Video: The Sky (Newly Diagnosed) Stage

The Staging Guide Video Series | Transcription:

Hi, I'm Dr. Scholz. Let's talk about prostate cancer.

The PCRI describes five types or stages of prostate cancer. Each has been assigned a different shade of blue; Sky, Teal, Azure, Indigo, and Royal. Today we're going to talk about Sky, the lowest grade - or the least dangerous - type of prostate cancer.

The Sky stage of prostate cancer means a PSA less than 10, a Gleason under 7, and no large tumor masses detected on digital rectal or on MRI. But we call Sky cancer. Interestingly, is it actually a cancer? Sky was assigned a cancerous categorization many, many years ago when it was believed that it could metastasize. We now know this is untrue. Unfortunately, the medical system has not adjusted, and they're still calling grade 6 prostate cancers "cancer". This is incorrect, but when you get your report, it will still say "cancer" on it. This is obviously an important distinction, because if there's a higher grade - a grade 7,8.9 - it indeed can metastasize and act like a cancer. So in a sense, grade 6 prostate cancer is a separate type of cancer than the other types of higher grade prostate cancers. It's completely distinct.  

More and more men these days are managing Sky with active surveillance. And why is that? Why do men forgo curative therapy? It may be a very low grade process, but wouldn't it be simpler just to cure it and get rid of it? There are problems with even the best treatments available. Both surgery and radiation are associated with a relatively high incidence of erectile dysfunction; permanent erectile dysfunction after therapy. There can also be complications with urinary issues, rectal issues, and, of course, the dangers anytime you go in the hospital and have an operation - anesthesia complications. All of these things are what give people pause when they put treatment in a context of a harmless condition - a cancer that can't spread. So, it's the toxicity of therapy that concerns people and causes them to embark upon active surveillance instead of going to immediate therapy.  

If you're considering doing active surveillance, there's some practical issues that we need to cover. First, you want to really make sure that you are Sky and not a higher grade of prostate cancer. You can start by having the biopsy slides that were obtained referred to a center of excellence, to confirm that it really is Gleason 6. You can also have that same material reviewed with a form of genetic testing. There's several products on the market - Prolaris, Oncotype, and Decipher - that can double check and make sure that the chance for metastasis is very low.

One really big question you're going to face is, how do you do the monitoring process? Standard approach is typically to get PSAs every 3 to 6 months, have a finger exam once or twice a year, and in most centers they're recommending that you have a 12 core random biopsy every couple years. That has been the standard approach for over ten years. What's changing is, now with more accurate MRIs, which have been demonstrated to be more accurate than a biopsy, many men are deciding to forgo the biopsy and use MRI imaging instead. When that is the case, typically the MRIs are performed on an annual basis, and biopsies - that is, targeted biopsies - are reserved for men who have abnormalities detected on their MRI or, if an abnormality that's been under surveillance changes, to undergo a targeted biopsy at that time. 

Some have asked, "Why is monitoring even necessary?" If Sky prostate cancer is truly so low grade that it can't spread, can't you just go on with your life? The answer is, probably most men could just go on with their life, but there's going to be a minority of people that can develop new cancers over a period of time. There's also the rare possibility of grade 6 cancer going to a slightly higher grade. But the biggest reason that men need to be monitored is that the methodology for seeing throughout the prostate accurately is good, but not perfect. If there's a small area of high grade cancer that was missed at the time of diagnosis, over a period of years that could grow into a problem, and this is the reason that we always monitor men on an ongoing basis. 

Don't be disappointed if you are talking to a doctor who's not very enthusiastic about active surveillance. Remember, your physician was trained to do things. He went into this field because he was going to fix problems. You're probably talking to a radiation expert or a surgeon. So it's very unnatural to simply sit tight and encourage someone to do nothing. That problem is compounded because doctors are paid to do stuff, doctors are only liable if they don't do something. If they do surgery or radiation, that's considered normal. So, they actually reduce their medical liability when they recommend treatment. So, the industry has been slow to digest this revolutionary understanding that grade 6 prostate cancer really isn't a cancer. By our industry still calling it cancer, the confusion continues to be ongoing. But now you're informed. You know that you are now in a different circumstance. And you're going to have to be consistent and think clearly, even though the medical industry has been slow to catch up in this area.

So let's summarize what we've covered in this video. First, if you have Sky you want to make sure it's really Sky. Get your genetic testing done, have your pathology reviewed, let there be no doubt that it really is the safe type of prostate cancer. It's not surprising that it is. Almost half of the men diagnosed have Sky. Second, once you've confirmed that you really are Sky, be disciplined and remember, it isn't really a cancer! You need to be monitored for other cancers that may show up, but what you have is essentially harmless. It is safe to watch it. Number three is to be aware of the new technology, particularly imaging with MRI. Prostate biopsies, which have traditionally been relied on for monitoring, can cause infections, erectile dysfunction, there's discomfort associated with it, and, of course, the accuracy is less than a good quality MRI. So think about imaging rather than doing biopsies for the monitoring process. And lastly, just a word of encouragement; medical technology is advancing very quickly. If you can postpone your therapy, you're going to grandfather into better technology in the future, less toxicity, higher cure rates. So, if active surveillance is right for you, then it's the best way to go.

To learn more about Sky, check out the PCRI's free Staging Guide on the PCRI website at pcri.org. Thanks for watching. If you enjoyed our video, please subscribe to our Youtube channel. You also might want to visit our annual September conference. You can visit our website for more information.