Prostate Cancer: Is It Time to Retire the Gleason Score?

Medscape Internal Medicine > George Lundberg: At Large at Medscape
COMMENTARY
Prostate Cancer: Is It Time to Retire the Gleason Score?

George D. Lundberg, MD
Disclosures | September 24, 2015


Hello. I am Dr George Lundberg and this is At Large at Medscape.

If you are an American adult male, you either now have prostate cancer—whether or not you know it—or will likely develop it if you live long enough.

In an average recent year, some 220,000 American men are diagnosed with prostate cancer and some 27,000 die from it. That means, obviously, that it kills 12% of those it is found to afflict and does not kill 88%. Of those patients freshly diagnosed, 98.9% are alive at 5 years.

Does interventional therapy account for the good results of some of that nearly 90% of men who are diagnosed and don't die? Well, yes, but probably not very many. Really bad prostate cancer tends to do its lethal thing, regardless of interventions.

Back when we collectively had a lot of autopsies, it was possible—even easy—- to follow and learn the natural history of many diseases.

Modern autopsy-less American physicians, including pathologists, are whizz-bang at computers, imaging, lab test panels, genes, microbiomes, electronic medical records, and coding. They are maybe not so great at physical exams, taking a useful personal and family history, or gross and microscopic pathology. This latter list is where physicians once got really good at understanding the natural history of diseases.

Now, epidemiologic facts, outcomes, and common sense have begun to prevail over the national hysteria of prostate-specific antigen (PSA) tests for all men. The hysteria tends to take this form: "Find that prostate cancer and root it out...no matter how small or indolent. That way, 'Megalopolis U' can keep those operating rooms, hospital beds, and—get this—unproven (but very elegant) proton beam economic monstrosities really humming in order to satisfy the overpaid MBAs that determined that such were a good investment idea."

But some prostate cancers really can kill. How about those? A pathologist named Donald Gleason came up with a numbering system intended to guide therapy based upon anaplasia and prognostic threat of prostate cancer. It was 1, 2, 3, 4, and 5. It makes sense. But then, another number dealing with the relative amount of each level of differentiation and pattern (also 1, 2, 3, 4, 5) got added, and combining the two scores became the Gleason score range of 2-10.

A reasonable human could interpret a 6 on a scale of 10 as middling, pretty bad, or a "better-whack-it-out"-type score. So, a team from Johns Hopkins Medical Institutions[1] has worked out the actual prognosis as falling back into 5 Prognostic Grade Groups (PGGs):

Gleason 1, 2, 3, 4, 5, and 6 become Prognostic Grade Group (PGG I);

Gleason 3 + 4 = 7 (PGG II);

Gleason 4 + 3 = 7 (PGG III);

Gleason 4 + 4 = 8 (PGG IV); and

Gleason 9-10 (PGG V).

This is so much simpler and less likely to confuse the treating clinician and the patient who is increasingly sharing in this treatment decision.

A European group has just published outcomes based on this PGG system,[2] and it fits nicely. Those many patients with low grades who may not need radical therapy will stand a better chance of not receiving radical therapy with new low-sounding numbers.

And, by the way, how did "watchful waiting" as a good way to handle those prostate "cancers"—which, from histology, seem like they would behave as indolentomas—morph so quickly into "active surveillance"? My guess is that it is very hard to bill a patient, Medicare, or an insurance company for just letting the patient watch and wait.

Chicago Mayor Rahm—not his physician brother Zeke—Emanuel was right: Never let a crisis go to waste. When the word "cancer" was uttered or written, hair lit on fire and something had to be done, right or wrong.

That is my opinion. I'm Dr George Lundberg, at large at Medscape.