Long-held beliefs can be difficult to change, even when evidence says otherwise. A classic example is the idea that the “geocentric” theory that the earth is the center of cosmos. While early Greek philosophers thought it was true, it was actually defined by an astronomer named Claudius Ptolemy around 150 BCE. According to his measurements, the earth had a fixed position as the sun, moon, planets and stars revolved around it in perfect circles.

The belief generally held for about sixteen centuries until 1543 when Copernicus calculated that the sun, not the earth, was at the center of planetary motion. The skeptics weren’t buying it. Ultimately, it took the hard evidence from Galileo’s telescope to persuade the diehards that Copernicus was right.

Is there a common belief about prostate cancer that may need to change?

There is a common belief about prostate cancer that it’s all equally dangerous. No matter how low-risk it may appear, it will kill you if it’s not treated.

This is understandable, because “the word cancer generally leads to anxiety.”^[i]  Cancer is called malignant, meaning wicked or behaving badly. There are several types of true cancers, but the National Cancer Institute (NCI) says they all share two main properties:

1. The abnormal cells divide without control, and
2. They have the ability to invade nearby tissues and spread to other parts of the body.

Therefore, by definition all cancer is potentially lethal. No wonder a prostate cancer diagnosis can easily be assumed to be a potential death threat. If that is so, the natural response is to kill the cancer before it kills you.

Now, new evidence is shaping a new belief: at the time of diagnosis, some prostate cancer matters less. In the new Grade Group system, grade 1 (lowest) is equal to Gleason 3+3 = 6. “Currently, doctors tend to consider International Society of Urological Pathology (ISUP) grade 1 (Gleason 6) clinically insignificant… This implies a strong probability that a man will never be bothered by the disease.”^[ii]

In fact, some experts have proposed that grade 1 prostate cancer should be called by another name, because it behaves more like a precancer than a cancer,^[iii] (e.g., indolent, latent, unimportant, low grade, and (very) low risk^[iv]). To be clear, this does NOT mean that grade 1 disease can be safely ignored. Rather, it suggests that rushing to clobber it with surgery or radiation is over-treating it. And over-treatment comes with risks of temporary or even permanent urinary, sexual or bowel problems.

A corollary of this new way of thinking is to reserve aggressive treatment for prostate cancer that matters more at the time of diagnosis.

What kind of prostate cancer matters more?

The kinds of prostate cancer that matter more are grade groups 2-5. These are cancers that have capacity to behave aggressively—the higher the grade group, the greater the capacity. For these cancers, the belief is justified that they are truly malignant and require treatment before they are invasive. They are called significant prostate cancer.

Significant prostate cancer requires immediate attention, but it matters that the degree of treatment aggressiveness be tailored to the nature of the tumor’s aggression. This requires that the tumor itself has been accurately diagnosed, located, and evaluated for the best treatment method based on several factors such as tumor volume, PSA density, cancer grade, and T-stage.

What are the standard treatments for each aggression level of prostate cancer?

For less aggressive tumors, such as grades 1 and 2, many patients will qualify for a focal therapy, which is a lethal ablation (tumor destruction) of the tumor plus a margin of safety, while sparing surrounding healthy tissue and neighboring urinary, sexual and bowel tissues. This approach has comparable cancer-killing power to treatments like surgery or radiation, but with significantly lower risk of side effects.

However, for grades 3-5, a more aggressive whole-gland or radical approach like surgery or radiation is appropriate. For many patients undergoing a radical treatment, side effect risks may be less depending on the experience and skill level of the doctor, and the precision of the device used for treatment.

How can you be confident the diagnosis was accurate?

It is reassuring to know that diagnostic methods are more accurate than ever, and even becoming more so with advances in the biology of prostate cancer, sophisticated multiparametric MRI, precision in-bore targeted biopsies, AI-assisted analysis of biopsy samples, and genomic testing.

At the Sperling Prostate Center, we are equipped with a powerful, state-of-the-art 3 Tesla (3T) magnet, AI-assisted diagnostic programs, and access to excellent lab analysis of test specimens. Furthermore, when diagnosis reveals that a patient interested in focal therapy is a candidate for this approach, our Center offers a suite of methods in order to match the focal method with the patient’s clinical factors and lifestyle choices.

Finally, patients newly diagnosed with grade 1 disease may be comfortable with Active Surveillance, a way to monitor the cancer while holding off on any treatment. Our Center provides monitoring services designed to detect any change in the patient’s tumor at the earliest point for next-step decision making, should need arise.

We know it is essential to identify for each patient what his options are, no matter what grade his cancer is. For more information, contact the Sperling Prostate Center.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Mertens LS, van Leeuwen PJ, van der Poel HG. Abandon the Label of Clinically Insignificant Prostate Cancer. Eur Urol Open Sci. 2022 Jan 22;37:36-37.
[ii] Ibid.
[iii] Eggener SE, Berlin A, Vickers AJ et al. Low-Grade Prostate Cancer: Time to Stop Calling It Cancer. J Clin Oncol. 2022 Sep 20;40(27):3110-3114.
[iv] Mertens, ibid.