Is low-grade prostate cancer really cancer? One U. of C. doctor says no.
A University of Chicago Medicine doctor is arguing that one of the most common types of cancer in men sometimes shouldn’t be called cancer at all — a stance that some say could save many patients from invasive, unnecessary treatments but others say could put patients at risk.
About one out of every eight men will be diagnosed with prostate cancer during his lifetime, according to the Centers for Disease Control and Prevention. The severity of prostate cancer is measured on what’s called a Gleason scale, with 6 being the lowest level and 10 being the highest.
Dr. Scott Eggener argues in a paper published in the Journal of Clinical Oncology on Monday that Gleason 6 prostate cancer should no longer be labeled as cancer.
Gleason 6 does not cause symptoms or spread, he said.
But the word “cancer” in the diagnosis likely scares some men into seeking unnecessarily aggressive treatments, such as prostate removal or radiation, he said. Having a diagnosis of cancer can also cause anxiety among patients and family and lead to trouble getting life insurance, he said.
“The word cancer has a lot of implications for the man, for the health system, for society,” said Eggener, a University of Chicago Medicine urologist and professor of surgery. “The patient now sees (himself ) as a cancer patient. Many men still choose to get aggressive treatments that can have short-term or life-altering side effects.”
Radiation or prostate removal can sometimes lead to urinary and sexual dysfunction.
Instead of getting radiation or surgery, patients with Gleason 6 can undergo what’s called active surveillance, which consists of regular blood tests, exams and occasional biopsies. Now, more than half of patients with Gleason 6 nationwide choose active surveillance, rather than radiation or surgery, Eggener said.
If the word “cancer” is removed from the diagnosis, patients would not seek radiation or surgery or even need active surveillance, he said.
Rather, they would undergo regular screenings — which are less time-consuming than active surveillance — because they would be considered cancer-free.
Patient Howard Wolinsky, 74, of Flossmoor, said the change is long overdue. When Wolinsky was diagnosed with Gleason 6 in 2010, a doctor recommended he have his prostate removed that week.
But Wolinsky, a health care journalist who has done freelance work for the Tribune, had researched the diagnosis, and he wanted a second opinion. He saw Eggener, who recommended active surveillance.
“He said, ‘Yeah, you could benefit from surgery, but frankly I think you’re the poster boy for active surveillance,’ ” Wolinsky said. “It was clear that I could benefit from this. I took the leap of faith.”
In the following years, Wolinsky underwent regular blood tests, exams and biopsies. No cancer was found on any of his other biopsies, he said. Wolinsky is a co-author on the paper published Monday, along with experts from hospitals in New York, California and Toronto.
Dr. Gopal Gupta, a urologic oncologist at Loyola Medicine, said Eggener’s argument is “right on point,” noting that “patients and other people who are not familiar with prostate cancer are still swayed by this word cancer.” Gupta worked on a previous paper with Eggener about Gleason 6.
Not everyone, however, agrees Gleason 6 should no longer be called a cancer. It’s been a topic of debate for 10 or 15 years, and many doctors feel it should still be classified as cancer, said Dr. William Catalona, a professor of urology at Northwestern University Feinberg School of Medicine.
“It is not like normal tissue,” Catalona said. He said removing the cancer label would be “a big mistake.”
One reason is that many men who are diagnosed with Gleason 6 prostate cancer are later found to have more severe forms of prostate cancer, he said. Part of that may be because initial biopsies miss the more severe forms, he said.
Though biopsies are the most accurate way to diagnose prostate cancer, they’re not perfect, he said.
When a urologist biopsies a patient’s prostate, the urologist will typically take about a dozen samples that are about an inch long and as thick as dental floss.
“If you had a haystack and took 12 pieces of hay out and looked at it, there’s still a lot of hay in there you haven’t looked at,” Catalona said.
Though active surveillance can help to catch a more severe form of cancer later on, if a patient is told he doesn’t have cancer, he may be less inclined to have those regular, follow-up biopsies, Catalona said.
“Calling it cancer, which is what it really is, does give the patients an incentive, if they don’t undergo treatment right away, to at least be actively surveilled,” Catalona said.
“If someone said we’re going to tell all these men this is not cancer, that would really be very harmful to the whole concept of active surveillance,” he said. “I think a greater percent of them would slip through the cracks, and I think more men would eventually suffer from metastatic prostate cancer and die of prostate cancer.”
Some men also prefer to have surgery or radiation rather than have to spend years getting additional tests and biopsies to make sure they don’t have more severe forms of prostate cancer, he said.
Eggener acknowledged that treatment might make sense for some men with Gleason 6, such as those who are very young or those who’ve had multiple family members with aggressive forms of prostate cancer, but “there’s still way too many men that race into treatment.”
He also acknowledged that some men may initially feel anxiety about getting a diagnosis of Gleason 6 but not undergoing treatment for it. He believes that initial anxiety is something that can be managed through explanation and by sharing longterm data.
“That, almost for all men, allays their anxiety,” he said.