Life's Roller Coaster

If I'm missing, or not taking messages sorry – I'm more angry about letting my friends down than YOU will ever be at being let down! Unfortunately that is sometimes a side effect of Cancer! Mea Culpa: may I blame being short fused & grumpy on it too! My first symptoms presented in Nov-1998 – Follow The Trail on >DIARY of CANCER< Immediately Below!

Some additional Links With Coping & Beating Cancer At Heart …

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Some additional Links With Coping & Beating Cancer At Heart …
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Posted by:

Greg Lance – Watkins

Greg_L-W

eMail: Greg_L-W@BTconnect.com

https://InfoWebSiteUK.wordpress.com

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Hi,
.

Hello there,

My sister’s breast cancer diagnosis came when she was only 23 and shook my entire family to its core. I’m endlessly grateful that my sister was able to conquer her disease, but I think a lot about how lucky she was. Not everyone is as fortunate, and many don’t realize how real the risk of cancer is. This has been something I’ve been thinking about a lot lately, since our family’s annual summer vacation is on the horizon.

In her honor, I wanted to pass along some really important cancer and terminal illness resources that would fit great here: https://greglw.com/cancer-links/ . I hope they’ll ease the minds of anyone going through a difficult time due to a cancer diagnosis.

 

9 Proven Ways to Reduce Your Cancer Risk

 

Asbestos: What You Need to Know When Buying, Selling or Remodeling

 

Creative play: Helping children cope with cancer

 

A Sobering Diagnosis: Coping With a Terminal Illness Diagnosis as a Recovering Addict

 

17 Simple Ways to Prevent Air Pollution in Your Home

 

Asbestos, Mold and Other Toxins

 

The health hazards of sitting

 

I appreciate your time and all you do to promote awareness and offer support.

 

Thanks in advance,

 

Katybeth

 

Katybeth Dee

http://selfexam.org/

340 S Lemon Ave #5780 | Walnut, CA | 91789

Regards,

Greg_L-W.

 

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Posted by: Greg Lance-Watkins
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IF You, Like I, Have A Garden – Its Odds On You Have Used Glyphosate …

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IF You, Like I, Have A Garden – Its Odds On You Have Used Glyphosate  …
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Posted by:

Greg Lance – Watkins
Greg_L-W

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Cancer agency left in the dark over glyphosate evidence

The World Health Organization’s cancer agency says a common weedkiller is “probably carcinogenic.” The scientist leading that review knew of fresh data showing no cancer link – but he never mentioned it and the agency did not take it into account.

Filed June 14, 2017, 1:05 p.m. GMT

LONDON – When Aaron Blair sat down to chair a week-long meeting of 17 specialists at the International Agency for Research on Cancer in France in March 2015, there was something he wasn’t telling them.

The epidemiologist from the U.S. National Cancer Institute had seen important unpublished scientific data relating directly to a key question the IARC specialists were about to consider: Whether research shows that the weedkiller glyphosate, a key ingredient in Monsanto’s best-selling RoundUp brand, causes cancer.

Previously unreported court documents reviewed by Reuters from an ongoing U.S. legal case against Monsanto show that Blair knew the unpublished research found no evidence of a link between glyphosate and cancer. In a sworn deposition given in March this year in connection with the case, Blair also said the data would have altered IARC’s analysis. He said it would have made it less likely that glyphosate would meet the agency’s criteria for being classed as “probably carcinogenic.”

But IARC, a semi-autonomous part of the World Health Organization, never got to consider the data. The agency’s rules on assessing substances for carcinogenicity say it can consider only published research – and this new data, which came from a large American study on which Blair was a senior researcher, had not been published.

The lack of publication has sparked debate and contention. A leading U.S. epidemiologist and a leading UK statistician – both independent of Monsanto – told Reuters the data was strong and relevant and they could see no reason why it had not surfaced.

Monsanto told Reuters that the fresh data on glyphosate could and should have been published in time to be considered by IARC, and that the failure to publish it undermined IARC’s classification of glyphosate. The legal case against Monsanto, taking place in California, involves 184 individual plaintiffs who cite the IARC assessment and claim exposure to RoundUp gave them cancer. They allege Monsanto failed to warn consumers of the risks. Monsanto denies the allegations.

The company also goes beyond saying the fresh data should have been published. It told Reuters the data was deliberately concealed by Blair, but provided no specific evidence of it being hidden.

Blair told Reuters the data, which was available two years before IARC assessed glyphosate, was not published in time because there was too much to fit into one scientific paper. Asked whether he deliberately did not publish it to avoid it being considered by IARC, he said that was “absolutely incorrect.” He said a decision not to publish the glyphosate data had been taken “several months” before IARC chose to conduct a review of the chemical.

The National Cancer Institute also cited “space constraints” as the reasons why the new data on glyphosate was not published.

SENIOR SCIENTIST: Aaron Blair, a retired epidemiologist, led the review of several pesticides, including glyphosate, by the International Agency for Research on Cancer in 2015. CREDIT: National Cancer Institute/Bill Branson/Handout via Reuters

The absence of the data from IARC’s assessment was important. IARC ended its meeting in 2015 by concluding that glyphosate is a “probable human carcinogen.” It based its finding on “limited evidence” of carcinogenicity in humans and “sufficient evidence” in experimental animals. It said, among other things, that there was a “positive association” between glyphosate and blood cancers called non-Hodgkin lymphoma. IARC told Reuters that, despite the existence of fresh data about glyphosate, it was sticking with its findings.

The agency’s assessment is at odds with other international regulators who have said the weedkiller is not a carcinogenic risk to humans. It led to a delay in Europe on a decision on whether to re-license or ban EU-wide sales of pesticides containing glyphosate. That decision is still pending. In the meantime, some countries have tightened restrictions on the weedkiller’s use in private gardens and public spaces and on crops before harvest.

In the United States, a California judge took the IARC assessment into account in a separate legal case in March when ruling that the state can require RoundUp to carry a warning label that it may cause cancer. Monsanto is now facing further litigation from hundreds of plaintiffs across the United States who say glyphosate gave them or their loved ones non-Hodgkin lymphoma, citing the IARC assessment as part of their claims.

Yet if the IARC panel experts had been in a position to take into account Blair’s fresh data, IARC’s analysis of the evidence on glyphosate would have been different, Blair acknowledged in the court documents reviewed by Reuters.

The unpublished research came from the Agricultural Health Study, a large and significant study, led by scientists at the U.S. National Cancer Institute, of agricultural workers and their families in the United States. Asked by Monsanto lawyers in March whether the unpublished data showed “no evidence of an association” between exposure to glyphosate and non-Hodgkin lymphoma, Blair replied: “Correct.”

Asked in the same deposition whether IARC’s review of glyphosate would have been different if the missing data had been included, Blair again said: “Correct.”  Lawyers had put to him that the addition of the missing data would have “driven the meta-relative risk downward,” and Blair agreed.

Scott Partridge, Monsanto’s vice president of strategy, told Reuters the IARC glyphosate review “ignored multiple years of additional data from the largest and most comprehensive study on farmer exposure to pesticides and cancer.”  

“We decided to remove it because … you couldn’t put it all in one paper.”

Aaron Blair, former epidemiologist at the U.S. National Cancer Institute, explaining why new data on glyphosate and cancer was not published

The Agricultural Health Study was particularly pertinent, he said, because it examined real-life human exposure to glyphosate, whereas much of the scientific research IARC analysed involved laboratory tests on rodents.

IARC told Reuters that its evaluations follow strict scientific criteria and that its carcinogen classification system “is recognised and used as a reference all around the world.” It reiterated that in the interests of transparency it considers only published data.

Reuters asked two independent statistical experts to review the data, which has still not been published, though the National Cancer Institute told Reuters researchers are currently working on an updated analysis of it. Neither of the two experts had seen the data before and both said they had no conflict of interest over glyphosate.

David Spiegelhalter, a professor of the Public Understanding of Risk at Britain’s University of Cambridge, said there was “no apparent scientific reason” for not publishing the data. Bob Tarone, a retired statistician who worked alongside Blair and others at the National Cancer Institute for 28 years before moving to the for-profit International Epidemiology Institute, said he could find “no ready explanation in terms of the available scientific evidence” for the data not to have been published.

Tarone had already raised the issue in a little-noticed paper in the European Journal of Cancer Prevention last year. He wrote that IARC’s classification of glyphosate as probably carcinogenic to humans was the result of “a flawed and incomplete summary” of the evidence.

In an email to Reuters, IARC declined to say whether Blair informed IARC staff about the unpublished data, whether he should have, and whether that data might have changed IARC’s evaluation of glyphosate had it been published in time. The agency said it had no plans to reconsider its assessment of the chemical.

NON-SELECTIVE HERBICIDE

Glyphosate is what’s known as a non-selective herbicide, meaning it kills most plants. Discovered by the Monsanto chemist John E. Franz in 1970, glyphosate is no longer under patent, is supplied by numerous companies and is now the world’s most widely used weedkiller, deployed in agriculture, forestry and domestic gardening. Monsanto and other companies have developed genetically engineered seeds that can tolerate glyphosate, allowing farmers to apply it to entire fields without destroying crops.

The safety of the chemical has been under scientific and regulatory scrutiny since the 1980s. The U.S. Environmental Protection Agency and other international bodies, including the European Food Safety Authority, Health Canada’s Pest Management Regulatory Agency, New Zealand’s Environmental Protection Authority and Japan’s Food Safety Commission, have kept it under regular review, and all say glyphosate is unlikely to cause cancer in humans.

But it is not settled science, and researchers across the world continue to study glyphosate – measuring traces of it in water and foods, exposing lab rats to it, and monitoring possible health effects in people who have used it year after year in their work.

One of the largest and most highly regarded studies to examine effects of pesticide use in real life is the Agricultural Health Study, a prospective investigation of about 89,000 agricultural workers, farmers and their families in Iowa and North Carolina. Since the early 1990s, it has gathered and analysed detailed information on the health of participants and their families, and their use of pesticides, including glyphosate.

AHS researchers have published numerous studies from their data. One paper looking at glyphosate and possible links with cancers was published in 2005. It concluded that “glyphosate exposure was not associated with cancer incidence overall.” Since then, more data has been collected, adding statistical power to subsequent AHS analyses.

In early 2013, Blair and other researchers began preparing new papers with updated AHS data on lymphoma and pesticides, including data on glyphosate. Reuters reviewed drafts dated February 2013 and March 2013, and asked Spiegelhalter and Tarone to examine them. They said the papers, while still in the editing process, were in relatively advanced manuscript form. The drafts contain notes in the margin and suggested changes signed “AEB,” Blair’s full initials.

After studying the draft papers, Tarone said the unpublished figures show “absolutely no evidence whatsoever” of an increased risk of non-Hodgkin lymphoma because of exposure to glyphosate.

Spiegelhalter told Reuters: “In the drafts I saw, none of the herbicides, including glyphosate, showed any evidence of a relation” with non-Hodgkin lymphoma. He noted that the study was statistically strong enough to show a relationship for other pesticides – so had there been any link to glyphosate, it should have shown up.

In his legal testimony, Blair also described the Agricultural Health Study as “powerful” and agreed the data showed no link.

But these draft papers were never published, even though Blair told Monsanto’s lawyers in March that the Agricultural Health Study was robust and statistically well-powered, and told Reuters the research was important for science and the public. Email exchanges between Blair and his fellow researchers in 2014 also show they were keenly aware there would be scientific and public interest in fresh AHS data.

On February 28, 2014, Michael Alavanja, a co-lead author of one of the draft papers, sent an email to another AHS co-researcher, copying the message to Blair. It noted that the research was “important to science, public health, IARC and EPA” – the U.S. Environmental Protection Agency.

In the same email, Alavanja referred to the findings on non-Hodgkin lymphoma, or NHL. He wrote: “It would be irresponsible if we didn’t seek publication of our NHL manuscript in time to influence IARCs (sic) decision.”

Yet the new AHS data on glyphosate and lymphoma did not surface.

Instead, a revised version of one of the 2013 draft papers prepared by Blair and other researchers appeared in a journal called PLoS One in October 2014. It did not include the data on herbicides, of which glyphosate is one.

This was unusual. Since 2003 AHS researchers had published at least 10 papers using different rounds of updated data to explore possible links between pesticides and specific diseases. And each one included all four pesticide classes: fungicides, fumigants, insecticides and herbicides.

Alavanja was one of the authors of the paper published in PLoS One in 2014. He said he and other authors and senior scientists at the National Cancer Institute decided to remove herbicides from that analysis primarily because of “the issue of statistical power and the need for a comprehensive evaluation of glyphosate and all cancers.”

Blair told Reuters the data on herbicides, including glyphosate, had been removed “to make the paper a more manageable size.” He gave a similar answer to the lawyer acting for Monsanto, who repeatedly asked in the legal deposition why the data was not published. Blair testified that the paper “went through many iterations.” He said he could not recall when the glyphosate data was removed, but “we decided to remove it because … you couldn’t put it all into one paper.”  

Monsanto argues that the data was not published because it showed no link between glyphosate and non-Hodgkin lymphoma.

The IARC review “ignored multiple years of additional data from the largest and most comprehensive study on farmer exposure to pesticides and cancer.”

Scott Partridge, vice-president of strategy at Monsanto

Tarone said the absence of herbicide data in the published 2014 paper was “inexplicable,” noting that volume of data had not been an issue in any previous published papers. He said updated AHS data and analyses on herbicides “should be published as soon as possible” to allow “a more complete evaluation of the possible association between glyphosate exposure and NHL risk in humans.”

Reuters asked nine other scientists listed as authors on the two draft papers of 2013 why these drafts had never been published. Some were unavailable for comment, and others referred questions to Laura Beane Freeman, who was a co-author on the draft papers and on the 2014 PLoS published study, and is the National Cancer Institute’s current principal investigator of the AHS.

In an email to Reuters, Freeman and a spokesman for the institute said: “After reviewing early drafts of the manuscript, it became clear that it would be impossible to do a thorough evaluation of all major pesticide groupings due to the sheer volume of information that was important to include.”

They said the decision to separate the results for herbicides, including glyphosate, allowed the scientists “to present more thorough evaluations” of the remaining pesticides.  An updated study on glyphosate is under way, Freeman said.

CULTURE CLASH

Despite IARC’s modest size and budget, its monographs – assessments of whether something is a cause of cancer – often catch the eyes and ears of policymakers and the public. Recent IARC monographs have included judgments that red meat is carcinogenic and should be classified alongside arsenic and smoking, and that coffee, which IARC previously said might cause cancer, probably is not carcinogenic.

The agency takes a different approach to many other regulators in two important ways. First, it says it assesses “hazard” – the strength of evidence about whether a substance or activity can cause cancer in any way, whether in a laboratory experiment or elsewhere. It does not assess the “risk” or likelihood of a person getting cancer from everyday exposure to something. Second, in general it only considers research that has been published in peer-reviewed scientific journals.

IARC considered around 1,000 published studies in its evaluation of glyphosate. But only a handful of those were cohort studies in humans – the kind like the Agricultural Health Study and the most relevant to real-life situations such as people working with glyphosate in agriculture.

The differing judgments on glyphosate by IARC and other regulators have stoked clashes on both sides of the Atlantic.  In the United States members of Congress have launched investigations into American taxpayer funding of IARC. They have yet to reach any conclusions.

In Europe, the battle centres on the looming decision about whether to re-license glyphosate for use in the European Union. The European Commission has said it wants EU member states to come to a decision by the end of 2017. Politicians will need to weigh the opinions of IARC and other scientific bodies when they decide whether or not to accept a Commission proposal to extend glyphosate’s marketing licence by 10 years.

It remains unclear whether the AHS data will see the light of day in time to be considered. Blair said he thought publishing the glyphosate data would be important and that his former colleagues at the NCI were working on it. The NCI’s Freeman said her team is currently “drafting a manuscript on this topic.” She said the new study “will explore the effects of glyphosate exposure in greater depth than a publication that includes multiple pesticides” and would, she hoped, be submitted “to a peer-reviewed journal in the coming months.”

Alavanja said a draft paper “should be available for submission to an appropriate scientific journal sometime later this year,” but that a publication date “is very difficult to predict.”          

Glyphosate battle

By Kate Kelland

Photo editing: Simon Newman

Design: Catherine Tai

Graphic: Ciaran Hughes

Edited by Richard Woods

To view the original article CLICK HERE

Regards,

Greg_L-W.

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Posted by: Greg Lance-Watkins
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The cancer-sufferer standing against Jeremy Corbyn in his own backyard …

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Posted by:
Greg Lance – Watkins
Greg_L-W

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Hi,

Anna’s article below puts into perspective not just the destruction of life as you may know it but in fact the confrontation of one’s own demise. Her article is wide ranging, very personal and in its way has the fascination that is seen in a rodent when confronted by a hungry snake!

On Rebuilding Your Life When Hit By An Exocet.

They were not, as you might imagine, all fellow patients with physical ailments. Exocets arrive in many forms.

For Mrs Blunt, it arrived in the form of her husband’s gleeful public declaration of his love for his homosexual partner. The media were delighted to report on his new relationship. She was left to rebuild her life with her children. An entirely innocent victim of a life shattering Exocet.

For Mrs Travis, it was the announcement that her husband was being investigated by Operation Yewtree. Mrs Travis had done nothing wrong, yet she lost her home, her peace of mind at a time that she was grappling with breast cancer – and her privacy. Her life would never be the same again.

Other who have been kind enough to make contact with me include a man who has recently been cleared of all charges, a totally innocent individual, yet who must still keep his head below the parapet for fear of further publicity so I shall not mention his name; and Rabbi Laura Janner-Klausner who finds time in her busy schedule every day to phone me and keep my spirits up.

That is not to ignore the many good friends I have made whilst running this blog – Gloria Smudd and Blocked Dwarf come to mind in particular, both have given of their time to help me settle into my new home; Andrew Rosthorn, Daedalus Parrot and ‘another’ who shall remain nameless (again with good reason to keep their head below the media parapet)  have given hours of their time to help me stand for election.

It is with those who have found themselves caught up as innocent participants in the whirlwind of false allegations that I feel a particular affinity with. I have a new understanding of what it is like to have your life turned upside down.

My life, their life, can never be the same again. We have done nothing wrong, yet have to accept that there is no road back to our old life – whether it is because, in their case, that the vile accusations will continue to be propagated on an unforgiving internet, their family name forever besmirched; or in my case, that I will never walk again with all the limitations that brings in its wake.

One thing I have quickly learned is to disassociate yourself from those who have a fixed view as to how you should ‘present’ yourself to the public in future.

You have to be true to yourself.

Yet there are many around you only too quick to give you advice as to what you should or shouldn’t be saying, nor how you should be saying it! You can rest assured that my decision to carry on blogging hasn’t gone down well with some people. My decision to ‘go public’ with my story in The Times with James Gillespie and the Mail on Sunday with David Rose in an effort to bring publicity to the issue of people suing the NHS has gone down like a lead balloon in some quarters…..

Fortunately that doesn’t include Mr G who has been a tower of strength for me, not just in terms of what he has had to do for me physically – and I cannot wait to publish the blog post which will carry pictures of the wonderful extension he has built on for me to live in, I am so very proud of what he has done – but he has also supported me mentally; mopping my tears when I have been overwhelmed by self pity, cheering me when I have managed to write a blog post, and, small point, bringing me back photographs of all the little things I can no longer see for myself.

I say ‘small point’ – but have you any idea what a difference it makes to me that he brings back a photograph of what the pub garden looks like now that they have taken down a large tent, rather than merely ‘telling’ me about it? It makes me feel as though I am still part of the wider world.

It was Mr G too, who brought into the hospital that photograph of me at 23, to remind me that that girl was still inside me, even if I could no longer recognise myself in the mirror. (One of the side effects of the massive dose of steroids that I was having at the time, apart from making you talk ten to the dozen in a loud voice, is that they literally change the shape of your jaw and puff out your cheeks, so much so that I nearly screamed the first time I caught sight of myself!)

I have had to get used to the lack of privacy too. I can no longer be alone. There must always be someone with me. No phone call is private. No part of my body is private – I have round the clock care to wash me and dress me. No bodily function is private. That is why it becomes so very important to have some control over some part of my life – and that is where I have some connection with others who have received an Exocet in the backside.

We can’t change the past, can’t change what has happened, but we have control over how we face the future.

Hidden away, licking our wounds; or blazing out in public saying ‘I don’t care what you think, this is the person I am, this is the person I choose to be, this is the person I am – you can either like it or lump it’.

It will come as no surprise to those of you who know me well, to learn that I am choosing the latter path. In fact you could say – the latter path ‘with knobs on’.

As we speak, there are two web experts doing their best to put my blog site back as it was. It can’t be exactly the same, because it will be going on a wordpress.com site rather than a self hosted wordpress.org site and the software is not identical. I’ve chosen not to go the self hosted route this time, because I still have to face the reality that the cancer will kill me at some unspecified time in the future, and if the blog was self hosted, that would mean that it would disappear again.

Thankfully the kind reader who had hosted the archive site is going to host the new site as well, so it will stay up and running when I am gone – it does mean though, that all the comments on all the back posts will disappear. Apparently there is no known piece of software that will scrape both the posts and the comments onto a new WordPress site. Edinburgh University have a full record of all the comments for any serious researchers. I’m just explaining that before someone thinks there is some nefarious reason why there are 0 comments on the old posts.

So, my choice as to how to deal with future is to write; what I want, when I want, how I want. Writing is my window on the world, it allows me to reach out to people from this bed. I hope that you will take the opportunity to comment as well – not just read, for it is that conversation that transports me from this bed into the world that I used to belong to.

A world that was full of people and events and colour.

If you have time – you can make it like that still for me, by telling me of what you have been doing, what you are thinking. I know there were hundreds, nay thousands, of you reading this blog before I closed it in December – if just a few of you take the time to continue that conversation you will be helping me to be part of my old world.

Thank you.

To view the original of this article CLICK HERE

Susanne, who is now 68, has battled her illness, leiomyosarcoma, a rare soft tissue cancer, for six years. After almost killing her several times, it has now attacked her spine, rendering her immobile.

Crushed: Susanne, pictured above in her 20s, was a victim of medical negligence in 1973 when she was given a hysterectomy at the Westminster Hospital when she was admitted for a ¿dilation and curettage¿, a minor operation used to deal with heavy periods 

Crushed: Susanne, pictured above in her 20s,

Perhaps you would like to enjoy the privilege of getting to know Susanne a little better, in her rapidly closing life, however long it will be – see:
https://twitter.com/AnnaRaccoon2017

Regards,
Greg_L-W.

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Posted by: Greg Lance-Watkins
tel: 44 (0)1594 – 528 337
Calls from ‘Number Withheld’ phones Are Blocked

All unanswered messages are recorded.
Leave your name & a UK land line number & I will return your call.

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I try to make every effort to NOT infringe copyrights in any commercial way & make all corrections of fact brought to my attention by an identifiable individual

Please Be Sure To
.Follow Greg_LW on Twitter.

Re-TWEET my Twitterings

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The cancer-sufferer standing against Jeremy Corbyn in his own backyard …

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The cancer-sufferer standing against Jeremy Corbyn in his own backyard …
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Posted by:
Greg Lance – Watkins
Greg_L-W

eMail: Greg_L-W@BTconnect.com

https://InfoWebSiteUK.wordpress.com

www.InfoWebSite.UK

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.

Hi,

The deathbed candidate: The cancer-sufferer standing against Jeremy Corbyn in his own backyard

  • Cancer sufferer Susanne Cameron-Blackie is standing in the General Election
  • The 68-year-old political blogger wants to use her dying days to fight Labour
  • Ms Cameron-Blackie will challenge Jeremy Corbyn for his seat in Islington 

Jeremy Corbyn claims the NHS isn’t safe in Tory hands. But the truth is, it’s not safe under Labour, either. The crisis that is threatening to destroy it gets deeper every day for reasons Corbyn hasn’t started to think about – and that’s why I’m running against him.’

Susanne Cameron-Blackie, better known as the political blogger Anna Raccoon, is speaking in her cottage kitchen, blessed with a stunning view across the Norfolk Broads. She is in a hospital bed, propped up by pillows. It is likely to be her death bed, her last resting place before the cancer that has ravaged her body finally claims her.

Yet it is from here that she will register this week as an independent candidate to fight Corbyn for his parliamentary seat in Islington North.

Defiant: Susanne does not know whether she will survive until Election Day on June 8. But she is determined to use every moment she has left to fight Corbyn 

Defiant: Susanne does not know whether she will survive until Election Day on June 8. But she is determined to use every moment she has left to fight Corbyn 

On a bedside table are some of the drugs keeping at bay the agony caused by the cancer which has spread through much of her body: Fentanyl, a clinical form of heroin, and the animal tranquilliser ketamine. A team of nurses visits every day.

Susanne does not know whether she will survive until Election Day on June 8. But she is determined to use every moment she has left to fight Corbyn.

‘I may be the first parliamentary candidate forced to lie down, rather than stand, for office. But I’m determined to do something useful with what’s left of my life.

‘I’m taking on Corbyn in his political comfort zone. He talks about shaping the future. As things stand, the future for the NHS is to vanish up its own backside because of the money going on lawyers and damages.’

Her campaign is based on the urgent need for sweeping reform of the personal injury legal system, to safeguard the NHS from the crippling and ever-increasing burden of medical negligence lawsuits. 

Last year, NHS Resolution, the body which handles such claims, revealed that cases arising from incidents up to the middle of 2016 are set to soak up a staggering £56 billion in lawyers’ fees and damages by the time they are settled – half NHS England’s annual budget.

Susanne, 68, has battled her illness, leiomyosarcoma, a rare soft tissue cancer, for six years. After almost killing her several times, it has now attacked her spine, rendering her immobile.

Crushed: Susanne, pictured above in her 20s, was a victim of medical negligence in 1973 when she was given a hysterectomy at the Westminster Hospital when she was admitted for a ¿dilation and curettage¿, a minor operation used to deal with heavy periods 

Crushed: Susanne, pictured above in her 20s, was a victim of medical negligence in 1973 when she was given a hysterectomy at the Westminster Hospital when she was admitted for a ‘dilation and curettage’, a minor operation used to deal with heavy periods 

But she shows no sign of giving up. ‘No politician has ever tackled this issue, least of all Corbyn,’ she says. ‘All Labour talks about is the amount of money going in through the NHS’s front door – ignoring the haemorrhaging out the back.’

Just how pressing the issue is was brought home to Susanne last month. After spending days in the cancer high-dependency unit at the Norwich and Norfolk Hospital, she had been prescribed the Fentanyl and ketamine, but an error by a nurse meant she was given a tiny dose of a much weaker drug – a prescription meant for another patient.

She shudders at the memory. ‘I can’t even begin to describe the pain I was in,’ she says. ‘It was a descent into hell.’ No wonder: a scan revealed that the erosion of one of her vertebrae had left her spinal cord exposed.

But for Susanne, worse was to come. ‘Excruciating as it was, the mistake was recognised and put right. But afterwards, I had a visit from someone in the hospital’s legal department. She wanted to know if had I engaged a lawyer, and was I planning to sue?

‘I was flabbergasted. Why? What would be the point? I know why the mistake was made: because the nurses in that unit are rushed off their feet. If I were to sue, the only thing that would change would be my husband’s bank account in several years, long after I’m gone.

Susanne will be challenging Labour leader Jeremy Corbyn in next month's General Election

Susanne will be challenging Labour leader Jeremy Corbyn in next month’s General Election

‘If I sued, I would be taking away yet more money from the NHS, so making it more likely that a future patient would endure a similar ordeal. This is the point Corbyn and Labour don’t get. They say they are socialists, yet they’re doing nothing about a system which treats the NHS as if it were a manufacturer making faulty products, instead of a provider of a vital social good.’

It wasn’t the first time Susanne had become a victim of medical negligence. In 1973, for reasons never explained, she was given a hysterectomy at the Westminster Hospital when she was admitted for a ‘dilation and curettage’, a minor operation used to deal with heavy periods.

‘I was only 23 – it left me psychologically crushed. Yet 45 years ago, people didn’t think of suing the NHS. One thing I do know is money would have made no difference. I picked myself up and moved on.’

It was not until she was in her 50s that she went to Aberystwyth University and obtained a double first in law. But by this time, she had spent years working for the Lord Chancellor’s department as an investigator for the Court of Protection, the tribunal which decides when people cannot administer their affairs through physical or mental incapacity.

‘As I thought about what had happened at the Norwich and Norfolk, I realised that through my work, I had witnessed some of the system’s worst abuses – in cases where incapacitated people were suing for medical negligence and getting enormous settlements. Then Mrs May announced the Election. I knew this was my chance.’

Among the most crucial reforms, she says, is the repeal of a 1948 law which means, bizarrely, that when patients sue the NHS, their damages are calculated on the basis they will pay for private healthcare for the rest of their lives – even though many will continue to be treated in the public sector, at public cost.

‘I saw this time and again,’ Susanne says. ‘Someone would get a huge settlement, but not fork out a penny on care. Meanwhile big awards, running into millions, are assessed on the basis that the beneficiary will live for several decades. But if they die a few years later, nothing goes back to the NHS. They can leave it to their relatives or a dogs’ home. This has to change.’

However, the biggest change she wants is more fundamental: an end to the legal lottery that means two patients with identical needs will be treated differently – one receiving millions, and the other nothing. ‘Take, for example, a cerebral palsy patient. The case will probably come down to something in the medical notes that a lawyer can argue means the midwife was absent for 19 minutes. These claims aren’t based on need, but on a narrow, legal definition of fault.

‘So they drag on for years. And it means a doctor or a hospital can never say sorry, which is all many patients want – because to do so will mean admitting liability.’

The last time the Government appointed a commission to examine this situation in 1978, it recommended a ‘no fault’ system be investigated.

Tomorrow, armed with the necessary ten local resident signatures and a campaign address in Mr Corbyn’s constituency, Susanne’s candidacy will be registered with the returning officer.

‘Just imagine: if some of the billions going to law firms and left legacies could be put into patient care, what a difference that would make. I will fight to my dying breath to make people – including Jeremy Corbyn – recognise this fact.’

To view the original article CLICK HERE
As I have known and followed Susanne Cameron-Blackie for a number of years and colluded on certain issues, particularly in her personna of Anna Raccoon, a link to her site can be found on CLICK HERE
I totally endorse her sentiments regarding suing the NHS, having refused to sue for considerable damage done to me during my nephrectomy and subsequently, damage that has given me both disability and pain every day since the operation in Sep-2001!
Every penny piece I might have been paid by way of compensation would have been money denied to other patients for their medical treatment, not to mention the obscene percentage that would have vanished in costs and fees!
I whole heartedly endorse Susanne’s stance and would commend to you her heartfelt and selfless essay on the subject CLICK HERE
Think of Susanne and join with me in wishing her a pain free final journey, having fulfilled so many challenges, acting ethically and with courage to the end in a reflection of her style through her lifetime. When the time comes I will miss her humour and the razor sharp ethical manner she always had to cut to the chase – I do so hope she will continue to out live both the odds and predictions, with her usual stoic determination, for a prolongued period until it suits her to avoid the risk of further pain and indignity.
Long before her diagnosis with cancer I never really thanked her for her compassion and encouragement in my battle with cancer, that most penicious and unwelcome visitation on ones body, life and loved ones.
Perhaps you would like to enjoy the privilege of getting to know Susanne a little better, in her rapidly closing life, however long it will be – see:
https://twitter.com/AnnaRaccoon2017

Regards,
Greg_L-W.

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Hi,

Cancer sufferer urges patients to stop suing NHS

Susanne Cameron-Blackie: ‘the NHS provides all you need without a penny going to lawyers’ALBAN DONOHOE/ALBANPIX

A woman dying of cancer has started a campaign to curb the compensation culture in the NHS despite suffering two cases of medical negligence herself.

Susanne Cameron-Blackie, 68, from Norfolk, has been given three months to live after being diagnosed with leiomyosarcoma, a soft tissue cancer, six years ago. It has spread through her body, leaving her virtually paralysed.

She is determined to spend her final weeks battling to cut the spiralling costs of litigation against the NHS. Last year, settlements and costs took £1.5bn out of the NHS budget.

NHS Resolution (formerly known as the NHS Litigation Authority) estimates that £56bn could be needed to deal with all cases arising from failures and mistakes made up to March 2016.

“That is the equivalent of half the annual budget of the NHS,” said Cameron-Blackie. She suffered in her early twenties when her womb was removed without permission as she was undergoing a dilation and curettage procedure. During recent treatment she was given another patient’s medication, leaving her in agony.

“But I didn’t sue,” Cameron-Blackie said. “The money from the original operation would have made no difference, I just got on with my life. The second time, I would not have got anything — the money would have gone to my husband in a few years’ time. What good would that do?

“Even the valid claims where somebody gets £6m and it’s entirely justified, that money goes into the court of protection and all their needs are met by the NHS.

“It is whether there is a fault that matters. If you can’t prove a fault, then you can have a patient with exactly the same damage, exactly the same needs and they are met in exactly the same way, but there is no payout.”

Cameron-Blackie, who formerly worked for the lord chancellor’s office, has returned home after her latest hospital treatment. The NHS has installed a bed and oxygen in her home on the Norfolk Broads.

“When the chips are down and you are left like this, the NHS provides everything and more that you need without a penny piece going anywhere near lawyers,” she said.

Cameron-Blackie is likely to find widespread support for her campaign.

Rob Hendry, medical director at the Medical Protection Society, which represents healthcare professionals, said: “A package of legal reforms is required to control the spiralling cost of clinical negligence, including a fixed cap on the legal fees that can be charged.”

A spokesman for NHS Resolution said it aimed to settle claims fairly and quickly. “We also have a responsibility to defend unjustified claims robustly. We received 10,965 new clinical negligence claims in 2015-16 [and] resolved 4,935 (46%) of clinical negligence claims without the payment of damages.”

10 comments
 
Ralph Naderbolsinmattu 6 days ago

 
 

The NHS Litigation Authority lost 76% of cases it contested in court, causing distress and pain to thousands of patients damaged by negligence.

 
PlatoSays 9 days ago

 
 

For those who’ve enjoyed the Anna Raccoon blog and twitter account over a decade or more.

A superb lady with a remarkable life story.

 
Kate Catleugh 9 days ago

 
 

There is a toxic chicken and egg situation here. Of course a cash-strapped NHS should not be paying enormous damages that result from expensive legal claims.  As things are now, the NHS very often will try and deny/defend/obfuscate to avoid the legal consequences of its actions. This of course not only escalates the costs but also prevents the lessons which should be learned from such errors to be learned.

If the NHS provides the remedies or reliefs needed as a consequence of it’s actions without charge anyway,  how much more rapidly, cleanly and efficiently this could happen if faults were admitted and rectified, as far as possible.  Where loss of life or hurt feelings are concerned,  surely an honest admission, a lesson truly learned and a prompt and sincere apology is far more appropriate than a long drawn out legal case and punitive financial damages awarded against the organisation least able to afford it without further jeopardising it’s ability to deliver for other patients.

 
Nick Simpson 9 days ago

 
 

My missus is a lawyer who spends her working week suing the NHS.  Go on, hate me.

Her typical client is a five year old with brain damage caused by an accident at birth.  By accident I mean a toxic combination of incompetence and stupidity. 

If such children die, compensation is minimal to non-existent.  The kids who really cost the NHS money are the ones that live, because they can live for decades unable to speak, walk, talk, feed themselves or wipe their own backside, let alone go to the shops or earn a living.  Someone has to look after them; and looking after them properly costs a lot of money.

The idea that the NHS treats everyone whose life chances are ruined in this way is absolute rubbish.  It doesn’t.

Legal Aid is no longer available for Clinical Negligence cases.  Lawyers must take such cases on contingency fee arrangements (No Win, No Fee).  That means lawyers like Mrs VoP have to decide very carefully which cases stand a reasonable chance of succeeding at trial.  She turns many down, because the alternative is to do a lot of work for nothing and unfairly raise the hopes of families.  Lawyers who push weak cases swiftly find out the consequences.

Yes, it’s true that Clin Neg lawyers are well paid (although not as well remunerated as doctors, whose average pensions are in the region of £50,000).  But the NHS could save enormous insurance fees by putting its own house in order.  Firstly, it could train its midwives properly (a common cause of negligence is that midwives are slow to grasp that a delivery might be in some way out of the ordinary).  Secondly, it could change the culture of defensiveness whereby doctors lie, cover each other’s backs and even alter medical notes in an attempt to avoid blame.  Thirdly, it could try making an early assessment of each allegation of negligence – Mrs VoP reports that again and again Trusts reject claims until a late stage of the procedure (presumably because to do so costs money and would involve medical staff being confronted with their mistakes), by which time the Claimants lawyers have spent tens of thousands which NHS insurers end up having to pay.

The reality is that, in an era where massive NHS failures are routine news items (a major one only last week), the fear of litigation exerts a powerful pressure on Trusts to raise standards.  Get rid of that if you like.  But don’t complain when clinical standards fall.

And by the way, no-fault insurance for medical accidents has been tried in other countries.  And abandoned as too expensive.

 
CM 9 days ago

 
 

Why in early can’t doctors and nurses be required to purchase their own insurance so insurance companies cover the costs? Do we even require this of our vastly over paid locums? It really is time to get rid of the vast state monolith and move to the perfect competition of multiple private suppliers paid by health insurance to drive up standards. I’d happily spend more on healthcare like they do in France if I knew the money followed the patient instead of creating loads of pointless back office non jobs for labour voters. The NHS is third world healthcare. No one who actually uses it regularly thinks it’s great except our many third world health tourists who really do get it for free, unlike the taxpayer, who pays over the odds for a third world service. I want healthcare as good as France’s or Germany’s. That means choosing and copying one of the several superior continental models. Get on with it.

Bobo08 9 days ago

 
 

@CM Insurance is business model that generates profit from premiums. So if doctors etc had to buy their own cover, then they’d ask for more pay to do so and the cost would actually increase. By self insuring, the NHS is saving money. It is as the article demonstrates, the ‘somebody must pay culture’ that drives these claims. My own wish would be that mistakes are recognised, lessons are learnt and corrections made to the process. 

Bryan Attewell 9 days ago

 
 

This lady deserves great credit for her stance on compensation culture. 

While there are no doubt some deserving cases, people in genuine need of financial support due to an error, too often this is seen as a route to easy money with cynical legal professionals stoking the fire. 

 
stella hollis 9 days ago

 
 

It is the level of damages which is the problem not the nmber of cases. Actual provable loss is no longer the yardstick. Huge damages are awarded for people’s feelings and the like. Future loss is assessed and handed over and not repaid if the recipient dies. And this extends as a problem far beyond the NHS to the military and insurance and everyday purchases. And it is all the time being encouraged by adverts on television .

To view the original article CLICK HERE
As I have known and followed Susanne Cameron-Blackie for a number of years and colluded on certain issues, particularly in her personna of Anna Raccoon, a link to her site can be found on CLICK HERE
I totally endorse her sentiments regarding suing the NHS, having refused to sue for considerable damage done to me during my nephrectomy and subsequently, damage that has given me both disability and pain every day since the operation in Sep-2001!
Every penny piece I might have been paid by way of compensation would have been money denied to other patients for their medical treatment, not to mention the obscene percentage that would have vanished in costs and fees!
I whole heartedly endorse Susanne’s stance and would commend to you her heartfelt and selfless essay on the subject CLICK HERE
Think of Susanne and join with me in wishing her a pain free final journey having fulfilled so many challenges, acting ethically and with courage to the end in a reflection of her style through her lifetime. When the time comes I will miss her humour and the razor sharp ethical manner she always had to cut to the chase – I do so hope she will continue to out live both the odds and predictions, with her usual stoic determination, for a prolongued period until it suits her to avoid the risk of further pain and indignity.
Long before her diagnosis with cancer I never really thanked her for her compassion and encouragement in my battle with cancer, that most penicious and unwelcome visitation on ones body, life and loved ones.

Regards,
Greg_L-W.

~~~~~~~~~~#########~~~~~~~~~~
Posted by: Greg Lance-Watkins
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CAVEAT:

This is a VERY long and detailed article which in full runs to over 10,000 words – with, at the end, LINKS to almost 2,000 other articles related to The Prostate!

Prostate Cancer: Stages and Grades

Approved by the Cancer.Net Editorial Board, 01/2017

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as what the cancer cells look like under a microscope. This is called the stage and grade. To see other pages, use the menu.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves looking at test results to find out if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

There are 2 types of staging for prostate cancer:

  • The clinical stage is based on the results of tests done before surgery, which includes DRE, biopsy, x-rays, CT and/or MRI scans, and bone scans. X-rays, bone scans, CT scans, and MRI scans may not always be needed. They are recommended based on the PSA level; the size of the cancer, which includes its grade and volume; and the clinical stage of the cancer.
  • The pathologic stage is based on information found during surgery, plus the laboratory results, referred to as pathology, of the prostate tissue removed during surgery. The surgery often includes the removal of the entire prostate and some lymph nodes.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

  • Tumor (T): How large is the primary tumor? Where is it located?
  • Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?
  • Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details about each part of the TNM system for prostate cancer.

Tumor (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during a DRE and is not seen during imaging tests. It may be found when surgery is done for another reason, usually for BPH or an abnormal growth of noncancerous prostate cells.

  • T1a: The tumor is in 5% or less of the prostate tissue removed during surgery.
  • T1b: The tumor is in more than 5% of the prostate tissue removed during surgery.
  • T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during a DRE.

  • T2a: The tumor involves one-half of 1 lobe (part or side) of the prostate.
  • T2b: The tumor involves more than one-half of 1 lobe of the prostate but not both lobes.
  • T2c: The tumor has grown into both lobes of the prostate.

T3: The tumor has grown through the prostate capsule on 1 side and into the tissue just outside the prostate.

  • T3a: The tumor has grown through the prostate capsule either on 1 side or on both sides of the prostate, or it has spread to the neck of the bladder. This is also known as an extraprostatic extension (EPE).
  • T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter, the part of the muscle layer that helps to control urination; the rectum; levator muscles; or the pelvic wall.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional (pelvic) lymph node(s).

Metastasis (M)

The “M” in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones. This is called distant metastasis.

MX: Distant metastasis cannot be evaluated.

M0 (M plus zero): The disease has not metastasized.

M1: There is distant metastasis.

  • M1a: The cancer has spread to nonregional, or distant, lymph node(s).
  • M1b: The cancer has spread to the bones.
  • M1c: The cancer has spread to another part of the body, with or without spread to the bone.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classification. See the table below the stage descriptions for all of the TNM combinations for each stage.

Stage I: Cancer is found in the prostate only, usually during another medical procedure. It cannot be felt during the DRE or seen on imaging tests. A stage I cancer is usually made up of cells that look more like healthy cells and is usually slow growing. 

Stage I Prostate Cancer

Stage IIA and IIB: This stage describes a tumor that is too small to be felt or seen on imaging tests. Or, it describes a slightly larger tumor that can be felt during a DRE. The cancer has not spread outside of the prostate gland, but the cells are usually more abnormal and may tend to grow more quickly. A stage II cancer has not spread to lymph nodes or distant organs. 

Stage IIA Prostate Cancer

Stage IIB Prostate Cancer

Stage III: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles. 

Stage I Prostate Cancer

Stage IV: This stage describes any tumor that has spread to other parts of the body, such as the bladder, rectum, bone, liver, lungs, or lymph nodes. 

Stage IV Prostate Cancer

Recurrent: Recurrent prostate cancer is cancer that has come back after treatment. It may come back in the prostate area again or in other parts of the body. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Stage Grouping Chart

Stage

T

N

M

I

T1a, T1b, or T1c

N0

M0

T2a

N0

M0

Any T1 or T2a

N0

M0

 

 

 

 

IIA

T1a, T1b, or T1c

N0

M0

T1a, T1b, or T1c

N0

M0

 

T2a

N0

M0

 

T2b

N0

M0

 

T2b

N0

M0

 

 

 

 

IIB

T2c

N0

M0

 

Any T1 or T2

N0

M0

 

Any T1 or T2

N0

M0

 

 

 

 

III

T3a or T3b

N0

M0

 

 

 

 

 

 

 

IV

T4

N0

M0

Any T

N1

M0

 

Any T

Any N

M1

Used with permission of the AJCC, Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition, published by Springer-Verlag New York, www.cancerstaging.org

Gleason score for grading prostate cancer

Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.

The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 1 to 5. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the doctor determines the main pattern of cell growth, which is the area where the cancer is most obvious; looks for any other less common pattern of growth; and gives each 1 a score. The scores are added together to come up with an overall score between 2 and 10.

The interpretation of the Gleason score by doctors has changed recently. Originally, doctors used a wide range of scores. Today, doctors no longer use Gleason scores of 5 or lower for cancer found with a biopsy. The lowest score used is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.

Doctors look at the Gleason score in addition to stage to help plan treatment. For example, active surveillance, described in the Treatment Options section, may be an option for a patient with a small tumor, low PSA level, and a Gleason score of 6. Patients with high Gleason score may need treatment that is more intensive, even if it does not appear that the cancer has spread.

Gleason X: The Gleason score cannot be determined.

Gleason 6 or lower: The cells are well differentiated, meaning they look similar to healthy cells.

Gleason 7: The cells are moderately differentiated, meaning they look somewhat similar to healthy cells.

Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated, meaning they look very different from healthy cells.

Recently, pathologists have begun to adopt a new Gleason grouping system that arranges the scores into simplified groups that are translated as follows:

  • Gleason Group I = Former Gleason 6
  • Gleason Group II = Former Gleason 3 + 4 = 7
  • Gleason Group III = Former Gleason 4 + 3 = 7
  • Gleason Group IV = Former Gleason 8
  • Gleason Group V = Former Gleason 9 or 10

Prostate Cancer Risk Groups

In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Two such risk assessment methods come from the National Comprehensive Cancer Network (NCCN) and the University of California, San Francisco (UCSF).

NCCN

The NCCN developed 4 risk-group categories based on PSA level, prostate size, needle biopsy findings, and the stage of cancer. The lower your risk, the lower the chance that the prostate cancer will grow and spread.

  • Very low risk. The tumor cannot be felt during a DRE and is not seen during imaging tests but was found during a needle biopsy (T1c). PSA is less than 10 ng/mL. The Gleason score is 6 or less. Cancer was found in fewer than 3 samples taken during a core biopsy. The cancer was found in half or less of any core.
  • Low risk. The tumor is classified as T1a, T1b, T1c, or T2a (see above). PSA is less than 10 ng/mL. The Gleason score is 6 or less.
  • Intermediate risk. The tumor has 2 or more of these characteristics:
    • Classified as T2b or T2c (see above)
    • PSA is between 10 and 20 ng/mL
    • Gleason score of 7
  • High risk. The tumor has 2 or more of these characteristics:
    • Classified as T3a (see above)
    • PSA level is higher than 20 ng/mL
    • Gleason score is between 8 and 10
  • Very high risk. The tumor is classified as T3b or T4 (see above). The histologic grade is 5 for the main pattern of cell growth, or more than 4 biopsy cores have Gleason scores between 8 and 10.

Source: Risk group information is adapted from the NCCN.

UCSF Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score

The UCSF-CAPRA score predicts a man’s chances of having the cancer spread and of dying. This score can be used to help make decisions about the treatment plan. Points are assigned according to a person’s age at diagnosis, PSA at diagnosis, Gleason score of the biopsy, T classification from the TNM system, and the percentage of biopsy cores involved with cancer. These categories are then used to assign a score between 0 and 10.

  • CAPRA score 0 to 2 indicates low risk.
  • CAPRA score 3 to 5 indicates intermediate risk.
  • CAPRA score 6 to 10 indicates high risk.   

Information about the cancer’s stage and other prognostic factors will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. Or, use the menu to choose another section to continue reading this guide.

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BELOW:
is another, even more detailed article, on Gleason Grading or Staging

Gleason grading system

Links

- Susan J. Maygarden and Raj Pruthi. Gleason Grading and Volume Estimation in Prostate Needle Biopsy Specimens Am J Clin Pathol Pathology Patterns Reviews 2005 123:S58-S66; doi : PDF)

- Grading of prostatic adenocarcinoma: current state and prognostic implications
Jennifer Gordetsky and Jonathan Epstein. Diagnostic Pathology 2016; 11:25. doi : 10 1186/s13000-016-0478-2 (Free)

Historical background

In the 1960s and 1970s, Donald F. Gleason and collaborators characterized various architectural patterns of prostatic cancer and grouped them into five grades or patterns, thus establishing the Gleason grading system.

More than four decades since its introduction, the Gleason system still remains the key prognostic factor in patients with prostatic cancer.

The Gleason system was derived largely from observations in larger specimens, such as prostatectomy and transurethral prostatic resection specimens.

Donald F. Gleason in 1966 created a unique grading system for prostatic carcinoma based solely on the architectural pattern of the tumor.

Another innovative aspect of this system was, rather than assigning the worst grade as the grade of the carcinoma, the grade was defined as the sum of the two most common grade patterns and reported as the Gleason score. The original description of this system was based on a study of 270 patients from the Minneapolis Veterans Administration Hospital.

Initially, Gleason intended to classify carcinomas into four Gleason patterns (GPs), but a small group of distinctive tumors (clear cell) was observed and they were placed in a separate 5th category (pattern 4).

Certain aspects of the original Gleason system would be interpreted differently in today’s practice. The cribriform pattern described, as a component of Gleason’s original pattern 2 and 3 would today typically be considered higher grade.

Individual cells listed under Gleason’s original pattern 3 would also be currently assigned a higher grade.

Pattern 4 has become significantly expanded beyond Gleason’s original description of tumors with clear cytoplasm that resembled renal cell carcinoma.

By 1974, Gleason and the Veterans Administration Cooperative Urological Research Group expanded their study to 1,032 men.

Gleason pattern 4 was described in a figure legend, as “raggedly infiltrating, fused-glandular tumor, frequently with pale cells, may resemble hypernephroma of kidney.”

The Gleason system was further refined by Mellinger in 1977 when the papillary and cribriform tumor under Gleason pattern 3 was described as having a “smooth and usually rounded edge”.

In describing the breakdown of Gleason patterns amongst 2,911 cases, Gleason pattern 1 was seen in 3.5%; pattern 2 in 24.4%; pattern 3 in 87.7%; pattern 4 in 12.1%; and pattern 5 in 22.6%.

These percentages added up to approximately 150% since 50% of the tumors showed at least two different patterns.

In 1977, Gleason provided additional comments concerning the application of the Gleason system. “Grading is performed under low magnification (40-100x).” He also stated “an occasional small area of fused glands did not change a pattern 3 tumor to pattern 4. A small focus of disorganized cells did not change a pattern 3 or 4 tumor to pattern 5.”

The only comment relating to tertiary patterns was “occasionally, small areas of a third pattern were observed.”

Synopsis Gleason Grade or Gleason Pattern Identification

The Gleason Grade is also known as the Gleason Pattern and ranges from 1 to 5:

- Gleason Grade 1 – Here, cancerous tissue is well differentiated and looks like normal prostate tissue. Glands are well packed and formed.
- Gleason Grade 2 – Here, well-formed large glands have more tissue between them.
- Gleason Grade 3 – Glands begin to look darker and show signs of randomness. They seem to be breaking away from monotony of their existence and invading surrounding tissue.
- Gleason Grade 4 – Majority of glands appear to be interspersed with surrounding tissue. A few recognizable glands are still present though.
- Gleason Grade 5 – There are no recognizable glands. Cells with distinct nuclei appear in sheets within surrounding tissue.

Description

Numerous grading systems have been designed for histopathological grading of prostate cancer. The main controversies have been whether grading should be based on glandular differentiation alone or a combination of glandular differentiation and nuclear atypia, and also whether prostate cancer should be graded according to its least differentiated or dominant pattern.

The Gleason grading system named after Donald F. Gleason is now the predominant grading system, and in 1993, it was recommended by a WHO consensus conference.

As described by Gleason, the initial grading of prostate carcinoma should be performed at low magnification using a 4x or 10x lens.

After one assesses the case at scanning magnification, one may proceed to use the 20x lens to verify the grade. For example, at low magnification one may have the impression of fused glands or necrosis but may require higher magnification at 20x to confirm its presence.

However, one should not initially use the 20x or 40x objectives to look for rare fused glands or a few individual cells seen only at higher power which would lead to an overdiagnosis of Gleason pattern 4 or 5, respectively.

The Gleason grading system is based on glandular architecture; nuclear atypia is not evaluated. Nuclear atypia as adopted in some grading systems, correlates with prognosis of prostate cancer but there is no convincing evidence that it adds independent prognostic information to that obtained by grading glandular differentiation alone.

The Gleason grading system defines five histological patterns or grades with decreasing differentiation.

- Normal prostate epithelial cells are arranged around a lumen.
- In Gleason patterns 1 to 3, there is retained epithelial polarity with luminal differentiation in virtually all glands.
- In pattern 4, there is partial loss of normal polarity.
- In pattern 5, there is an almost total loss of polarity with only
occasional luminal differentiation.

Prostate cancer has a pronounced morphological heterogeneity and usually more than one histological pattern is present.

The primary and secondary pattern, i.e. the most prevalent and the second most prevalent pattern are added to obtain a Gleason score or sum.

It is recommended that the primary and secondary pattern as well as the score be reported, e.g. Gleason score 3+4=7.

If the tumour only has one pattern, Gleason score is obtained by doubling that pattern, e.g. Gleason score 3+3=6.

Gleason scores 2 and 3 are only exceptionally assigned, because Gleason pattern 1 is unusual.

Gleason score 4 is also relatively uncommon because pattern 2 is usually mixed with some pattern 3 resulting in a Gleason score 5.

Gleason score 2-4 tumour may be seen in TURP material sampling the transitional zone.

With the introduction of the needle core biopsy technique, the Gleason system evolved to accommodate needle biopsy practice, in which the grading was done on limited biopsy core tissue.

In needle biopsy material, it has been proposed that a Gleason score of 2-4 should not be assigned. Gleason scores 6 and 7 are the most common scores and include the majority of tumours in most studies.

Gleason pattern 1

Gleason pattern 1 is composed of a very well circumscribed nodule of separate, closely packed glands, which do not infiltrate into adjacent benign prostatic tissue. The glands are of intermediate size and approximately equal in size and shape. This pattern is usually seen in transition zone cancers. Gleason pattern 1 is exceedingly rare. When present, it is usually only a minor component of the tumour and not included in the Gleason score.

Gleason pattern 2

Gleason pattern 2 is composed of round or oval glands with smooth ends. The glands are more loosely arranged and not quite as uniform in size and shape as those of Gleason pattern 1. There may
be minimal invasion by neoplastic glands into the surrounding non-neoplastic prostatic tissue. The glands are of intermediate size and larger than in Gleason pattern 3. The variation in glandular size and separation between glands is less than that seen in pattern 3. Although not evaluated in Gleason grading, the cytoplasm of Gleason pattern 1 and 2 cancers is abundant and pale-staining. Gleason pattern 2 is usually seen in transition zone cancers but may occasionally be found in the peripheral zone.

Gleason pattern 3

Gleason pattern 3 is the most common pattern. The glands are more infiltrative and the distance between them is more variable than in patterns 1 and 2. Malignant glands often infiltrate between adjacent non-neoplastic glands. The glands of pattern 3 vary in size and shape and are often angular. Small glands are typical for pattern 3, but there may also be large, irregular glands. Each gland has an open lumen and is circumscribed by stroma. Cribriform pattern 3 is rare and difficult to distinguish from cribriform high-grade PIN.

Gleason pattern 4

In Gleason pattern 4, the glands appear fused, cribriform or they may be poorly defined. Fused glands are composed of a group of glands that are no longer completely separated by stroma. The edge of a group of fused glands is scalloped and there are occasional thin strands of connective tissue within this group. Cribriform pattern 4 glands are large or they may be irregular with jagged edges. As opposed to fused glands, there are no strands of stroma within a cribriform gland. Most cribriform invasive cancers should be assigned a pattern 4 rather than pattern 3. Poorly defined glands do not have a lumen that is completely encircled by epithelium. The hypernephromatoid pattern described by Gleason is a rare variant of fused glands with clear or very pale staining cytoplasm.

Gleason pattern 5

In Gleason pattern 5, there is an almost complete loss of glandular lumina. Only occasional lumina may be seen. The epithelium forms solid sheets, solid strands or single cells invading the stroma. Care must be applied when assigning a Gleason pattern 4 or 5 to limited cancer on needle biopsy to exclude an artefact of tangential sectioning of lower grade cancer. Comedonecrosis may be present.

Grade progression

The frequency and rate of grade progression is unknown. Tumour grade is on average higher in larger tumours. However, this may be due to more rapid growth of high grade cancers. It has been demonstated that some tumours are high grade when they are small.

Many studies addressing the issue of grade progression have a selection bias, because the patients have undergone a repeat transurethral resection or repeat biopsy due to symptoms of tumour progression.

The observed grade progression may be explained by a growth advantage of a tumour clone of higher grade that was present from the beginning but undersampled. In patients followed expectantly there is no evidence of grade progression within 1-2 years.

Grading minimal cancer on biopsy

It is recommended that a Gleason score be reported even when a minimal focus of cancer is present. The correlation between biopsy and prostatectomy Gleason score is equivalent or only marginally worse with minimal cancer on biopsy. It is recommended that even in small cancers with one Gleason pattern that the Gleason score be reported. If only the pattern is reported, the clinician may misconstrue this as the Gleason score.

Tertiary Gleason patterns

The original Gleason grading system does not account for patterns occupying less than 5% of the tumour or for tertiary patterns.

In radical prostatectomy specimens, the presence of a tertiary high
grade component adversely affects prognosis. However, the prognosis is not necessarily equated to the addition of the primary Gleason pattern and the tertiary highest Gleason pattern.

For example, the presence of a tertiary Gleason pattern 5 in a Gleason score 4+3=7 tumour worsens the prognosis compared to the same tumour without a tertiary high grade component.

However, it is not associated with as adverse prognosis as a Gleason score 4+5=9. When this tertiary pattern is pattern 4 or 5, it should be reported in addition to the Gleason score, even when it is less than 5% of the tumour.

Although comparable data do not currently exist for needle biopsy material, in the setting of three grades on biopsy where the highest grade is the least common, the highest grade is incorporated as the secondary pattern.

An alternative option is in the situation with a tertiary high grade pattern (i.e. 3+4+5 or 4+3+5) is to diagnose the case as Gleason score 8 with patterns 3, 4 and 5 also present.

The assumption is that a small focus of high grade cancer on biopsy will correlate with a significant amount of high grade cancer in the prostate such that the case overall should be considered high grade, and that sampling artefact accounts for its limited nature on biopsy.

Reporting Gleason scores in cases with multiple positive biopsies

In cases where different positive cores have divergent Gleason scores, it is controversial whether to assign an averaged (composite) Gleason score or whether the highest Gleason score should be considered as the patient’s grade.

In practice, most clinicians take the highest Gleason score when planning treatment options.

Grading of variants of prostate cancer

Several morphological variants of prostate adenocarcinoma have been described (e.g. mucinous and ductal cancer).

They are almost always combined with conventional prostate cancer and their effect on prognosis is difficult to estimate.

In cases with a minor component of a prostate cancer variant, Gleason grading should be based on the conventional prostate cancer present in the specimen.

In the rare case where the variant form represents the major component, it is controversial whether to assign a Gleason grade.

Grading of specimens with artefacts and treatment effect

Crush artefacts

Crush artefacts are common at the margins of prostatectomy specimens and in core biopsies. Crush artefacts cause disruption of the glandular units and consequently may lead to overgrading
of prostate cancer. These artefacts are recognized by the presence of noncohesive epithelial cells with fragmented cytoplasm and dark, pyknotic nuclei adjacent to preserved cells. Crushed areas should not be Gleason graded.

Hormonal and radiation treatment

Prostate cancer showing either hormonal or radiation effects can appear artefactually to be of higher Gleason score. Consequently, Gleason grading of these cancers should not be performed. If there is cancer that does not show treatment effect, a Gleason score can be assigned to these components.

Correlation of needle biopsy and prostatectomy grade

Prostate cancer displays a remarkable degree of intratumoural grade heterogeneity. Over 50% of total prostatectomy specimens contain cancer of at least three different Gleason grades, and cancer of a single grade is present in only 16% of the specimens.

Of individual tumour foci, 58% have a single grade, but most of these foci are very small.

Several studies have compared biopsy and prostatectomy Gleason score. Exact correlation has been observed in 28.2-67.9% of the cases. The biopsies undergraded in 24.5-60.0% and overgraded in 5.2-32.2%.

Causes for biopsy grading discrepencies are undersampling of higher or lower grades, tumours borderline between two grade patterns, and misinterpretation of patterns.

The concordance between biopsy and prostatectomy Gleason score is within one Gleason score in more than 90% of cases.

Reproducibility

Pathologists tend to undergrade. The vast majority of tumours graded as Gleason score 2 to 4 on core biopsy are graded as Gleason score 5 to 6 or higher when reviewed by experts in urological pathology.

In a recent study of interobserver reproducibility amongst general pathologists, the overall agreement for Gleason score groups 2-4, 5-6, 7, and 8-10 was just into the moderate range.

Undergrading is decreased with teaching efforts and a substantial interobserver reproducibility can be obtained.

Prognosis

Multiple studies have confirmed that Gleason score is a very powerful prognostic factor on all prostatic samples. This includes the prediction of the natural history of prostate cancer and the assessment of the risk of recurrence after total prostatectomy or radiotherapy.

Several schedules for grouping of Gleason scores in prognostic categories have been proposed.

Gleason scores 2 to 4 behave similarly and may be grouped.

Likewise, Gleason scores 8 to 10 are usually grouped together, although they could be stratified with regard to disease progression in a large prostatectomy study.

There is evidence that Gleason score 7 is a distinct entity with prognosis intermediate between that of Gleason scores 5-6 and 8 to 10, respectively.

Although the presence and amount of high grade cancer (patterns 4 to 5) correlates with tumour prognosis, reporting the percentage pattern 4/5 is not routine clinical practice.

Gleason score 7 cancers with a primary pattern 4 have worse prognosis than those with a primary pattern 3.

ISUP 2005 modifications

A group of urological pathologists convened at the 2005 United States and Canadian Academy meeting in San Antonio in an attempt to achieve consensus in controversial areas relating to the Gleason grading system.

The goal of the meeting was to achieve consensus amongst leading urological pathologists in specific areas of Gleason grading, including areas where there was either a lack of data or scant information as to the optimal method of grading.

In the latter instances, the consensus was based on personal and institutional experience with a large number of cases. Over 70 urological pathologists from around the world were invited to attend, with most attending.

For the purposes of this meeting, we defined “consensus” when two-thirds of the participants were in agreement, although for almost all of the issues discussed a much higher degree of agreement was reached.

See also : ISUP 2005 modifified Gleason score

At the turn of the century, attempts and recommendations were made in order to clarify how the Gleason system should be applied in practice, since it was evident that differences in Gleason system interpretation and application existed.

However, several issues remained unresolved, as this system was ultimately dependent on a subjective interpretation of various morphological patterns of cancer.

For example, it was unclear what extent of variations in size and shape of neoplastic glands should be scored as Gleason pattern (GP) 3 and what represented the scope of gland fusion patterns, interpreted as GP4.

Additional problematic issues included the grading of ill-defined glands with poorly formed lumina, defining the morphological spectrum of cribriform glands, and the grading of a tertiary grade, when it was higher than the primary and secondary grades.

In order to resolve these and other issues pertaining to Gleason grading in practice, the International Society of Urological Pathology (ISUP) convened a consensus conference on Gleason grading at the 2005 United States and Canadian Academy of Pathology Annual Meeting in San Antonio, TX, USA.

Uropathologists from 20 countries attempted to clarify and standardize the contemporary use of the Gleason system by providing consensus recommendations, based on accumulated evidence and practice standards, as to how the Gleason system should be applied and reported in contemporary practice.

Thus, a 2005 ISUP modified Gleason system was proposed, outlining the morphological patterns 1–5, which were accompanied by a modified diagram, similar to the original Gleason system.

It was reiterated that GP1 and GP2 are quite rare on biopsy and prostatectomy.

The most significant modifications pertained to patterns 3 and 4.

GP3 was restricted to discrete glandular units (as in the original system) and to smoothly circumscribed but only small cribriform tumour nodules, which, in essence, reduced the spectrum of cribriform glands interpreted as pattern 3.

Pattern 4 included fused glands and large cribriform glands or cribriform glands with border irregularities, as well as hypernephromatoid glands.

Additionally, a category of ill-defined glands or glands containing poorly formed glandular lumina was introduced (not present previously) and was included under GP4.

GP5 was reserved for cancers containing essentially no glandular differentiation, composed of solid sheets, cords, and single cells, as in the original system.

Comedocarcinoma with central necrosis was also retained in pattern 5, regardless of whether it was surrounded by papillary, cribriform or solid sheets.

The consensus also provided clarifications on the grading of variants and variations of acinar adenocarcinoma of prostate, which were illustrated by examples.

These included the issues of interpretation and grading of: vacuoles, foamy gland cancer, ductal adenocarcinoma, colloid (mucinous) carcinoma, small cell carcinoma, adenocarcinoma with focal mucinous extravasation, mucinous fibroplasia (collagenous micronodules), glomeruloid structures, and pseudohyperplastic carcinoma.

The consensus also recommended that secondary patterns of higher grade when present to a limited extent (≤5% of the tumour area) should always be reported on needle biopsy, while there was no consensus on reporting on prostatectomy.

Secondary patterns of lower grade when present to a limited extent (≤5% of the tumour area) in needle biopsies, prostatectomies and transurethral resections of prostate should be ignored.

Regarding the issue of tertiary GP, it was recommended that the Gleason score (GS) on needle biopsy should be derived by adding the primary and the highest pattern, whereas tertiary pattern on prostatectomy, when it is higher than the primary and the secondary patterns, should be reported separately.

Another recommendation was that separate dominant tumour nodules of different Gleason patterns should be scored separately on prostatectomy.

Finally, it was recommended that individual Gleason scores should be reported on needle biopsy specimens with different cores showing different grades, as long as the cores are submitted in separate containers. In addition, it was left as an option to provide an overall GS at the end of the case.

The impact of these recommendations on prostatic cancer grading in contemporary practice remains unknown, because they were introduced relatively recently and because it is uncertain how much they have penetrated and potentially altered routine prostatic pathology practice.

Hence, the objective of this study was to determine whether and how the proposed ISUP consensus recommendations have influenced the application of the modified Gleason system in grading biopsy and prostatectomy specimens in a contemporary setting of a large uropathology practice.

Reporting secondary patterns of lower grade when present to a limited extent

It was the consensus of the ISUP group that in the setting of high-grade cancer one should ignore lower grade patterns if they occupy less than 5% of the area of the tumor.

For example, a needle biopsy core that is 100% involved by cancer, with 98% Gleason pattern 4 and 2% Gleason pattern 3 would be diagnosed as Gleason score 4+4=8.

These cases with extensive pattern 4 cancer, where a significant amount of tumor is available for examination, should be considered as high grade (Gleason score>8).

At the other extreme, one can occasionally see small foci of Gleason pattern 4 on needle biopsy with a few glands of pattern 3. In the setting of very limited cancer on needle biopsy, the few glands of pattern 3 would typically occupy over 5% of the area of the tumor focus, and one would grade these tumors as Gleason score 4+3=7. Given the significant potential in this scenario of a sampling error resulting from only limited cancer on biopsy, the presence of a relatively small amount of pattern 3 would most likely correspond to a Gleason score 7 tumor in the corresponding prostate. The same 5% cut off rule for excluding lower grade cancer also applies for TURPs and radical prostatectomy specimens, which in most cases would relate to extensive cancer with more than 95% Gleason pattern 4 tumor.

Reporting secondary patterns of higher grade when present to a limited extent

It was the consensus of the group that high-grade tumor of any quantity on needle biopsy, as long as it was identified at low to medium magnification (see General applications of the Gleason grading system) should be included within the Gleason score. Any amount of high grade tumor sampled on needle biopsy most likely indicates a more significant amount of high grade tumor within the prostate due to the correlation of grade and volume and the problems inherent with needle biopsy sampling. Consequently, a needle biopsy which is entirely involved by cancer with 98% Gleason pattern 3 and 2% Gleason pattern 4 would be diagnosed as Gleason score 3+4=7.

In radical prostatectomy specimens with the analogous situation of a tumor nodule having 98% Gleason pattern 3 and 2% pattern 4, there was no consensus within the group. Approximately half of the group would diagnose these foci in an analogous fashion to that done on needle biopsy and interpret the case as Gleason score 3+4=7 regardless of the percentage of pattern 4. The other half would note these tumors as Gleason score 3+3=6 with a minor component of Gleason pattern 4. The rationale for the latter method is based on radical prostatectomy data; cancers with more than 95% Gleason pattern 3 and less than 5% pattern 4 have pathological stages that are worse than a pure Gleason score 3+3=6 tumor yet not as adverse as a Gleason score 3+4=7 where pattern 4 occupies more than 5% of the tumor.

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Historical background

Donald F. Gleason in 1966 created a unique grading system for prostatic carcinoma based solely on the architectural pattern of the tumor [1, 2, 3]. Another innovative aspect of this system was, rather than assigning the worst grade as the grade of the carcinoma, the grade was defined as the sum of the two most common grade patterns and reported as the Gleason score. The original description of this system was based on a study of 270 patients from the Minneapolis Veterans Administration Hospital.

Initially, Gleason intended to classify carcinomas into four patterns, but a small group of distinctive tumors (clear cell) was observed and they were placed in a separate 5th category (pattern 4) [2]. Certain aspects of the original Gleason system would be interpreted differently in today’s practice. The cribriform pattern described, as a component of Gleason’s original pattern 2 and 3 would today typically be considered higher grade. Individual cells listed under Gleason’s original pattern 3 would also be currently assigned a higher grade. Pattern 4 has become significantly expanded beyond Gleason’s original description of tumors with clear cytoplasm that resembled renal cell carcinoma.

By 1974, Gleason and the Veterans Administration Cooperative Urological Research Group expanded their study to 1,032 men [4]. Gleason pattern 4 was described in a figure legend, as “raggedly infiltrating, fused-glandular tumor, frequently with pale cells, may resemble hypernephroma of kidney.” The Gleason system was further refined by Mellinger in 1977 when the papillary and cribriform tumor under Gleason pattern 3 was described as having a “smooth and usually rounded edge” [5]. In describing the breakdown of Gleason patterns amongst 2,911 cases, Gleason pattern 1 was seen in 3.5%; pattern 2 in 24.4%; pattern 3 in 87.7%; pattern 4 in 12.1%; and pattern 5 in 22.6% [5]. These percentages added up to approximately 150% since 50% of the tumors showed at least two different patterns.

In 1977, Gleason provided additional comments concerning the application of the Gleason system [6]. “Grading is performed under low magnification (40-100x).” He also stated “an occasional small area of fused glands did not change a pattern 3 tumor to pattern 4. A small focus of disorganized cells did not change a pattern 3 or 4 tumor to pattern 5.” The only comment relating to tertiary patterns was “occasionally, small areas of a third pattern were observed.”
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Why the need for a consensus on Gleason grading?

It is a testament to the enduring power of the original Gleason grading system that it is the accepted grading system throughout the world, despite its inception almost 40 years ago. How many other things in medicine have stood the test of time so well? Nonetheless, medicine in general and prostate carcinoma in specific has changed dramatically since the late 1960s, when the Gleason grading system was derived. In the 1960s, there was no screening for prostate cancer other than by digital rectal exam, as serum PSA had not yet been discovered. In Gleason’s 1974 study, the vast majority (86%) of men had advanced disease with either local extension out of the prostate on clinical exam or distant metastases. Only 6% of patients had nonpalpable tumor diagnosed by transurethral resection and 8% of patients were diagnosed with a localized nodule on rectal exam [4]. The method of obtaining prostate tissue was also very different from today’s practice. Typically, only a couple of thick gauge needle biopsies were directed into an area of palpable abnormality. The use of 18-gauge thin biopsy needles and the concept of sextant needle biopsies to more extensively sample the prostate were not developed until the 1980s [7]. Consequently, the grading of prostate cancer in thin cores and in multiple cores from different sites of the prostate were not issues in Gleason’s era.

In the 1960s, radical prostatectomy was relatively uncommon, prostates were not as often removed intact, and glands were not processed in their entirety or as extensively and systematically to the degree currently seen. Further issues relating to radical prostatectomy specimens such as the grading of multiple nodules within the same prostate or dealing with tertiary patterns were not addressed within the original Gleason system.

The Gleason system also predated the use of immunohistochemistry. It is likely that with immunostaining for basal cells many of Gleason’s original 1+1=2 adenocarcinomas of the prostate would today be regarded as adenosis (atypical adenomatous hyperplasia). Similarly, many of the cases in 1967 diagnosed as cribriform Gleason pattern 3 carcinoma would probably be currently referred to as cribriform high grade prostatic intraepithelial neoplasia (PIN) or intraductal carcinoma of the prostate, if labeled with basal cell markers [8, 9].

Another issue not dealt with in the original Gleason grading system is how to grade newly described variants of adenocarcinoma of the prostate. Some of the more common variants where grading controversy exists include: mucinous carcinoma, ductal adenocarcinoma, foamy gland carcinoma, and pseudohyperplastic adenocarcinoma of the prostate. In addition, there are certain patterns of adenocarcinoma of the prostate such as those with glomeruloid features and mucinous fibroplasia (collagenous micronodules) where the use of Gleason grading was not defined.

The application of the Gleason system for all of the reasons noted above varies considerably in contemporary surgical pathology practice and has led to several recent attempts to achieve consensus on Gleason grading.
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2005 ISUP consensus conference

A group of urological pathologists convened at the 2005 United States and Canadian Academy meeting in San Antonio in an attempt to achieve consensus in controversial areas relating to the Gleason grading system [10]. The goal of the meeting was to achieve consensus amongst leading urological pathologists in specific areas of Gleason grading, including areas where there was either a lack of data or scant information as to the optimal method of grading. In the latter instances, the consensus was based on personal and institutional experience with a large number of cases. Over 70 urological pathologists from around the world were invited to attend, with most attending. For the purposes of this meeting, we defined “consensus” when two-thirds of the participants were in agreement, although for almost all of the issues discussed a much higher degree of agreement was reached.
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General applications of the Gleason grading system

As described by Gleason, the initial grading of prostate carcinoma should be performed at low magnification using a 4x or 10x lens. After one assesses the case at scanning magnification, one may proceed to use the 20x lens to verify the grade. For example, at low magnification one may have the impression of fused glands or necrosis but may require higher magnification at 20x to confirm its presence. However, one should not initially use the 20x or 40x objectives to look for rare fused glands or a few individual cells seen only at higher power which would lead to an overdiagnosis of Gleason pattern 4 or 5, respectively.

Gleason patterns
Gleason score 1+1=2

It was the consensus that a Gleason score of 1+1=2 is a grade that should not be diagnosed regardless of the type of specimen, with extremely rare exception. Most cases which were diagnosed as Gleason score 1+1=2 in the era of Gleason would today be referred to as adenosis (atypical adenomatous hyperplasia).
Gleason scores 3-4

These low-grade tumor scores were assigned by members of the consensus panel occasionally on transurethral resection specimens (TURPs) and in multifocal low-grade tumors within radical prostatectomy specimens. In contrast to Gleason’s diagram and text, the consensus was that cribriform patterns are not allowed within Gleason pattern 2. It is now accepted that Gleason score 2-4 should not be assigned to cancer on needle biopsy for several reasons:

poor reproducibility even amongst experts;

poor correlation with prostatectomy grade with almost all cases showing higher grade at resection;

a diagnosis of Gleason score 3-4 may misguide clinicians and patients into believing that the patient has an indolent tumor [11, 12].

The major limitation of rendering a diagnosis of Gleason score 4 on needle biopsy is that one cannot see the entire edge of the lesion to determine if it is completely circumscribed. Consequently, most of the lesions that appear to be very low grade on needle biopsies are diagnosed by urological pathologists as Gleason score 2+3=5 or 3+2=5.
Gleason pattern 3

A departure from the original Gleason classification system is that “individual cells” would not be allowed within Gleason pattern 3. Rather, Gleason pattern 3 cancer consists of variably sized individual glands. A further area of divergence from the original Gleason system is the controversial area of cribriform Gleason pattern 3. Within Gleason’s original illustrations of his cribriform pattern 3, he depicts large cribriform glands, which the consensus panel would uniformly diagnose as cribriform pattern 4. The consensus panel required extremely stringent criteria for the diagnosis of cribriform pattern 3, with remaining cribriform patterns typically falling into Gleason pattern 4. The criteria used to diagnose cribriform pattern 3 were rounded, well circumscribed glands of the same size of normal glands. When various images were shown to the consensus panel of potential candidates for cribriform Gleason pattern 3, almost none of them met the criteria based on subtle features, such as slight irregularities of the outer border of the cribriform glands. Subsequent to the 2005 meeting, this author reviewed 3590 consecutive prostate cancers sent to me over seven months; 30 needle biopsy cases were selected that possibly represented cribriform Gleason pattern 3 cancer [13], 36 digital images were taken and sent to ten experts in prostate pathology with a consensus defined when at least 7/10 experts agreed on the grade. Even in this highly selected set of images thought to be the best candidates for cribriform pattern 3 from a busy consult service, most experts interpreted the cribriform patterns as pattern 4. There was only one consensus pattern 3 case. Furthermore, most of the cribriform foci investigated (73%) were associated with more definitive pattern 4 elsewhere on the needle biopsy specimen. There was poor reproducibility amongst experts as to cribriform pattern 3 vs. pattern 4 due to:

disagreement as to what are the key diagnostic features in a given case (i.e. irregular distribution of lumina and variable slit-like lumina, favor pattern 4 vs. small glands and regular contour, favor pattern 3;

disagreement as to assessment of given criteria: regular vs. irregular distribution of lumina and regular vs. irregular contour.

Conceptually, one would expect the change in grade from pattern 3 to pattern 4 to be reflected in a distinct architectural paradigm shift where cribriform as opposed to individual glands are formed, rather than merely a subjective continuum of differences in size, shape and contour of cribriform glands.

The only reason why cribriform pattern 3 even exists is because of the original Gleason schematic diagram. Gleason never specifically published the prognostic difference between what he called cribriform Gleason pattern 3 compared to Gleason pattern 4. Many of Gleason’s cribriform Gleason pattern 3 cancers may not even have been infiltrating carcinomas due to the lack of availability of immunohistochemistry for basal cell markers. Today we might have diagnosed them either as cribriform high-grade PIN or intraductal carcinoma of the prostate (concepts not present in Gleason’s era). Based on all the above data, all cribriform cancer should be interpreted as Gleason pattern 4 and not pattern 3.
Gleason pattern 4

A controversial area where consensus was reached was that ill-defined glands with poorly formed glandular lumina also warrant the diagnosis of Gleason pattern 4. Only a cluster of such glands, where a tangential section of Gleason pattern 3 glands cannot account for the histology, would be acceptable as Gleason pattern 4. It was also noted that in most cases ill-defined glands with poorly formed glandular lumina are accompanied by fused glands. Very small, well-formed glands still are within the spectrum of Gleason pattern 3. This definition differs from Gleason’s original description of pattern 4 which only included the hypernephromatoid pattern [2]. Only in subsequent years were fused glandular masses added to the definition [5]. The original schematic diagram of Gleason pattern 4 consisted almost entirely of cribriform patterns without depicting fused glands or ill-defined glands with poorly formed glandular lumina. Gleason pattern 4 closely resembling renal cell carcinoma (hypernephromatoid pattern) makes up only a very small percentage of Gleason pattern 4 cases.
Gleason pattern 5

Gleason pattern 5 consists of individual cells, cords of cells, and sheets of tumor. Although typically one sees comedonecrosis with solid nests, occasionally one can see necrosis with cribriform masses that by themselves might be cribriform pattern 4. If there is true comedonecrosis, the consensus was that these patterns should be regarded as Gleason pattern 5. One must be stringent as to the definition of comedonecrosis, requiring intraluminal necrotic cells and/or karyorrhexis, especially in the setting of cribriform glands. We have noted in two studies using different patient populations the tendency for pathologists to undergrade Gleason pattern 5 in almost 50% of cases sent for a second opinion at the request of the patient of urologist where this author has diagnosed Gleason pattern 5. Pattern 5 was missed more frequently when it was not the primary pattern.

Grading variants and variations of acinar adenocarcinoma of the prostate
Vacuoles

Adenocarcinomas of the prostate may contain clear vacuoles and these should be distinguished from true signet-ring carcinomas which contain mucin. Whereas vacuoles in adenocarcinoma of the prostate are not uncommon, true mucin-positive signet-ring cell carcinomas of prostate are exceedingly rare with only a handful of bona fide cases reported in the literature. Vacuoles may distort the architecture and it is controversial as to what grade should be assigned. Gleason’s only mention of vacuoles described them as signet cells under pattern 5 tumor [6]. The panel concluded that although typically vacuoles are seen within Gleason pattern 4 cancer, it may be seen within Gleason pattern 5 and even Gleason pattern 3 tumors. The consensus was that tumors should be graded, as if the vacuoles were not present, by only evaluating the underlying architectural pattern.
Foamy gland carcinoma

In an analogous fashion to handling cancers with vacuoles, it was the consensus of the panel that in grading foamy gland carcinomas one should ignore the foamy cytoplasm and grade the tumor solely based on the underlying architecture. Whereas most cases of foamy gland carcinoma would be graded as Gleason score 3+3=6, higher grade foamy gland carcinomas exist and should be graded accordingly based on the pattern [14, 15].
Ductal adenocarcinoma

Ductal adenocarcinomas of the prostate most commonly are composed of either papillary fronds or cribriform structures [16]. Ductal adenocarcinomas are recognized as being aggressive tumors with most studies showing comparable behavior to acinar cancer with a Gleason score 4+4=8. The consensus of the panel was that ductal adenocarcinomas should be graded as Gleason score 4+4=8, while retaining the diagnostic term of ductal adenocarcinoma to denote their unique clinical and pathological findings. This can be achieved by diagnosing such a tumor as “prostatic ductal adenocarcinoma (Gleason score 4+4=8).” In cases with mixed ductal and acinar patterns, the ductal patterns should be assigned Gleason pattern 4. The only exceptions to grading ductal adenocarcinoma as Gleason pattern 4 are:

PIN-like ductal adenocarcinoma;

ductal adenocarcinoma with comedonecrosis.

PIN-like ductal adenocarcinoma consists of individual glands lined by tall pseudostratified columnar cells resembling high grade PIN [17]. Its prognosis appears comparable to Gleason pattern 3. Although it has not been specifically studied, ductal adenocarcinoma with comedonecrosis is graded as Gleason pattern 5.
Colloid (mucinous) carcinoma

The majority of cases with colloid carcinoma consist of irregular cribriform glands floating within a mucinous matrix [18, 19]. It was the uniform consensus that these cases would be scored Gleason score 4+4=8. However, uncommonly one may see individual round discrete glands floating within mucinous pools. There was no consensus in these cases whether such cases should be diagnosed as Gleason score 4+4=8 or Gleason score 3+3=6. Approximately half of the group said that by definition all colloid carcinomas should be assigned a Gleason score of 8, while the other half felt that one should ignore the extracellular mucin and grade the tumor based on the underlying architectural pattern. The excellent prognosis of mucinous carcinomas in a large study of mucinous carcinoma at radical prostatectomy supports grading mucinous prostate carcinomas based on the underlying architectural pattern rather than assuming that all of these tumors are aggressive [20].
Small cell carcinoma

It was the consensus that small cell carcinoma of the prostate has unique histological, immunohistochemical, and clinical features [21]. Comparable to its more common pulmonary counterpart, chemotherapy is the mainstay of therapy for prostatic small cell carcinomas. These clinicopathologic features differ from those associated with Gleason pattern 5 prostatic acinar carcinoma, such that small cell carcinoma should not be assigned a Gleason grade.
Adenocarcinoma with focal mucin extravasation

There was consensus amongst the group that adenocarcinomas of the prostate with focal mucinous extravasation should not be by default graded as Gleason score 4+4=8. Rather, one should ignore focal mucinous extravasation and grade the tumor based on the underlying architecture of the glands. The distinction between focal mucinous extravasation and colloid carcinoma is the presence of epithelial elements floating within the mucinous matrix within the latter whereas with mucinous extravasation there is only focal acellular mucin adjacent to cancer.
Mucinous fibroplasia (collagenous micronodules)

The delicate ingrowth of fibrous tissue seen with mucinous fibroplasia can result in glands appearing to be fused resembling cribriform structures although the underlying architecture is really that of individual discrete rounded glands invested by loose collagen. The tumor should be graded on the underlying glandular architecture, whereby the majority are graded as Gleason score 3+3=6 [22]. Only when there are distinct cribriform glands in areas of mucinous fibroplasias does this author diagnose Gleason pattern 4.
Glomeruloid structures

Glomeruloid glands in prostatic adenocarcinoma are characterized by dilated glands containing intraluminal cribriform structures with a single point of attachment, resembling a renal glomerulus [22]. On prostate biopsy, glomeruloid glands are exclusively associated with carcinoma and not associated with benign mimickers. The grading of such glomeruloid structures is controversial. Some urological pathologists do not assign a grade to glomeruloid patterns and rather just grade the surrounding tumor. According to some experts for the rare case where the entire tumor is composed of glomeruloid glands, a grade of 3+3=6 is assigned as long as the glomeruloid structures are small. Larger glomeruloid structures are uniformly accepted by urological pathologists as Gleason pattern 4. Other experts in the field feel that all glomeruloid structures should be assigned a Gleason pattern 4. A study of ours, subsequent to the consensus conference, indicated that glomerulations were overwhelmingly associated with concurrent Gleason pattern 4 or higher-grade carcinoma [23]. In several cases, transition could be seen among small glomerulations, large glomeruloid structures, and cribriform pattern 4 cancer. These data suggest that glomerulations represent an early stage of cribriform pattern 4 cancer and are best graded as Gleason pattern 4.
Pseudohyperplastic adenocarcinoma

Uncommonly, adenocarcinomas of the prostate share some architectural features with benign glands, including larger size, branching, and papillary infolding. These cancers should be graded as Gleason score 3+3=6 with pseudohyperplastic features [24, 25]. This convention is in large part based on the recognition that they are most often accompanied by more ordinary Gleason score 3+3=6 adenocarcinoma.

Reporting secondary patterns of lower grade when present to a limited extent

It was the consensus of the group that in the setting of high-grade cancer one should ignore lower grade patterns if they occupy less than 5% of the area of the tumor. For example, a needle biopsy core that is 100% involved by cancer, with 98% Gleason pattern 4 and 2% Gleason pattern 3 would be diagnosed as Gleason score 4+4=8. These cases with extensive pattern 4 cancer, where a significant amount of tumor is available for examination, should be considered as high grade (Gleason score>8). At the other extreme, one can occasionally see small foci of Gleason pattern 4 on needle biopsy with a few glands of pattern 3. In the setting of very limited cancer on needle biopsy, the few glands of pattern 3 would typically occupy over 5% of the area of the tumor focus, and one would grade these tumors as Gleason score 4+3=7. Given the significant potential in this scenario of a sampling error resulting from only limited cancer on biopsy, the presence of a relatively small amount of pattern 3 would most likely correspond to a Gleason score 7 tumor in the corresponding prostate. The same 5% cut off rule for excluding lower grade cancer also applies for TURPs and radical prostatectomy specimens, which in most cases would relate to extensive cancer with more than 95% Gleason pattern 4 tumor.

Reporting secondary patterns of higher grade when present to a limited extent

It was the consensus of the group that high-grade tumor of any quantity on needle biopsy, as long as it was identified at low to medium magnification (see General applications of the Gleason grading system) should be included within the Gleason score. Any amount of high grade tumor sampled on needle biopsy most likely indicates a more significant amount of high grade tumor within the prostate due to the correlation of grade and volume and the problems inherent with needle biopsy sampling. Consequently, a needle biopsy which is entirely involved by cancer with 98% Gleason pattern 3 and 2% Gleason pattern 4 would be diagnosed as Gleason score 3+4=7.

In radical prostatectomy specimens with the analogous situation of a tumor nodule having 98% Gleason pattern 3 and 2% pattern 4, there was no consensus within the group. Approximately half of the group would diagnose these foci in an analogous fashion to that done on needle biopsy and interpret the case as Gleason score 3+4=7 regardless of the percentage of pattern 4. The other half would note these tumors as Gleason score 3+3=6 with a minor component of Gleason pattern 4. The rationale for the latter method is based on radical prostatectomy data; cancers with more than 95% Gleason pattern 3 and less than 5% pattern 4 have pathological stages that are worse than a pure Gleason score 3+3=6 tumor yet not as adverse as a Gleason score 3+4=7 where pattern 4 occupies more than 5% of the tumor [26, 27].

Tertiary Gleason patterns

Needle biopsy

On needle biopsies with patterns 3, 4, and 5, both the primary pattern and the highest grade should be recorded, which is a departure from the original Gleason grading system [10]. For example, tumors with Gleason score 3+4 and a tertiary pattern 5 would be recorded as Gleason score 3+5=8. Men with biopsy Gleason score 7 with tertiary pattern 5 have a higher risk of PSA failure whether treated with radical prostatectomy or radiation therapy when compared to men with Gleason score 7 without tertiary grade 5 and have a comparable risk with men with Gleason score 8-10 [28, 29]. In cases where there are three patterns consisting of patterns 2, 3, and 4, pattern 2 is ignored and the biopsy is graded as Gleason score 3+4=7 or Gleason score 4+3=7, depending on whether pattern 3 or pattern 4 was more prevalent.

Radical prostatectomy

In radical prostatectomy specimens, tertiary Gleason patterns are associated with higher pathological stage and biochemical recurrence as compared to the same Gleason score cancers without tertiary patterns. [26, 27, 30, 31, 32, 33, 34, 35]. The presence of a tertiary higher grade component is associated with an increased risk of biochemical recurrence, typically raising the risk of recurrence to a level intermediate between those of cancers without a tertiary component in the same Gleason score category and cancers in the next higher Gleason score category. The one exception is Gleason score 4+3=7 with tertiary pattern 5, which has progression rates more comparable to Gleason score 8. Typically, the tertiary pattern is added to the Gleason score (i.e. 3+4=7 with tertiary pattern 5).

Radical prostatectomy specimens with separate tumor nodules

It was recommended that radical prostatectomy specimens should be processed in an organized fashion where one can make some assessment as to whether one is dealing with a dominant nodule or separate tumor nodules. This does not necessarily require serially sectioning and embedding a radical prostatectomy in its entirety. Rather, multiple sampling techniques have described how one can subtotally submit the prostate, yet still maintain orientation in order to distinguish between different tumor nodules [36, 37, 38]. This issue becomes critical in the situation where one has a higher-grade peripheral nodule and a smaller, typically transition zone, lower-grade nodule. One can have a nodule of Gleason score 4+4=8 within the peripheral zone and a Gleason score 2+2=4 nodule within the transition zone. Occasionally these Gleason score 2+2=4 transition zone tumors may even reach relatively sizable proportions although typically they are organ-confined. If one were to assign an overall score considering all of the tumor within the prostate as one lesion, the score of such a tumor would be Gleason score 4+2=6 or Gleason score 2+4=6. It was the consensus of the group that such a grade would be misleading as it is not logical to expect that the presence of a lower grade tumor that is discrete from a separate high grade tumor nodule could in some way mitigate the poor prognosis associated with the higher grade tumor nodule. It was also recognized that if a tumor was graded, for example, as Gleason score 4+2=6 or 2+4=6, the presence of pattern 4 within such a diagnosis would not be emphasized and the patient would typically merely be recorded as having a Gleason score 6 tumor, which would not accurately reflect the nature of his lesion. The recommendation of the consensus conference was that one should assign a separate Gleason score to each dominant tumor nodule(s). With only a couple of exceptions, pathologists within the consensus conference who were authors of large radical prostatectomy series had already adopted this method of grading and the prognostic impact of the Gleason score within these series already reflects this approach. Most often, the dominant nodule is the largest tumor, which is also the tumor associated with the highest stage and highest grade. In the unusual occurrence of a non-dominant nodule (i.e. smaller nodule) that is of higher stage, one should also assign a grade to that nodule. If one of the smaller nodules is the highest grade focus within the prostate, the grade of this smaller nodule should also be recorded. In general this will be the exception; in most cases, separate grades will be assigned to only one or at most two dominant nodules.

Needle biopsy with different cores showing different grades

In current practice within the United States, a minimum of ten to 12 cores are sampled for the initial biopsy to rule out prostate cancer. In cases where multiple cores are positive for cancer, different cores may have a different Gleason grade. What overall grade should be assigned to such a patient for purposes of treatment and prognosis? This issue assumes its greatest importance when one or more of the cores show pure high-grade cancer (i.e. Gleason score 4+4=8) and the other cores show pattern 3 (3+3=6, 3+4=7, 4+3=7) cancer. Should the overall grade be the core with the highest grade or does one assign the grade by mentally adding all the cancer together as if it was one long core. Assume a case with Gleason score 4+4=8 on one core with pattern 3 (3+3=6, 3+4=7, 4+3=7) on other cores. The “Global” score for the entire case, averaging all involved needle biopsies together as if they were one long positive core, would be 4+3=7 or 3+4=7 depending on whether pattern 4 or 3 predominated.

Several studies have demonstrated that in cases with different cores having different grades, the highest Gleason score on a given core correlates better with stage and Gleason score at radical prostatectomy than the average or most frequent grade amongst the cores [39, 40, 41]. Additional support for giving cores a separate grade rather than an overall score for the entire case is that all of the various tables (i.e. Partin tables) and nomograms that have been validated and proven to be prognostically useful have used the highest core grade in cases where there are multiple cores of different grades.

It is therefore incumbent on pathologists to report the grades of each core separately as long as the cores are submitted in separate containers or the cores are in the same container yet specified by the urologist as to their location (i.e. by different color inks). As a consequence, the core with the highest grade tumor can be selected by the clinician as the grade of the entire case to determine treatment [42, 43]. In addition to giving separate cores individual Gleason scores, it is an option for pathologists to also give an overall score at the end of the case.

There is no consensus how to grade different cores with different grades when the different cores are present within the same specimen container without a designation as to site [10]. For example, there may be two cores of tissue from the left base in one jar without further designation, or multiple cores divided into containers from the left and right side of the gland. If more than one core contains cancer in the setting of multiple cores per container, some urological pathologists still grade each core separately with the remaining experts in the field giving an overall grade for the involved cores per specimen container. A rationale for the latter approach is that it is implicit that clinicians submitting multiple cores together in one container do not value the specific information derived from the cores within a given container. On the other hand, assigning a Gleason score to each core even when there are multiple positive cores in a given jar provides the most accurate information for patient care.

In cases with multiple fragmented cores in a jar, only an overall Gleason score for that jar can be assigned. For example, diagnosing Gleason score 4+4=8 on a tiny tissue fragment where there are other fragments with Gleason score 3+3=6 could be in error; if the cores were intact and the tumor was all on one core, it would be assigned a Gleason score 3+4=7 or 4+3=7.

Prognostic Gleason grade grouping

A problem with the current system is that Gleason score 6 is typically recommended as the lowest grade assigned on biopsy material. However, the Gleason scale ranges from 2-10, such that patients are unduly concerned when told they have Gleason score 6 cancer on biopsy, logically but incorrectly assuming that their tumor is in mid-range of aggressiveness. Another problem is that Gleason score 7 tumor is often considered as one grade, without distinction of 3+4=7 and 4+3=7. Finally, most studies combine Gleason scores 8-10 as high grade cancer without differentiating Gleason score 9-10 from Gleason score 8.

Based on a series of 6,462 men treated by radical prostatectomy (RP) where both the needle biopsy and RP were graded using the current modified Gleason grading system, the 5-year biochemical free survival rates for men with 3+3, 3+4, 4+3, 8, and 9-10 at biopsy were 94.6%, 82.7%, 65.1%, 63.1%, and 34.5% respectively (p < 0.001 for trend); and 96.6%, 88.1%, 69.7%, 63.7%, and 34.5% based on RP pathology respectively (p < 0.001).

It has been proposed the following Gleason grade groups and reporting of grade that accurately reflects prognosis while incorporating descriptive terminology:

- Gleason score 2-6 (well-differentiated), prognostic grade group I/V;
- Gleason score 3+4=7 (moderately differentiated), prognostic grade group II/V;
- Gleason score 4+3=7 (moderately-poorly differentiated), prognostic grade group III/V;
- Gleason score 8 (poorly differentiated), prognostic grade group IV/V;
- Gleason score 9-10 (undifferentiated), Prognostic grade group V/V.

See also

- tumoral grade
- prostate cancer

  • prostate adenocarcinoma
    • prostate acinar adenocarcinoma

References

- Update on the Gleason grading system. Jonathan I. Epstein. Ann Pathol. 2011 Nov;31(5 Suppl):S20-6. PMID: 22054451. (Link)

- Diagnosis of limited adenocarcinoma of the prostate. Epstein JI. Histopathology. 2012 Jan;60(1):28-40. PMID: 22212076

- The impact of the 2005 International Society of Urological Pathology (ISUP) consensus on Gleason grading in contemporary practice. Zareba P, Zhang J, Yilmaz A, Trpkov K. Histopathology. 2009 Oct;55(4):384-91. PMID: 19817888

- Gleason DF. Classification of prostatic carcinoma. Cancer Chemother. Rep. 1966; 50; 125–128.

- Bailar JC 3rd, Mellinger GT, Gleason DF. Survival rates of patients with prostatic cancer, tumor stage, and differentiation: preliminary report. Cancer Chemother. Rep. 1966; 50; 129–136.

- Mellinger GT, Gleason DF, Bailar JC 3rd. The histology and prognosis of prostatic cancer. J. Urol. 1967; 97; 331–337.

- Gleason DF, Mellinger GT. Prediction of prognosis for prostatic adenocarcinoma by combined histological grading and clinical staging. J. Urol. 1974; 111; 58–64.

- Gleason DF and the Veterans Administration Cooperative Urological Research Group. Histologic grading and clinical staging of prostate carcinoma. In TannenbaumM ed. Urologic pathology: the prostate. Philadelphia, PA: Lea & Febiger, 1977; 171–198.

- Mellinger GT. Prognosis of prostatic carcinoma. Recent Results Cancer Res. 1977; 60; 61–72.

- Association of Directors of Anatomical and Surgical Pathology. Recommendations for reporting of resected prostate carcinomas. Am. J. Clin. Pathol. 1996; 105; 667–670.

- Srigley JR, Amin MB, Bostwick DG et al. Updated protocol for the examination of specimens from patients with carcinoma of the prostate gland: a basis for checklist. Arch. Pathol. Lab. Med. 2000; 124; 1034–1039.

- Epstein JI. Gleason score 2–4 adenocarcinoma of the prostate on needle biopsy: a diagnosis that should not be made. Am. J. Surg. Pathol. 2000; 24; 477–478.

- Epstein JI, Yang XJ. Grading of prostatic adenocarcinoma. In EpsteinJI, YangXJ eds. Prostate biopsy interpretation, 3rd edn. Philadelphia: Lippincott Williams & Wilkins, 2002; 154–176.

- Amin MB, Grignon DJ, Humphrey PA, Srigley JR. Reporting of prostate carcinoma by the Gleason system. In AminMB, GrignonDJ, HumphreyPA, SrigleyJR eds. Gleason grading of prostate cancer: a contemporary approach. Philadelphia, PA: Lippincott Williams & Wilkins, 2004; 101–111.

- Egevad L, Allsbrook WC, Epstein JE. Current practice of Gleason grading among genitourinary pathologists. Hum. Pathol. 2005; 36; 5–9.

- Epstein JI, Allsbrook WC Jr, Amin MB, Egevad LL and the ISUP Grading Committee. The 2005 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma. Am. J. Surg. Pathol. 2005; 29; 1228–1242.

- Nakanishi H, Wang X, Ochai A et al. A nomogram for predicting low-volume/low grade prostate cancer: a tool in selecting patients for active surveillance. Cancer 2007; 110; 2441–2447.

- Trpkov K, Warman L. Use of digital maps and sampling of radical prostatectomy specimens. Arch. Pathol. Lab. Med. 2006; 130; 1751–1752.

- Schellhammer P, Moriarty R, Bostwick D, Kuban D. Fifteen-year minimum follow-up of a prostate brachytherapy series: comparing the past with the present. Urology 2000; 50; 436–439.

- Gilliland FD, Gleason DF, Hunt WC, Stone N, Harlan LC, Key CR. Trends in Gleason score for prostate cancer diagnosed between 1983–1993. J. Urol. 2001; 165; 846–850.

- Smith EB, Frierson HF Jr, Mills SE, Boyd JC, Theodorescu D. Gleason score of prostate biopsy and radical prostatectomy specimens over past 10 years. Cancer 2002; 94; 2282–2287.

- Chism DB, Hanlon AL, Troncoso P, Al-Saleem T, Horowitz EM, Pollack A. The Gleason score shift: score four and seven years ago. Int. J. Radiat. Oncol. Biol. Phys. 2003; 56; 1241–1247.

- Kondylis FI, Moriarty RP, Bostwick D, Schellhammer P. Prostate cancer grade assignment: the effect of chronological, interpretative and translation bias. J. Urol. 2003; 170; 1189–1193.

- Albertsen PC, Hanley JA, Barrows GH et al. Prostate cancer and the Will Rogers phenomenon. J. Natl Cancer Inst. 2005; 97; 1248–1253.

- Helpap B, Egevad L. The significance of modified Gleason grading of prostatic carcinoma on biopsy and radical prostatectomy specimens. Vichows Arch. 2006; 449; 622–627.

- Billis A, Guimaraes MS, Freitas LL, Meirelles L, Magna LA, Fereira U. The impact of the 2005 International Society of Urological Pathology consensus conference on standard Gleason grading of prostatic carcinoma in needle biopsies. J. Urol. 2008; 180; 548–552.

- Lin KK. Pathologic findings in 5912 prostate biopsies. [Abstract.] Mod. Pathol. 2008; 21 (Suppl. 1); 166A.

- Gofrit ON, Zorn KC, Steinberg GD, Zagaja GP, Shalhav AL. The Will Rogers phenomenon in urological oncology. J. Urol. 2008; 179; 28–33.

- Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon: stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. New Engl. J. Med. 1985; 312; 1604–1608.

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Treat life-threatening SEPSIS within the hour, says NICE, to Save Lives & Limbs …

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Treat life-threatening SEPSIS within the hour, says NICE, to Save Lives & Limbs …
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Posted by:
Greg Lance – Watkins
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Hi,

10 March 2017

Treat life-threatening sepsis within the hour, says NICE

NICE is urging hospital staff to treat people with life-threatening sepsis symptoms within one hour.

In a new draft quality standard, NICE says people showing signs of sepsis must be checked carefully. Once someone is classed as high-risk they should be seen by senior staff and given the right treatment within an hour.

Professor Gillian Leng, NICE deputy chief executive, said: “Severe symptoms can develop in sepsis very quickly. If high-risk patients are not identified and treated promptly, people can be left with debilitating problems. In the worst cases, they may die.

“This quality standard highlights priorities in the continued fight to improve sepsis care. We know from recent case reviews that there are inconsistencies in how people’s symptoms are assessed in different settings. More can be done to provide rapid treatment.”

The quality standard highlight areas from NICE’s 2016 sepsis guideline that will help health professionals improve care for those who are at risk of becoming seriously ill.

It stresses that staff in any setting, from GPs to paramedics, should check people for specific signs that will show if their symptoms are life-threatening. This includes taking their temperature or heart rate, or checking for rashes and skin discolouration.

Anyone found to be high-risk should be seen by senior hospital staff immediately. This review would be carried out by an available doctor or nurse who is authorised to prescribe antibiotics.

Dr Ron Daniels BEM, Chief Executive of the UK Sepsis Trust, comments: “An emphasis on timely treatment and diagnosis is crucial if we are to improve outcomes for people with sepsis, and this quality standard could be a hugely impactful reinforcement of the recent guideline recommendation that sepsis is treated with same urgency as heart attacks.” 

NICE says that high-risk sepsis patients should get antibiotics and IV fluid treatment within the hour. If it will take more than an hour to get someone to hospital, GPs or ambulance staff can also administer antibiotics.

Prompt treatment means people are more likely to survive and it reduces the risk of further problems like heart failure or limb amputation.

The 2015 report from the National Confidential Enquiry into Patient Outcome and Death found that 40% of people admitted to A&E with sepsis did not have a timely review by a senior clinician. It also reported avoidable delays in administering antibiotics in more than a quarter (29%) of cases and inconsistencies in early use of intravenous (IV) fluid.

Health Secretary Jeremy Hunt said: “Every death from sepsis is a tragedy, yet too often the warning signs are missed – we need to get far better at spotting sepsis across the NHS and this advice shows how vital it is for clinicians to treat life-threatening symptoms as soon as possible.

sepsis symptoms hospital check in screen

“Our relentless drive to raise awareness of this deadly condition, as well as the tireless efforts of campaigners and families who have lost loved ones, has seen a million leaflets and posters already distributed to GP clinics, hospitals and other public places – helping raise awareness to fight against this devastating condition.”

A recent study from the York Health Economics Consortium suggests that 260,000 people in the UK develop sepsis every year. And the UK Sepsis Trust estimates that sepsis kills around 44,000 people per year.

Not everyone with sepsis will be at risk of getting seriously ill. NICE says that people who are classed as low-risk should get information on what to do if they continue to feel unwell and how to get further medical help.

NICE is asking for views on the draft quality standard. It is out for public consultation until Friday 7 April 2017.

To view the original of this article CLICK HERE

To view additional information on SEPSIS CLICK HERE
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