. It's a sad thing when I see someone has 3+3 and meets all the criteria for
active surveillance and they get a genetic test that indicates something's more worrisome and
and triggers them going off into radical therapy when studies have shown that 3+3 is safe to watch.
I don't take the genetic tests as being a gospel; I think they can be effective as a a tiebreaker in
patients where you're kind of on the fence about whether you think you can do active surveillance,
but I think patients that have pure three 3+3 that have been thoroughly evaluated, as they should be,
I would not counsel them to get any genetic testing.
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