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Why The Gleason Scores Fail Men · Intellectual Medicine

• 0:00
  So the Gleason score is subjective.
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  The Gleason score is variable even when the same cells are
• 0:06
  looked at by different pathologies.
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  All of which means it's a dart on the wall does not predict
• 0:15
  aggression. Aggression we judge with
• 0:18
  sequential assessment. I advocate PSA levels at three
• 0:22
  month intervals. Guys, do not suffer yourself
• 0:25
  with PSA anxiety syndrome. Stop.
• 0:30
  This is a slow moving train. 2 frequent points can lead to
• 0:34
  confusion and misguided assessments.
• 0:40
  Well I've heard the argument that you have to have a biopsy
• 0:45
  so you can tell what the Gleason score is.
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  I'm going to tell you why the Gleason score in my view is
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  irrelevant. But wait, how will I know how
• 0:58
  aggressive my cancer is? These terms have been confused
• 1:04
  for decades, and the Gleason score, like the PSA, has been
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  leveraged to create anxiety to have men rush into the arms of
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  treatment that does harm but doesn't achieve the objective.
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  What's the objective? Not dying from prostate cancer.
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  So we've got to be thoughtful about how we connect the dots.
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  Does a Gleason score tell you how aggressive the cancer is?
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  No, it doesn't do that. Doctor Gleason, probably a very
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  nice guy back in the 1970s and 80s, was charged with, or maybe
• 1:47
  with 60s, was charged with the responsibility of describing
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  what the cells look like under a microscope.
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  He judged them as best he could. Well, it's a little bit
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  disorganized. I'm going to call that a three.
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  That one's more disorganized. I'm going to call it a four.
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  You get the picture. It was a subjective guesstimate
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  based upon what he thought the cell looked like.
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  As a consequence, he came up with a Gleason score, zero to
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  10. Now the lowest the score can
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  ever be is a six. So a Gleason 6 is the bottom of
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  the pyramid. Recently it's been relabeled
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  instead of the numeric scale, 6 to 10.
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  They call them grades. So Grade 1 is the old number
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  six. It's like on the highway, they
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  change your off your exit ramp. They're just renaming stuff.
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  They're trying. They're trying to get their arms
• 2:47
  around it. They're trying to have the
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  Gleason score means something relevant.
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  It doesn't. It can give you a prognosis.
• 2:59
  Now that's a different than a judgement of aggression.
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  A prognosis based on a Gleason score is predicting what's the
• 3:08
  likelihood of future progression or death from prostate cancer.
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  It does have some correlation, but it's not worth exposing you
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  to the risk of a biopsy to get information that, in my view,
• 3:23
  will not affect your treatment. Now, what is the term?
• 3:26
  How do you determine then aggression?
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  Dr. If I don't get a biopsy, how do I know how aggressive my
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  cancer is? How do I know what treatment to
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  do? I'm going to tell you that's why
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  you tuned this in. Is my fist aggressive?
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  It could be if it were coming at you, right?
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  That's the difference between static and kinetic energy.
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  The kinetic energy behind a prostate cancer progression is a
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  point of change from point A to point B.
• 3:57
  Now, you could, if you chose to do this against my advice.
• 4:01
  If you chose to get sequential biopsies, you could potentially
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  correlate some change. Here's the problem, amongst
• 4:09
  others. The Gleason score itself is
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  subjective. In some studies there's been as
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  much of A 50% discrepancy in how 2 pathologists interpreted the
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  same slide. It means the first pathologist
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  called it a Gleason 6, the next one called it A7, the third one
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  called it an 8. Was all over the place.
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  So there's a lack of concordance, significant
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  deviance in how it's interpreted.
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  The take home message for those of you that have had Gleason
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  scores performed and are contemplating a treatment based
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  on a number, have another pathologist take a look at that,
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  not somebody from the same hospital.
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  You don't want his buddy on the the bench next to him.
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  There's conformity bias at play. He doesn't want to make his
• 4:59
  friend feel bad. It should be a totally
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  independent location. You have to consider human
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  behavior and everything, folks. So the Gleason score is
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  subjective. The Gleason score is variable
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  even when the same cells are looked at by different
• 5:14
  pathologists. All of which means it's a dart
• 5:19
  on the wall does not predict aggression.
• 5:22
  Aggression we judge with sequential assessment.
• 5:25
  I advocate PSA levels at three month intervals.
• 5:29
  Guys, do not suffer yourself with PSA anxiety syndrome.
• 5:35
  Oh my God, what is it this week? Let me see what happens when I
• 5:38
  eat a doughnut. I'm going to get it done next
• 5:40
  week. Stop.
• 5:43
  This is a slow moving train. 2 frequent point can lead to
• 5:48
  confusion and misguided assessments.
• 5:52
  So I like 3 month intervals. A prostate MRI.
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  The MRI did not exist when Doctor Gleeson was alive.
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  The PSA wasn't around when he started his score.
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  He did the best he could in the more primitive days.
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  Why we're still doing it has more to say about inertial
• 6:12
  financial dynamics and conformity bias.
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  Doctors like to do what their colleagues do.
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  Doctors like to do what they've always done.
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  My analogy is to bloodletting. Why do we still do biopsies?
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  Why are we looking at Gleason scores?
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  I'll get to bloodletting in a moment, but the outcomes is what
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  we are after. So it is true, some men will die
• 6:40
  from prostate cancer. However, that doesn't mean that
• 6:44
  any of the conventional treatments make a difference.
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  The best research to date has shown that it does not matter
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  that when you looked at the Protect T trial, whether you had
• 6:56
  your gland removed, had radiation or did nothing, the
• 7:01
  rate of death from prostate cancer was the same.
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  That's scary to think about, isn't it?
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  That the treatment was not only irrelevant to the outcome of
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  death by prostate cancer, but you, you had harm imposed upon
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  you. So that is very uncomfortable.
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  Another detail about Protect T the outcomes did not matter
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  regardless of the PSA, the Gleason score, or any other
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  variable prior to the surgery, it didn't matter.
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  The Gleason score didn't matter. The surgery didn't help, the
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  radiation didn't help. So you're getting a biopsy to
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  give you psychological comfort, to get a number of Gleason score
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  that gives you and the surgeon a sense of certainty.
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  Another problem with a Gleason score.
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  God, I hate the score. You're only sampling about 1% of
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  the whole gland. I had a patient recently, he had
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  12 biopsies done right. Twelve of these, these trocars
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  jabbing into the prostate. This is a risk of metastatic
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  spread. I don't care what they tell you
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  otherwise they have no proof to defend themselves.
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  You stick a needle in cancer, you make a bloody mess of it.
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  That's cellular spray biology. Common sense and research
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  supports what I just said. What is not supported is any
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  urologist or doctor that tells you it can't happen.
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  That's denying biological reality.
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  So now 12 biopsies my patient had, six of them were a Gleason
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  of six. It's pretty benign.
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  One of the 12 was a Gleason of seven and one only one was a
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  Gleason of eight. So we think perhaps another
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  pathologist, we call it a 7. The point of this story is that
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  based on that one out of 12, they want to take his gland out.
• 9:06
  Yikes. Now, fortunately, by virtue of,
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  you know, listen to my podcast, he made a different decision.
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  In my view, the Gleason score irrelevant.
• 9:16
  Back to the blood letter, it was Hippocrates back in his era and
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  before where bloodletting was performed.
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  At the time, they thought that releasing these negative
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  energies could help people recover.
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  In fact, when they did bloodletting, some people
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  recovered, A coincidental phenomenon.
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  We took the blood out and you know, Maximilius over there, his
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  fever went away. A spontaneous recovery
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  coincidentally associated to bloodletting.
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  It reinforced the doctor's confidence.
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  Hey, this is working. Over the centuries, they
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  developed different protocols, very scientific sounding, which
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  vein to drain, how much blood to take out.
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  Let the blood flow until it changes color, Let the blood
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  flow until the patient gets light headed or passes out.
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  This was very scientific, methodical, widely embraced
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  until the 1800s. Folks, we're talking thousands
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  of years of a completely useless treatment.
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  How did it persist in the absence of any research
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  supporting its harm, in the absence of any willingness to
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  contemplate an alternative at that time, and with the
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  coincidence of some people recovering?
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  I maintain the same thing is true today regarding prostate
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  cancer treatment. These toxic treatments that men
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  are exposed to coincidentally on occasion correlate with the lack
• 10:54
  of disease progression and men in whom it was unlikely to have
• 10:58
  ever progressed ever. So you have a treatment causing
• 11:03
  harm, you have a patient who doesn't die, and you have a
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  conclusion that the treatment must have been the reason.
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  Bloodletting folks, it's the same thing.
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  The difference is we now have solid evidence that what we're
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  doing is not helping men. In fact, there is.
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  Well, we're on the cusp of a revolution in prostate cancer
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  treatment. We, you and I, we're on the
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  inside track of what will soon be the non biopsy era of
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  prostate cancer treatment. We need to put this in the
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  rearview mirror. In the United Kingdom recently,
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  they decided as a nation they're no longer going to do screening
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  Psas. That is a screening to judge
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  whether or not cancer may be present.
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  Why they decided to cause more harm than benefit.
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  It's not the screening that does the harm.
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  It's the PSA induced anxiety combined with the doctor saying
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  you're going to die, you're going to die.
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  We need a biopsy. We have to get a biopsy.
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  They don't even think many of these doctors, I've heard many
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  histories from my patients. The doctor got an IPSA, do an
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  MRI. All roads lead to the biopsy.
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  Why? Treatments are not going to be
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  directed by a Gleason score nor the biopsy result.
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  Treatments do not need to be assessed with tissue.
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  The PSA, the MRI, can tell us what's happening.
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  So that's why I don't like biopsies.
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  That's why the Gleason score, in my view, is a useless metric.
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  Nearly useless. Not worth putting you through
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  the risk when the doctor tells you, don't you want to know?
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  Of course you do. But you don't want to expose
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  yourself to harm to get that information.
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  You don't need the tissue. You don't need the biopsy.
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  You don't need the Gleason score.
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  We need to just not worry about reorganizing the Gleason score
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  into better numbers. We need to weigh with it.
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  In my practice, we have in my practice, my protocol, we
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  approach this putting vitality first.
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  We're not nihilistically saying, oh, don't worry about it.
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  Prostate cancers, no worry. Of course it's a concern.
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  Yes, some men die from it, but is it possible?
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  And I believe it is. I believe this is possible that
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  we are actually amplifying and increasing the risk of
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  metastatic disease and by extension the death rate from
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  prostate cancer because of all the biopsies we're doing.
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  Think about it for a moment. We really don't know what the
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  likelihood would be of death from prostate cancer if we just
• 13:57
  stop doing biopsies. We will have that data in the
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  years to come because we're building patients through my
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  protocol. We've opted out of the biopsy
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  madness and over time, we're going to get the results.
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  And those results, I believe are going to show vitality,
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  longevity and a decrease of death and metastatic process to
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  be determined. All right, gang, Well, enough
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  heresy for one day. Talking about the Gleason score,
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  Why you don't need to worry about ever getting one.
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  If you've had it in the past, that's cool.
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  Just don't do any more. Note, look back, don't look back
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  at your treatment decisions. All of those were made as as
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  best you could with the information at hand.
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  All right, team, until next time, thanks for spending time
• 14:45
  with me. Let's live vitally.
• 14:47
  Let's fight cancer like a man.