Post by Allen on Feb 13, 2014 19:16:11 GMT -8
Bob, a healthy 62 y.o. man, has recently been dx'd with PC. His Urologist, Dr.Shmalsh, records the following:
Dr. Shmalsh assigns Bob to the NCCN "very low risk" category, and recommends Active Surveillance. He sends Bob for a confirming mpMRI. The radiologist confirms the small tumor, but notes: "possible extracapsular extension (ECE) at right base in peripheral zone." Dr.Schmalsh cannot discern the ECE on the MRI himself, but trusts his rockstar radiologist. He fingers Bob once again, and even brings in another Uro to give poor Bob the finger - they both agree it's as smooth as a baby's behind.
Dr. Shmalsh knows that the AJCC staging criteria allows him to upstage Bob based on the MRI, but wonders if he should. If he upstages Bob to stage T3a, Bob will be assigned to the "high risk" category, and no longer be a candidate for Active Surveillance. In fact, it changes several of the therapies available to him at his university hospital. He knows that the NCCN risk categories are based on historical data on correlations between PSA, stage, and Gleason score and risk of recurrence after treatment. He knows that none of that data included advanced imaging techniques like mpMRIs or CDUS. He wonders whether it is statistically defensible to use the new data sources that were not included in developing the model.
Consulting the AJCC staging manual (7th edition), he reads that the clinical staging is based on whether the tumor or extension is apparent to the managing clinician (This is why the stage isn't changed based on biopsy findings). A palpable tumor on DRE is the gold standard. Because of inter-observer variability on mpMRI and CDUS, the managing clinician must make the call. Dr. Shmalsh knows his radiologist is never wrong. Should he upstage Bob? Is Bob "very low risk" or "high risk" or something in between?
- PSA=5.0, up from 4.0 two years ago
- prostate size=40cc (PSA density=.125)
- Nothing was felt on a very careful DRE -Stage T1c
- 2/12 cores positive, both at right lateral base
- 45% in both cores
- Gleason score 3+3 (confirmed by Epstein's lab)
Dr. Shmalsh assigns Bob to the NCCN "very low risk" category, and recommends Active Surveillance. He sends Bob for a confirming mpMRI. The radiologist confirms the small tumor, but notes: "possible extracapsular extension (ECE) at right base in peripheral zone." Dr.Schmalsh cannot discern the ECE on the MRI himself, but trusts his rockstar radiologist. He fingers Bob once again, and even brings in another Uro to give poor Bob the finger - they both agree it's as smooth as a baby's behind.
Dr. Shmalsh knows that the AJCC staging criteria allows him to upstage Bob based on the MRI, but wonders if he should. If he upstages Bob to stage T3a, Bob will be assigned to the "high risk" category, and no longer be a candidate for Active Surveillance. In fact, it changes several of the therapies available to him at his university hospital. He knows that the NCCN risk categories are based on historical data on correlations between PSA, stage, and Gleason score and risk of recurrence after treatment. He knows that none of that data included advanced imaging techniques like mpMRIs or CDUS. He wonders whether it is statistically defensible to use the new data sources that were not included in developing the model.
Consulting the AJCC staging manual (7th edition), he reads that the clinical staging is based on whether the tumor or extension is apparent to the managing clinician (This is why the stage isn't changed based on biopsy findings). A palpable tumor on DRE is the gold standard. Because of inter-observer variability on mpMRI and CDUS, the managing clinician must make the call. Dr. Shmalsh knows his radiologist is never wrong. Should he upstage Bob? Is Bob "very low risk" or "high risk" or something in between?
