New Prostate nomogram especially useful for gleason 7s

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An38
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Date Joined Mar 2010
Total Posts : 1147
   Posted 1/11/2011 12:10 AM (GMT -6)   
Dr Strum consider's Dr Cohen from Western Australia as one of the worlds expert pathologists.
 
This is Dr Cohen's nomogram, just been released:
 
 
It's especially useful for Gleason 7s due to the question about % of grade 4/5 which rarely gets asked in other nomograms.
 
Hope this is useful.
 
An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01

Radical
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Date Joined Mar 2009
Total Posts : 739
   Posted 1/11/2011 2:18 AM (GMT -6)   
Tks An - I will have a look at it now..............Cheers Kev.
Age 52yrs [Gold Coast Qld, Australia]
PSA 4 Gleason 7 [3+4=7]
RP 24/12/08 Dr Philip Stricker [Sydney]
Upgrade Gleason Score 7.6 [4+3=7]
Margin status- Focal Involvement
Nil - EPE
ED- okay with Meds.
PSA at 2 yrs, no change remains 0.03
"Everyday in Every-way I Get Better'

English Alf
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Date Joined Oct 2009
Total Posts : 2211
   Posted 1/11/2011 5:55 AM (GMT -6)   
Thanks An

Note that for them their definition of PCa not being cured (ie a BCR) is a PSA greater than 0.2

Alf

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 1/11/2011 7:38 AM (GMT -6)   
I used the nomogram and it rather oddly increased my odds of survival from 94 to 95% when answering "yes" to EPE versus "no."  My stats are 3.2; 29 gm; 30% Grade 4;  EPE+ and "no" to the rest.  Very strange.

woodstock97
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Date Joined Apr 2008
Total Posts : 44
   Posted 4/23/2011 3:24 PM (GMT -6)   
Seems like the biggest impact comes from posiitve margins

Purgatory
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Date Joined Oct 2008
Total Posts : 25364
   Posted 4/23/2011 4:18 PM (GMT -6)   
An,

I am most impressed. This is only one of these that ever had my situation reasonably accurate. Punched my numbers in, and showed me being at 1 out 3 chance of a "cure" at 3 years. I had BCR at 9 months. Most of the more commonly used ones were overly optimistic about my numbers.

Thanks

David in SC
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

reachout
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Date Joined May 2009
Total Posts : 725
   Posted 4/23/2011 5:29 PM (GMT -6)   
I don't understand the "Percentage of Gleason pattern 4/5 present." Does that mean the % in the overall prostate, or the % of the cancer present? I had cancer in 25% of my prostate, of which about 60% was Gleason 4/5. So do I put 60% in there, or 60% x 25% = 15%?

proscapt
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Date Joined Aug 2010
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   Posted 4/24/2011 12:11 AM (GMT -6)   
reachout - I believe you would use 60% in the calculation, but I am not a doc and could be wrong. I base this on what I read in this article: jama.ama-assn.org/content/281/15/1395.long (free) which is linked to from the nomogram. Excerpt below:

"The Stanford modified Gleason scale was used to estimate the proportion of each cancer that was poorly differentiated in all 379 radical prostatectomies.6 Briefly, from the Gleason scale of 5 grades,1​ grades 4 and 5 (poorly differentiated) constitute a variety of histological patterns having the common feature that they do not form intact gland units mimicking normal architecture. Grades 4 and 5 contrast sharply with Gleason grades 1, 2, and 3, all of which form complete gland units and appear to have similar favorable prognostic significance.7 Accordingly, we combined grades 1, 2, and 3 into a single well-differentiated category. The percentage of each cancer occupied by Gleason grades 4 and 5 (% Gleason grade 4/5) was estimated by a single pathologist (J.E.M.) and performed prospectively before biochemical failure was detected by serum PSA findings. These % Gleason grade 4/5 data were compared with the Gleason scores, in which the 2 most prevalent grades in each cancer are added together and used as a sum or score. Most commonly, the score reflects 2 adjacent grades (ie, 3 + 4=7 or 4 + 3=7) or cancers of pure grade (ie, 3 + 3=6). For a score of 7, the proportion of Gleason grade 4 cancer may vary between 5% and 95% without altering the score (sum). To use the traditional Gleason scoring system, fractional areas of tumor less than 5% of the total tumor area should be ignored; if the secondary grade is less than 5%, the primary grade (most common) is simply doubled to obtain the score. "

reachout
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Date Joined May 2009
Total Posts : 725
   Posted 4/24/2011 7:00 AM (GMT -6)   
Thanks proscapt, I think you're right. I get around 82% and am at a PSA of .05 with 18 months to go to the 3 year point. 82% seems as right as any other number I've seen, and better than MSK which seems too optimistic.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

clocknut
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Date Joined Sep 2010
Total Posts : 2649
   Posted 4/24/2011 7:20 AM (GMT -6)   
I should know this, but just what is meant by "intraductal cancer of the prostate" on the nomogram?  It has a "yes/no" answer. 

logoslidat
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Date Joined Sep 2009
Total Posts : 5649
   Posted 4/24/2011 11:40 AM (GMT -6)   
What I gleaned from google is that it is better if you don't have it as it is usually related to high gleason scores, advanced cancer, EPE pos margins etc. Not much help but i never heard of it before either. I know intra means within inter means among. In previous job, intrafacility coordination,meant coordinating within the facility, interfacility coordination was coordinating with other facilities other than your own, suffice to say that muddies the water somewhat.

logoslidat
Veteran Member


Date Joined Sep 2009
Total Posts : 5649
   Posted 4/24/2011 11:40 AM (GMT -6)   
What I gleaned from google is that it is better if you don't have it as it is usually related to high gleason scores, advanced cancer, EPE pos margins etc. Not much help but i never heard of it before either. I know intra means within inter means among. In previous job, intrafacility coordination,meant coordinating within the facility, interfacility coordination was coordinating with other facilities other than your own, suffice to say that muddies the water somewhat.
Diagnosed 8/14/09 psa 8.1 66,now 67
2cores 70%, rest 6-7 < 5%
gleason 3+ 3, up to 3+4 @ the dub
RPP U of Wash, Bruce Dalkin,
pathology 4+3, tertiary5, 2 foci
extensive pni, prostate confined,27 nodes removed -, svi - margins -
99%continent@ cath removal. 1% incont@gaspass,sneeze,cough 18 mos, squirt @ running. psa std test reported on paper as 0.0 as of 12/14/10 ed improving

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 4/24/2011 12:14 PM (GMT -6)   
I still have my doubts about this namogram.  When someone can explain why the stats with EPE are better than without it, then maybe I'll be more impressed.  Right now, the results leave me doubtful about the accuracy of this calculator.
PSA 1.5 to 3.2 in 11 months. First 12 core biopsy on 2/10 negative in 11, atypical in 1. Second 13 core biopsy on 5/10 at Hopkins positive in 2 with Gleason 3+3 (focal). Robotic "Super VIP" Mani Menon 8/10. Postop G 3+4 (70%/30%). Focal ECE right posteriolateral mid. Neg. margins, lymphs, SV. Post op PSAs 9/14 <.1; 1/11 <.1; 4/11 <.1.

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 4/24/2011 1:17 PM (GMT -6)   
AJ, my numbers go down 3% with EPE, which is the right direction
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

AJ 47 (Maryland)
Regular Member


Date Joined Aug 2010
Total Posts : 64
   Posted 4/24/2011 4:26 PM (GMT -6)   
Mine goes from 94.06% without to 94.98% with???
PSA 1.5 to 3.2 in 11 months. First 12 core biopsy on 2/10 negative in 11, atypical in 1. Second 13 core biopsy on 5/10 at Hopkins positive in 2 with Gleason 3+3 (focal). Robotic "Super VIP" Mani Menon 8/10. Postop G 3+4 (70%/30%). Focal ECE right posteriolateral mid. Neg. margins, lymphs, SV. Post op PSAs 9/14 <.1; 1/11 <.1; 4/11 <.1.

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 4/24/2011 4:45 PM (GMT -6)   
AJ, I'm 83.9% with and 86.57% without. In your case I think the problem is that you are so close to 100% that there is no real difference between with and without. Actually, in both our cases, I'm surprised that EPE makes such a small difference. Positive margins is much more important.

But here again, the devil is in the details. The nomogram predicts a "PSA cure" which I think is an unfortunate term. What it means, I think, is the chance for PSA remaining less than BCR, which usually means 0.2. That doesn't mean a "cure" in the sense of the cancer not ever coming back.

Positive margins, I understand, is a good thing to have if the PSA comes back because it indicates it's probably a local occurence that can be treated with radiation.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25364
   Posted 4/24/2011 8:22 PM (GMT -6)   
reachout,

i was told that too about how its can be good to have a positive margin, for the reason you mentioned. however, that good fortune didn't happen to me, or some others on the board. i only had one teeny weeny positive margin, yet had bcr in 9 months from surgery. never anything constant in our world of pc

david in sc
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos margin
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06, 2/11 1.24, 4/11 3.81
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/10

An38
Veteran Member


Date Joined Mar 2010
Total Posts : 1147
   Posted 4/25/2011 6:26 AM (GMT -6)   
Hi David,

Yes I was also impressed by the nomogram and also by speaking to Dr Cohen. His findings are that the % of Gleason 4/5 and positive margins have the biggest impact on the outcome.

 
Hi Reachout,

The % of Gleason 4/5 that he is referring to is the % out of the total prostate cancer that is Gleason 4/5. So in your example this would be 60%. I know this for a fact because I went to him for a second opinion on Paul's pathology, post RP. His view was that Pauls PC was 30% Gleason 4/5 as opposed to the first pathologist who said it was only 5% Gleason 4/5. He said this did make a difference, increasing the likelihood by a couple of % points of a recurrance. Paul's chances of a recurrance are about 4.5% according to Dr Cohon's nomogram using 30% Gleason 4/5 and 2.5% using 5% Gleason 4/5. A small but significant difference.

Regards,
An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03|Feb10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01|Feb10 – 0.01

reachout
Veteran Member


Date Joined May 2009
Total Posts : 725
   Posted 4/25/2011 6:35 AM (GMT -6)   
Thanks for the clarification, An. I also note that this nomogram lumps together most Gleasons 8, 9, and 10 into a single number. What I mean is, a 4+4, 4+5, 5+4, or 5+5 would all be 100% Gleason 4/5 and would have the same outcome. I'm not sure if this is intentional or if the nomograms is only valid for Gleason 7s and below. Or, I suppose, for something like a 3+5 which I assume is pretty rare.
Age: 66
PSA: 7 tests over 2 years bounced around from 2.6 to 5.6
Biopsy 8 of 12 positive, Gleason 3+4, T2a
DaVinci August 2009, pathology Gleason 4+3, neg margins, T2c
Continent right away, ED
Viagra, Cialis did't work, Trimix works well
Post-surgery PSA:
3, month: undetectable <.1; 6 month: undetectable <.014 (ultrasensitive); 9, 12, 15 month: undetectable <.1; 18 month detectable .05

tatt2man
Veteran Member


Date Joined Jan 2010
Total Posts : 2840
   Posted 4/25/2011 7:04 AM (GMT -6)   
even though they are just numbers and we all react to treatment differently - the results for mine - 85.5% - are encouraging for me.
-still enjoying my pudgey anti-cancer diet (with a little cajun seasoning thrown in)
hugs,
BRONSON
Age:55 -gay with spouse of 14 years, Steve -Peterborough, Ontario, Canada
PSA:10/06/09 3.86
Biopsy:10/16/09- 2 of 12 cancerous, 5% involvement -Gleason 7 (3+4)
Radical Prostatectomy:11/18/09
Pathology:pT3a -Gleason 7 -extraprostatic extension -perineural invasion -prostate weight -34.1 gm
PSA:04/08/10 -0.05 -Zero Club
PSA:09/23/10 -0.05 -Zero Club
PSA:03/24/11 -0.02 -Zero Club
PSA:03/24/12- TBA
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