The SKY Shade of Blue

BY MARK SCHOLZ, MD

The worst mistakes are to believe that prostate cancer is just one disease and that it will always need treatment. The entire physician community has stumbled into this terrible blunder by assuming that every tiny little spec of cancer being found through needle biopsy is equivalent to the long-familiar, deadly metastatic variety.  It was the invention of the spring-loaded needle biopsy gun, not just the discovery of PSA that launched the modern prostate cancer industry as we know it today.

Tragically, over the last twenty years, millions of men have had their sex lives ruined by unnecessary surgery or radiation. Only recently has it come to light that the Gleason six type of prostate cancer is harmless, that it never metastasizes.

Yet to this day, practically all men with Gleason six are still being treated. Justification is that since it’s called “cancer” we need to be safe and remove the gland. While many men and their doctors continue making this tragic mistake, now that we know how to differentiate between the harmless and dangerous types of prostate cancer, you can be spared.

Blue is the color for prostate cancer as pink is the color for breast cancer. So the PCRI has labeled the major subtypes of prostate cancer with different Shades of Blue. The five shades are Sky, Teal, Azure, Indigo and Royal.

Sky is the first and most favorable shade of blue, the type that can be safely monitored without treatment. Men in the Sky shade category are defined by having the following four characteristics:

1.       A PSA less than 10

2.       A Gleason score under 7

3.       A tiny nodule on digital rectal or no nodule at all

4.       Color Doppler ultrasound or multiparametric MRI scans showing no extra-capsular extension

Treatment for Sky

Studies show that initial observation, termed Active Surveillance, is a safe way to manage favorable forms of prostate cancer like Sky. In a ten-year observational study at Johns Hopkins out of1,000 carefully selected men it was reported that not a single man died of prostate cancer.  In fact there was not even a single case of metastasis.

Observation is preferred because even with the most skilled doctors, standard therapy with surgery or radiation is frequently associated with permanent impotence and incontinence.

A typical Active Surveillance program consists of PSA testing three or four times a year, a digital rectal examination once or twice a year, and periodic random prostate biopsy every one to three years. Bone scanning is not recommended.

Recently, the policy of performing routine random biopsies is being reconsidered. Biopsy is unpleasant and can occasionally be dangerous. Certain centers, those with access to quality imaging, are substituting an annual multi-parametric MRI or color Doppler ultrasound.  Biopsy is reserved only for the men whose imaging shows a new or growing lesion in the prostate. And rather than doing 12-core random biopsy, one to two targeted cores are used.       

|+| Dr. Scholz will be periodically emailing regarding the topics of Imaging, Active Surveillance, the dangers of prostate biopsy and the existence of safe alternatives.

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