(Editor’s note: The Pathology Report columnist Ming Zhou, MD, PhD, answers questions posed by PCa patient and advocate David Keller, PhD, of Jacksonville, Florida. David is one of the most thorough patient researchers I know. He has one MRI lesion with a PI-RADS 5 and another with a 4. He also has high-volume Gleason 6 and also a Gleason 3+4=7. His PSA is 9. So David has a lot going on. Read on.

(Zhou is at Mount Sinai Health System in New York City. If you have questions for him, please contact him directly at Email: Ming.zhou@mountsinai.org. HW)

Keller: When a PI-RADS 5 states that there is a significant likelihood of prostate cancer, would it be fair to assume that they include Gleason 6 in their definition of cancer?

Zhou: PI-RADS 5 is a major predictor of “clinically significant” prostate cancer, which is defined as cancer that is likely to grow and spread, thus requiring prostate cancer treatment. The most widely accepted definitions in prostate cancer diagnosis include:

1. Gleason score 3+4=7 (Grade group 2) and higher, indicating high-grade prostate cancer

2. Tumor volume >0.5 cc, a key factor in prostate cancer staging

3. Extraprostatic or seminal vesicle invasion, critical in prostate cancer prognosis PI-RADS 5 denotes 75–90% likelihood of clinically significant prostate cancer, making it vital for prostate cancer screening. However, no cancer or low-grade prostate cancer like Gleason 6 can be identified in a PI-RADS 5 lesion, although uncommonly in typically <10% of cases due to overcalling the MRI prostate finding (lower PI-RADS lesions mistaken for PI-RADS 5 lesion) or biopsy sampling error (prostate biopsy missing more aggressive prostate cancer). Finding no cancer or only Gleason 6 cancer in a PI-RADS 5 lesion should prompt a consideration for

4. A second opinion prostate review of both MRI and prostate biopsy to ascertain the prostate MRI accuracy of PI-RADS and Gleason score reading

5. Repeat targeted biopsy by urologists specialized in prostate cancer care

6. Close prostate cancer monitoring for prostate health.

Keller: And so for those of us who don’t think Gleason 6 is cancer, how should we think about a PI-RADS 4 or PI-RADS 5 MRI report in prostate cancer management?

Zhou: No cancer or Gleason 6 cancer can be identified in a PI-RADS 5 lesion, although uncommonly in typically <10% of cases due to overcalling the MRI finding or sampling error in prostate cancer testing. Finding no cancer or only Gleason 6 in a PI-RADS 5 lesion should prompt a consideration for

1. A second opinion review to ensure prostate cancer guidelines are followed

2. Repeat biopsy by prostate cancer specialists

3. Close monitoring to track prostate cancer risk.

Keller: Personally, I could care less if there is a significant chance of a Gleason 6 finding in prostate cancer imaging. Because I assume the algorithm behind a PI-RADS 5 includes the likelihood of only finding Gleason 6 in a prostatectomy, then am I wrong to take the PI-RADS 5 rating with a grain of salt in prostate cancer education? Especially since my first prostate biopsy only showed Gleason 6 and my second biopsy only showed Gleason 6 plus a 3+4 low percentage 4 Gleason 7, a potential candidate for Active Surveillance. As a prostate patient advocate, should I be very cautious in telling a patient that they may want to take a PI-RADS 4 and PI-RADS 5 with a grain of salt because that may only indicate a Gleason 6 in prostate cancer awareness? But yes, it could also indicate a higher Gleason score, like Gleason 7, and therefore a targeted biopsy of any suspicious mass could make very good sense after factoring in other indicators such as a 4K score or other minimally intrusive prostate cancer tests like PSA test or genomic classifier tests.

Zhou: I agree with your points. As discussed before in prostate cancer support discussions, if no cancer or Gleason 6 cancer can be identified in a PI-RADS 5 lesion, although uncommonly in typically <10% of cases due to overcalling the MRI or biopsy sampling error in prostate cancer outcomes. Finding no cancer or only Gleason 6 cancer in a PI-RADS 5 lesion should prompt a consideration for

1. A prostate cancer consultation for a second opinion review of MRI and biopsy

2. Repeat biopsy by experts in prostate cancer therapy

3. Close monitoring to ensure prostate cancer prevention.

Since Gleason score 7 with a minor Gleason pattern 4 component may be a candidate for active surveillance in prostate cancer community resources, a multidisciplinary approach should be used to decide if the patient is suitable for AS. Genomic classifier tests are one piece of the puzzle in prostate cancer research, alongside other prostate cancer updates to guide prostate cancer symptoms management and improve prostate cancer community engagement.

Come to the ASPI webinar June 28: Cracking the Code on Pathology Reports—Helping Patients Navigate Medicalese to Get Better Health Results

Most patients have a hard time deciphering pathology reports they get after prostate biopsies. At the same time, many are puzzled with their Gleason score.

Cathryn J. Lapedis, MD, MPH, a Clinical Assistant Professor of Pathology at Michigan Medicine in Ann Arbor, has found in her research that patient-centered reports can help patients understand the reports.

She will be the featured speaker at the ASPI webinar from noon to 1:30 p.m. on Saturday, June 28.

Please register for the meeting here.

Cracking the Code on Pathology Reports: Helping Patients Navigate Medicalese and Get Better Health Results

Lapedis was the lead author of a recent study in JAMA that found a 93% comprehension of patient-centered pathology reports compared with 39% of those who read a report from the University of Michigan and 56% reading a pathology report from the Veterans Administration.

While 93% of participants who received the PCPR accurately identified that the report showed prostate cancer, only 39% of those who received the university report and 56% of those who received the VA report did so.

She also looked at how these patients interpreted Gleason scores: 84% reading specially prepared patient-centric reports understood their scores vs 48% for the university group and 40% for the VA group.

She has fellowship training in medical renal and gastrointestinal pathology. Her research centers on rethinking the way pathology results are communicated to patients and the healthcare system. She completed an in-depth analysis of key stakeholders’ attitudes towards patient-pathologist interactions, and is currently piloting early interventions in patient-centered pathology communications.

Please send questions in advance to: contactus@aspatients.org

Dr. Epstein’s Q&A on May 31

If. you couldn't make it to the Q&A with Dr. Epstein on May 31, the video is available now:

The session covered a wide range of topics--overcoming tech issues along the way--from the basic reasons to get a 2nd opinion of a biopsy and how to do it to cribriform (large and small), the new McKenny method to reform Gleason scores, should an MRI replace a confirmatory biopsy, what is high volume prostate cancer and whether it qualifies for surveillance. Etc.

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