Risk Factors / Prognosis

How bad is my prostate cancer?

If you have prostate cancer then you want to know "will I be cured?" You may want to know if your cancer is slow growing enough to just ignore, or early enough to treat with a permanent seed implant or surgery. You might wonder whether the cancer is aggressive enough to consider getting additional opinions or maybe a combination of treatments. How do you and your doctors determine all this? Through prognostic variables.

You can never know exactly where the cancer is in your prostate and body, how fast it's growing, whether it has spread or will spread, or whether you will be cured. Even though the bone scan or MRI scans may not show any cancer beyond the prostate gland, in some patients the cancer has already spread, but the metastatic tumors are too small to be picked up on scans. What we can determine are probabilities, for example the percentage chance that the cancer has broken beyond the prostate capsule, or spread to the lymph nodes, or will be cured by treatment-A.

Of course, probabilities are never exact. You may be told that you have an "80% chance of being cured", but either you will be, or you won't be. You cannot be 80% cured, it is like being 80% pregnant. Your particular outcome will be Yes or No. Probabilities and prognoses are calculated from research studies and from experience on the doctors part. A research study may show that patients with a PSA of less than 10 have a 90% chance of being cancer free at five years, whereas those with a PSA of over 20 the chance may have only a 60% chance. PSA is being used as a prognostic variable. However, there are many more prognostic variables than just the PSA. For example, what happens if a patient with a PSA of less than 10 also has a high Gleason score of 9? His chance of being cancer free at five years may be only 60%. The more variables that are taken into account, the more accurate the prognosis can be determined. Unfortunately, most research studies can only take into account just one or two prognostic variables. There are many more than just two. This is where a doctors subjective experience comes into play. He can start with the research results, and then adjust his expectations based on all your test results, to "guesstimate" your prognosis and which treatments would be best for you. This may seem like a scary proposition to you that there is guessing involved. Obviously, some doctors are much better than others at prognosticating.

The most commonly used prognostic variables are the PSA, stage, and Gleason score. Using these three variables, localized prostate cancers may be divided into "low risk", "intermediate risk", and "high risk". These divisions are arbitrary. The easiest classification is:

Low Risk	PSA less than 10, Gleason 2 to 6, and Stage T1 - T2a
Intermediate Risk	PSA 10 to 20, or Gleason 7, or Stage T2b - T2c
High Risk	PSA over 20, Gleason 8 to 10, or Stage T3 - T4

If you do not know your PSA, tumor stage, or Gleason score should ask your physician. You should use a PSA value which was obtained prior to starting any treatment. We have combined three variables to come up with three risk groups. A low risk level means you have a very good chance of being cured with any of the common treatment methods. There is only a low chance that the cancer has spread to other parts of the body. There is only a low chance that you will die from the cancer. Those in the high risk group do not fare so well. I believe that those patients need an aggressive treatment program, combining different treatments together. The intermediate risk group needs to be carefully tested, and treatment chosen carefully.

You can also plug PSA, Gleason, and stage into the Partin tables. Originally developed at Johns Hopkins, these tables tell you the statistical chance that the cancer is organ contained (OC), penetrates through the prostate capsule (CP), invades the seminal vesicles (SV), or has spread to the lymph nodes (LN). All men with prostate cancer should know their Partin numbers before they embark on any treatment program.

There is an Excel 2000 spreadsheet on this website which will automatically calculate your Partin table numbers along with other values. zeropsa.com/prognosis.xls

Technical Quirk:

The Partin tables do *not* acknowledge that a man may have a combination of LN+, SV+, and CP+. If a man was found at surgery to be LN+, the status of his SV and CP were not included in the tables. If a man was found to be LN- but SV+, the status of his CP was not included in the tables. Thus, the only truly accurate numbers are for LN and OC. A man with really bad cancer (stage T3a, Gleason 9, PSA 30) would have 1997 Partin values of OC 1%, CP 17%, SV 40%, LN 42%. But surely he has a higher chance of capsular penetration than 17%! He does. The corrected estimated values would be CP 94%, SV 69%. My spreadsheet calculator also shows the corrected results.

With risk levels and Partin tables we are taking three separate variables (PSA, stage, Gleason), and combining them to get another variable. Anytime you combine variables like this you are actually losing information. The risk levels and Partin tables do not tell all. For example, let's compare two high risk patients:

#1 has a PSA of 23, a Gleason score of 3 + 4 = 7, and stage T1c (no nodule).
#2 has a PSA of 107, a Gleason score of 4 + 5 = 9, and stage T3a (expraprostatic extension.)

Both of these patients are in the high risk category. However, one is clearly more curable than the other.

As mentioned, there are many other prognostic variables besides PSA, Gleason, and stage. These are very important to consider. You need as complete a picture as possible to determine how aggressive the cancer is, and what form of treatment is best. Here is a list of some prognostic variables. There are others that aren't listed.

PSA	Usually ranhes from 1.0 to 100 in localized prostate cancer. 1 - 4 is great. 4 - 10 is good. 10 - 20 is intermediate. Over 20 is potentially bad.
PSA doubling time	How many months has it taken the PSA to double. Slower is better, more than 12 months is good. This calculation is on my spreadsheet.
Gleason Score	How aggressive the cancer looks under the microscope. Goes from 1+1=2 to 5+5=10. Six is average. 8 - 10 is bad. 3 + 4 =7 is better than 4 + 3 = 7 .
% Gleason 4	The percentage of tumor that is composed of Gleason pattern 4 and 5.
Stage	T1= no nodule. T2= nodule felt. T3= beyond prostate. T4= involves rectum or bladder. These stages are all subdivided.
# biopsy cores positive	How many biopsy cores contain cancer, versus how many were taken in the biopsy. Is the cancer on one side or both sides.
% biopsy positive	In the biopsy cores that show cancer, what % of the core length has cancer (versus normal prostate tissue.) Percentage involvement can be determined for each core, greatest involvement, average amount, right side, left side, and total biopsy involvement.
perineural invasion	Are the cancer cells invading nerves in the prostate? This is a sign that the cancer is more aggressive or can follow nerves outside the prostate.
p53, bcl-2, S phase, DNA ploidy	Special pathology tests. Not available on most reports. p53+ can mean better results from radiation.
Family history	A family history of brothers or a father with metastatic prostate cancer can mean your cancer might be more aggressive
Age	Younger men sometimes have more aggressive prostate cancer. Also, younger = longer life expectancy = need to make sure cancer is cured and does not recur 5 - 20 years later.
Health	Overall health, weight, stress levels, diet, supplements, outlook and attitude may play a complex role in treatment success.
Treatment	The type of treatment chosen and the expertise by which it is delivered will play a complex role in determining treatment success.

There are so many prognostic variables, including others I have not shown, that it would be impossible to factor all these into an equation that gives prognosis. I have tried to come up with a better system that includes more variables than the risk level system but is still manageable. Here is my point system for determing prognosis:

Kelly Prognostic Scale

Risk Factor	Very Low Risk	Low Risk	Int Risk	High Risk
PSA	Less than 4	Less than 10	10 to 19.9	20
Gleason	2 to 4	5 to 6	7	8 to 10
Tumor Stage	T1a	T1b, T1c, T2a	T2b (both sides)	T3 (beyond prostate)
Pathology Report Cancer Bulk	Only 1 core(+), containing less than 5%	Cancer on one side only	Both sides, or more than 50% of cores have cancer, or perineural invasion	80% or more of cores contain cancer or positive seminal vesicle biopsy
Age	Over 80	60 - 79	50 to 60	Under 50
TOTAL POINTS
Multiply by factor	x0= zero	x1=	x2=	x3=

You multiply the total #points in each column by a factor of 0, 1, 2, or 3 and sum them all up to get a score which can range from 0 to 15. Then, divide that score by 5 to get a final score of 0 to 3.
~ 0.5 = very low risk. ~1.0 = low risk. ~1.5 = intermediate risk. ~2.0 = high risk.

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