Gleason Scores

What is a Gleason Score? 

With prostate cancer, the Gleason Score is a measurement of how fast-growing and widespread the cancer is. After you have a prostate biopsy, a doctor called a pathologist looks at the sample of prostate tissue with a microscope.  

When a pathologist looks at prostate biopsy tissue under a microscope, they look for details about the cancer cells. These details include how abnormal the cancer cells look, and how they may grow and spread. Very abnormal cells tend to grow more quickly, spread, and invade other tissues. This is referred to as aggressive. More details about this are in our risk stratification content.

Learn more about Gleason scores here.

What Does It Mean to Have Gleason Score 6 Prostate Cancer? 

Gleason score 6 is also called Grade Group 1 prostate cancer. It is the least aggressive type of prostate cancer.

In recent years, medical experts have discussed whether Gleason score 6 cancer should be considered cancer at all. This is because it most often does not grow into nearby organs or spread to other parts of the body.

However, the most important question for men diagnosed with Gleason score 6 prostate cancer is whether the cancer grade found on the biopsy – a tiny sample of tissue – represents the cancer throughout the prostate.

Biopsy Results May Not Tell the Whole Story 

A prostate biopsy only samples small areas of the prostate and the tumors in it. Doctors hope that these samples accurately represent the entire prostate and the cancer. But this is not always the case.

Studies of men who had their prostates surgically removed show that some men diagnosed with Gleason score 6 cancer on biopsy were found to have Gleason score 7 cancer when the entire prostate was examined after surgery.

The opposite can also happen. Some men who appear to have Gleason score 7 cancer on biopsy have been found to have Gleason score 6 cancer after the prostate is removed and examined.

In recent years, many urologists have adopted newer technologies to improve the diagnosis of prostate cancer. One of the most important advances is magnetic resonance imaging (MRI).

MRI scans can identify areas of the prostate that look abnormal. Doctors can then perform targeted biopsies of these areas. This increases the chance of finding the accurate traits of the cancer.

What Are Treatment Options for Gleason Score 6 Prostate Cancer? 

Most men with Gleason score 6 prostate cancer are classified as having low-risk prostate cancer. However, other factors may increase the risk level, such as:

  • A PSA level higher than 10 ng/mL
  • More advanced cancer found during a rectal exam

For most men with Gleason score 6 prostate cancer, no additional testing is needed before deciding on treatment.

The treatment options include:

Active Surveillance 

Active surveillance means closely monitoring the cancer rather than treating it right away. This approach is based on the fact that only a small number of men with low-risk prostate cancer will develop disease that causes problems, such as:

  • Growing large enough to cause urinary problems
  • Spreading outside the prostate (metastasizing)

The American Society for Clinical Oncology (ASCO) recommends active surveillance as the best available care option for men with very-low risk prostate cancer (most men with Gleason score 6 prostate cancer). It is also the “preferable care option” for most men with low-risk prostate cancer.

Why Avoid or Delay Treatment? 

Prostate cancer treatments, including surgery and radiation therapy, can cause side effects and complications. These may include:

For some men, avoiding or delaying treatment can help maintain quality of life, as long as it does not increase the risk of the cancer becoming more serious.

Recent studies show that active surveillance is being used more often in the United States. However, it is used even more frequently in countries such as Canada, Sweden, the United Kingdom, and others.

What Happens If You Choose Active Surveillance? 

Men who choose active surveillance are monitored regularly. Follow-up usually includes:

  • PSA blood tests (often every 6 months)
  • MRI scans, if one has not already been done
  • A confirmatory biopsy (see below)

The confirmatory biopsy is more tissue taken after the original diagnostic biopsy. This second biopsy helps make sure that a more aggressive cancer was not missed during the first biopsy.

You can learn more about this in our article on active surveillance.

Choosing Treatment Instead of Active Surveillance 

Active surveillance is the preferred approach for most men with Gleason score 6 prostate cancer. But some men may choose treatment after discussing their options with their family and doctors.

Treatment options may include:

  • Surgery: Surgery is done to remove the prostate. This is called a radical prostatectomy. This procedure is often done using the da Vinci robotic platform.
  • Radiation therapy: This may be done with a machine that directs radiation into the prostate. This is called external beam radiation therapy (EBRT). Or it may be done with small radioactive pellets placed inside the prostate. This is called brachytherapy.

For men with Gleason score 6 prostate cancer, hormone therapy (androgen deprivation therapy, or ADT) is usually not needed when radiation therapy is given.

Talking With Your Healthcare Team 

The best treatment for you depends on these factors:

  • Your Gleason score
  • The amount of cancer found
  • Your age and overall health
  • Your personal preferences

Talk with your doctor about your Gleason score, test results, treatment options, and preferences. Together you can decide the best type of treatment for you.

What is a Gleason Score? 

With prostate cancer, the Gleason Score is a measurement of how fast-growing and widespread the cancer is. After you have a prostate biopsy, a doctor called a pathologist looks at the sample of prostate tissue with a microscope.  

When a pathologist looks at prostate biopsy tissue under a microscope, they look for details about the cancer cells. These details include how abnormal the cancer cells look, and how they may grow and spread. Very abnormal cells tend to grow more quickly, spread, and invade other tissues. This is referred to as aggressive. More details about this are in our risk stratification content.

Learn more about Gleason scores here.

What Does It Mean to Have Gleason Score 7 Prostate Cancer?

Gleason score 7 prostate cancer is the name for 2 different types of prostate cancer:

  • Gleason score 3 + 4 (Grade Group 2)
  • Gleason score 4 + 3 (Grade Group 3)

Although both types have a Gleason score of 7, they do not behave the same way. The order of the numbers shows which cancer cells are most common.

Both types are considered intermediate-risk prostate cancer. However, a man with Gleason score 7 prostate cancer may have higher-risk disease if he also has:

  • A high PSA level (greater than 20 ng/mL)
  • A more advanced tumor stage (if and where cells have spread)

Gleason Score 3 + 4 (Grade Group 2) Prostate Cancer

In Gleason score 3 + 4 (Grade Group 2) prostate cancer, most of the tumor cells are the less aggressive Gleason 3. A smaller portion of the tumor are the more aggressive Gleason 4 cells.

Because most of the cancer is made up of the less aggressive cells, Gleason score 3 + 4 prostate cancer is generally expected to grow more slowly than Gleason score 4 + 3 (Grade Group 3) prostate cancer.

Unless the PSA level is greater than 10 ng/mL, most doctors will not order additional imaging tests to look for spread of the cancer in men with Gleason score 3 + 4.

Gleason Score 4 + 3 (Grade Group 3) Prostate Cancer

In Gleason score 4 + 3 prostate cancer, most of the tumor cells are the more aggressive Gleason 4, with a smaller amount as Gleason 3.

Because of the larger amount of more aggressive cancer cells, Gleason score 4 + 3 prostate cancer is more likely to grow and spread than Gleason score 3 + 4.

For this reason, most doctors will recommend additional imaging tests to help see if the cancer has spread. These tests may include:

What Are Treatment Options for Gleason Score 7 Prostate Cancer?

If the PSA level is less than 20 ng/mL and there is no evidence of cancer spread outside the prostate (or the risk of spread is low), treatment options may include:

Treatment Options for Gleason Score 3 + 4 Prostate Cancer

Active Surveillance

Active surveillance means closely monitoring the cancer with regular testing rather than treating it right away.

Some men with Gleason score 3 + 4 prostate cancer may be candidates for active surveillance. This may include:

  • Men older than age 70
  • Men with other health problems
  • Men with a small amount of cancer found on biopsy (about 1 to 2 positive biopsy cores)

What Happens If You Choose Active Surveillance?

Men who choose active surveillance are monitored regularly. Follow-up usually includes:

  • PSA blood tests (often every 6 months)
  • MRI scans, if one has not already been done
  • A confirmatory biopsy (see below)

The confirmatory biopsy is more tissue taken after the original diagnostic biopsy. This second biopsy helps make sure that a more aggressive cancer was not missed during the first biopsy.

Focal Therapy

Some men with Gleason score 3 + 4 disease may be candidates for focal therapy. This may be an option for men who have a visible target (known as an index lesion) on MRI.

One type of focal therapy is high-intensity focused ultrasound (HIFU). This uses focused sound waves to treat areas of cancer within the prostate.

Radiation Therapy or Surgery

For most men with Gleason score 3 + 4 prostate cancer, especially younger and healthier men, traditional treatment options are usually recommended.

These options include:

  • Radiation therapy: This may be done with a machine that directs radiation into the prostate. This is called external beam radiation therapy (EBRT). Or it may be done with small radioactive pellets placed inside the prostate. This is called brachytherapy.
  • Surgery: Surgery is done to remove the prostate. This is called a radical prostatectomy. This procedure is often done using the da Vinci robotic platform.

For men who choose radiation therapy, hormone therapy (androgen deprivation therapy, or ADT) is usually not needed during or after treatment for Gleason score 3 + 4 prostate cancer.

Treatment Options for Gleason Score 4 + 3 Prostate Cancer

Most men with Gleason score 4 + 3 prostate cancer will need treatment. They are generally not candidates for active surveillance.

Most men with Gleason score 4 + 3 prostate cancer have these treatment options:

  • Radiation therapy: This may be done with a machine that directs radiation into the prostate. This is called external beam radiation therapy (EBRT). Or it may be done with small radioactive pellets placed inside the prostate. This is called brachytherapy.
  • Androgen deprivation therapy (ADT): This is hormone therapy that’s done along with radiation therapy. This treatment is done for about 6 months.
  • Surgery: Surgery is done to remove the prostate. This is called a radical prostatectomy. This procedure is often done using the da Vinci robotic platform.

Very few men with Gleason score 4 + 3 disease are candidates for focal therapy. This is because of the higher risk that focal therapy may not treat all of the cancer.

Talking With Your Healthcare Team

The best treatment for you depends on these factors:

  • Your Gleason score
  • The amount of cancer found
  • Your age and overall health
  • Your personal preferences

Talk with your doctor about your Gleason score, test results, treatment options, and preferences. Together you can decide the best type of treatment for you.

What is a Gleason Score? 

With prostate cancer, the Gleason Score is a measurement of how fast-growing and widespread the cancer is. After you have a prostate biopsy, a doctor called a pathologist looks at the sample of prostate tissue with a microscope.  

When a pathologist looks at prostate biopsy tissue under a microscope, they look for details about the cancer cells. These details include how abnormal the cancer cells look, and how they may grow and spread. Very abnormal cells tend to grow more quickly, spread, and invade other tissues. This is referred to as aggressive. More details about this are in our risk stratification content.

Learn more about Gleason scores here.

What Does It Mean to Have Gleason Score 8, 9, or 10 Prostate Cancer? 

A Gleason score of 8, 9, or 10 means high-risk prostate cancer. This means all of the cells are abnormal, and more likely to grow faster and spread to other parts of the body.

This includes the following Gleason scores found on a prostate biopsy:

  • Gleason score 4 + 4 (Grade Group 4)
  • Gleason score 4 + 5 (Grade Group 5)
  • Gleason score 5 + 4 (Grade Group 5)
  • Gleason score 5 + 5 (Grade Group 5)

Based on the Gleason score or Grade Group alone, these cancer grades are considered high risk. This is true even if the PSA level or cancer stage suggests a lower risk.

How Aggressive Is Gleason Score 8, 9, or 10 Prostate Cancer? 

The Gleason score describes how abnormal the cancer cells look under a microscope. It helps doctors understand how aggressive the cancer may be. “Aggressive” means how fast the cancer cells grow and spread.

  • Gleason Score 4 + 4: All of the cancer cells are abnormal. These cells are considered likely to be aggressive.
  • Gleason Score 4 + 5, 5 + 4, or 5 + 5: All of the cancer cells look very abnormal. These cancers are considered very aggressive. They are more likely to grow and spread.

Additional Tests to Check for Cancer Spread 

With Gleason score 8, 9, or 10, more tests are needed to see if the cancer has spread. This will help guide treatment decisions. These tests are called staging studies. They may include:

Based on current National Comprehensive Cancer Network (NCCN) guidelines, a PSMA PET/CT scan is recommended, and does not require a negative bone scan and CT/MRI first.

Active Surveillance and Focal Therapy: Not Good Treatment Options 

For most men, prostate cancer with Gleason score 8, 9, or 10 requires treatment. Unless a man has other serious health problems and a very limited life expectancy, active surveillance is not advised. Men with these Gleason scores are also not candidates for focal therapy. This is because of the risk that this approach may not treat all areas of cancer.

Main Treatment Options for Gleason Score 8, 9, or 10 Prostate Cancer 

For men whose staging tests do not show cancer spread outside the prostate (metastasis), the 2 main treatment options are:

  • Radiation therapy
  • Radical prostatectomy (surgery)

Radiation Therapy 

Radiation therapy may be done with a machine that directs radiation into the prostate. This is called external beam radiation therapy (EBRT). Or it may be done with small radioactive pellets placed inside the prostate. This is called brachytherapy.

Androgen deprivation therapy (ADT) is done along with radiation therapy. This is hormone therapy. This treatment is done for 18 to 24 months. Research has shown that combining radiation therapy with ADT improves survival for many men with high-risk prostate cancer.

Radical Prostatectomy (Surgery) 

Radical prostatectomy is surgery to remove the prostate. This procedure is often done using the da Vinci robotic platform.

This option is most often considered for younger men, particularly those with Gleason score 4 + 4 disease.

During radical prostatectomy, some pelvic lymph nodes are removed for testing. They are checked for cancer cells. This helps show if the cancer has spread.

Additional Treatment After Surgery 

Some men with Gleason score 8, 9, or 10 who have surgery may need radiation treatment after surgery. This is called salvage radiation therapy.

This is most often needed when:

  • The PSA level does not become undetectable after surgery (persistent PSA)
  • The PSA level begins to rise again in the months after surgery

Talking With Your Healthcare Team 

The best treatment for you depends on these factors:

  • Your Gleason score
  • The amount of cancer found
  • Your age and overall health
  • Your personal preferences

Talk with your doctor about your Gleason score, test results, treatment options, and preferences. Together you can decide the best type of treatment for you.