Shared Decision Making in Medicine

psychtodaymagazineThe urologist broke the news: “Out of 12 cores, three were positive for cancer, so you have a small amount of cancer.”

He would soon explain the treatment choices—surgery, radiation, or active surveillance (watching the cancer closely with blood tests and biopsies). He described each option in elaborate detail, because he knew that the “right choice” would depend on what his 70-year-old patient thought about the pros and cons of treatment versus surveillance.

But before explaining the choices, the urologist wanted to make sure that the man in front of him understood the limited extent of his cancer:

We grade prostate cancer on how it looks under the microscope. We give it a score between 6 and 10.

Is that the Teason? the patient asked.

That’s the Gleason score.

Oh, Gleason score, OK.

Yep, so 6 is what we consider the lowest grade, least aggressive-looking, but it’s just abnormal enough for us to call it cancer. If it were any less than that—if there were less atypical-looking cells—we couldn’t call it cancer. So it’s just enough to get a grade of cancer, and then that goes all the way up to a score of 10, which is very abnormal looking and is more aggressive.

But 6 is the beginning number?

Yes, 6 is the least aggressive, 10 is the most aggressive, the doctor clarified.

I’m used to like, 1, the patient said, laughing.

Yeah well, the way we typically split it up is into thirds; low risk, intermediate risk, and high risk.

Right, said the patient.

Low risk is Gleason 6, intermediate is usually 7’s—3+4 or 4+3, depending on how it looks under the microscope. And then 8, 9, and 10 are all high risk. Yours is an intermediate risk. So it’s in the middle. It is 3+3 and 3+4, so just enough of the atypical cells of the grade 4 to make it 3+4, which means you’re intermediate risk.

The conversation is remarkable not just for its inscrutability but for the very fact that it took place… (Read more here)

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