The information Dr. A gave me about prostate cancer was sparse. It was also somewhat misleading. He said I had a score of seven on the biopsy, which he said was high. Not so fast. The score is based on the Gleason grading system. That system rates every cancerous cell detected on a 1 to 5 scale, 5 being the most active (dangerous) cancer. The first two, 1 and 2, are rarely found in biopsies. Dr. N (who will be introduced soon) told me that 1 and 2 look so much like healthy prostate cells, that pathologists usually can’t distinguish them. So the lowest biopsy score for an individual cancerous cell is really a 3. Dr. A did not tell me that. Furthermore, the Gleason system adds two scores, the predominant cell type and the non-predominant cell type. Thus the lowest possible score on a positive biopsy is 3+3 or 6. Not only that, a 7 can be a 3+4 or a 4+3, i.e. do the bad 4 cells predominate or the less bad 3 cells? It can’t be a 2+5 because a 2 can’t be detected. There is a significant difference between a 3+4, which is what I had, and a 4+3. A 3+4 is thus the second lowest possible Gleason score on a positive test.
Dr. Zachary Zumsteg of Cedars-Sinai, among others, has tried to divide Gleason 7 patients into subgroups labeled favorable and unfavorable. He defines favorable as a 3+4 or less with a positive result in no more than 50% of the needles. I had 5 of 12 positive so I fit this category. I had cells in grade 4 in only two of the five. He defines unfavorable as 4+3 or two intermediate NCCN risk factors (e.g. PSA test over 10) or 1 risk factor plus a positive test on more than 50% of the needles. There appears to be a group fitting between these two that presumably is of intermediate risk. Zumsteg says the unfavorable group has a seven times higher risk of prostate cancer death than the unfavorable group. I would have liked to have had a clearer picture from Dr. A about these finer points. In retrospect I tend to believe that he intended to make the result seem more foreboding than it really is in order to steer me toward the treatment he favored, prostatectomy.
After my receipt of the biopsy results, I consulted Dr. M, my family doctor. I wanted his opinion on what I should do about the cancer and I also wanted a cortisone shot for my right heel. When he saw that I had just had Cipro, he warned me about the risk to my Achilles from Cipro and he refused to give me the shot because it would increase my risk even more. I would have had all 7 risk factors for tendon rupture. Once I realized the right heel pain was probably due to the Cipro, I decided to gut it out, although it hurt like a SOB. It faded after a few more days. Dr. M was visibly upset about my biopsy results. His comment was something to the effect that that’s what a family doctor gets for ordering a PSA test; a perfectly healthy patient has to lose his prostate. He said that if he hadn’t ordered the test, I wouldn’t have known I had those cells and I wouldn’t have gotten treated. He said the statistics are that I would live just as long being treated or not. When I told him Dr. A had recommended prostatectomy his exact words were: “He’s a urologist. He makes his living removing prostates.” He also said Dr. A would disagree with just about everything he said. Now I am not suggesting Dr. A recommended the prostatectomy in order to make money doing unnecessary surgery, nor, I am sure, was Dr. M. It may be a cliche, but it’s also true that surgeons like to cut. They went into that field because they believe in its efficacy and because they have confidence in their ability. I have no doubt Dr. A thought that was the best option for me. But he is biased toward his own practice. Even so, after Dr. M studied the results he informed me of the fact I had a 3+4 and that two of the needles had the Grade 4 cells. It became clear from his manner that he felt my results were more troubling than some others he’d seen. I know of a friend who had EBRT when his PSA was below 1 and his biopsy showed only level 3 in one needle, so a 3+4 is not all that minor. I asked him what most patients of his do when presented with a positive prostate biopsy. He said about 70% have the prostatectomy and 30% have radiation. He said they all seem to do fine and reassured me that I would too. He also said that if were him, he doesn’t know what he would do. He recommended I explore all options. I told him I wanted to talk to someone about the radiation option. I knew someone who had had radiation for his prostate and he had minimal side effects and seemed to be living a normal life. Dr. M gave me two names of local specialists who do prostate radiation oncology, Dr. K and Dr. N. I recognized Dr. N’s name as the physician who had treated my friend. I decided to go to him for a second opinion.
Before I leave this visit, I should mention that the statistics Dr. M gave me on those who do not get treated were overly optimistic based on the numbers I’ve seen from the National Comprehensive Cancer Network (NCCN), and other reliable sources, but not by much. The vast majority of patients like me lead a normal lifestyle and lifespan whether or not they get treated, but those getting treated do better statistically. I discuss this more in a later post.
In part 5 I’ll tell you about my visit with Dr. N.