What does it mean to have Gleason Score 7 prostate cancer?

Gleason score 7 prostate cancer includes both Gleason score 3 + 4 (Grade Group 2) and Gleason score 4 + 3 (Grade Group 3) prostate cancer. In general, both of these are called intermediate-risk prostate cancer. However, a man with Gleason 7 prostate cancer could have high-risk disease if he had a high PSA (over 20) or more advanced tumor stage.

Comparing these two, for men with Gleason score 3 + 4 prostate cancer, most of the tumor cells are the less aggressive Gleason pattern 3 while a smaller amount is the more aggressive pattern 4. So, compared to Gleason 4+3 disease, the cancer is likely to grow more slowly. Unless the PSA is greater than 10 ng/mL, most doctors will not order more imaging studies for patients with Gleason 3 + 4 disease to see if the prostate cancer has spread. Because of the more aggressive cells in Gleason score 4 + 3 prostate cancer, most doctors will order more staging imaging studies (such as CT, MRI, or PSMA PET/CT) for these men. If the PSA level is less than 20 ng/mL and there is no obvious (or low risk of) spread outside of the prostate gland, the following are treatment options for Gleason Score 7 prostate cancer:

What are the treatment options for Gleason Score 7 prostate cancer?

Gleason Score 3 + 4 Prostate Cancer

Patients over 70 years of age or unhealthy patients with low volume (about 1-2 cores positive on prostate biopsy) Gleason 3 + 4 disease may be candidates for active surveillance. Also, men with Gleason score 3 + 4 disease that have MRI visible index lesions may be candidates for focal therapy, such as high-intensity focused ultrasound (HIFU) treatment.

However, for most men with Gleason 3+4 disease, and particularly for younger and healthier men, traditional treatment options are preferred. These include radiotherapy, which may be external beam radiotherapy or brachytherapy, or surgery.

For men who choose radiotherapy, androgen deprivation therapy (ADT) during or after treatment typically is not necessary for Gleason score 3 + 4 prostate cancer. Men may also choose radical prostatectomy (surgical removal of the prostate).

Gleason Score 4 +3 Prostate Cancer

Most men with Gleason score 4 + 3 disease will require some form of treatment. They will not be candidates for active surveillance. Also, very few of these men will be candidates for focal therapy secondary to the risk of under-treatment of disease. Because of this, most men with Gleason 4 + 3 disease will choose radiotherapy options (often with about 6 months of ADT) or radical prostatectomy (surgery).

Zachary Klaassen, MD, MSc
Urologic Oncologist, Georgia Cancer Center, Augusta University, Augusta, GA, USA