Tall Allen do you believe that gleason 6 can turn into a more aggressive disease and if so , should folks have the choice to nip it in the bud, given that they are aware of the S/E.
I'll repeat what I wrote elsewhere... I have to disagree with Dr. Scholz (which I rarely do) in his belief that a G3 always
remains a G3. (For this purpose, it makes more sense to speak of the Gleason grade rather than the score.) In the following study, they found that G3 and G4 DNA from adjacent sites had too much DNA in common to have separate origins, but that the G4 had to have originated from that G3, or at least had a common ancestor. In particular, they shared a common genetic impairment called TMPRSS:ERG fusion (which there is a test for):Clonal progression of prostate cancers from Gleason grade 3 to grade 4.
They start with an important question: why do 70-80% of G3s never progress to higher grade, while the remaining 20-30% do? The answer, from what we've learned so far, is highly complex: genetic variations, switches and mutations, interactions with neighboring cells, endocrine and paracrine effects, and interactions with the environment all play a role.
This study argues for a common ancestor, rather than progression from G3->G4->G5, which supports Scholz' thesis:The genomic relationship among matched prostate cancer foci.
This study found that true
GS6 was never
metastatic:Gleason 6 Prostate Cancers Diagnosed in the PSA Era Are Never Metastatic at the Time of Radical Prostatectomy
but this study found that about
10% of men who died after a diagnosis of CRPC started with GS6... Were they truly GS6 at the time of biopsy, or was there really higher Gleason score cancer that was missed?Evidence That Gleason Score 6 Cancer Can Evolve to Lethal Disease.
So to answer your first question, what we know so far about
the natural history of prostate cancer is true GS6's rarely, if ever, turn into more aggressive disease. Distinguishing true
GS6 from those where higher score lesions were missed is part of the job of an AS program -- through biochemical indicators of progression, detectable & growing lesions, and confirmatory biopsies (by saturation or advanced image detection).
To answer your second question about
whether a man should be able to choose to have it radically removed anyway... yes -- some men would find it psychologically torture just knowing it's there. I would hope that those men would receive full disclosure of all SEs of treatment, information about
what is known of the natural history of PCa, information about
the potential benefits and lack of benefits to radical treatment, alternatives to radical treatment, and be given adequate time and perhaps counseling before making such an irrevocable decision. If given all that, he still wants radical treatment and has a willing and able doctor, he should be able to choose it, imho. However, as medved pointed out -- where do we draw the line? Should a man with Gleason 3+2 have this choice? What about
Gleason 1+1? Should prophylactic removal of a healthy prostate be allowed based on family history or genetic disposition? All good ethical questions.