What does it mean to have Gleason Score ≥8 prostate cancer? (A Gleason Score of 8 or higher)

Gleason score ≥8 prostate cancer means that you have high-risk prostate cancer. This includes any of the following on 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, regardless of PSA or clinical stage, all of these combinations are enough to make a man’s prostate cancer high risk.

For Gleason score 4 + 4 prostate cancer, all of the cells are abnormal and are likely to be aggressive.

For men with Gleason 4 + 5, Gleason 5 + 4, or Gleason 5 + 5, the cells look very abnormal and are quite likely to be very aggressive.

What are the treatment options for Gleason Score ≥8 prostate cancer?

With Gleason ≥8 prostate cancer, this is enough information to show that the prostate cancer is high risk. Given the high-risk prostate cancer, staging studies are needed to help decide on treatment options. These additional staging imaging studies typically include bone scan + CT/MRI, or PSMA PET/CT. Based on the NCCN guidelines, a PSMA/CT scan is recommended and does not require a negative bone scan + CT/MRI.

For most men, Gleason ≥8 prostate cancer is aggressive and requires treatment. Unless men have other severe health problems with very poor life expectancy, active surveillance or watchful waiting are not recommended. Also, men with Gleason ≥8 prostate cancer are not candidates for focal therapy due to the risk of under-treatment of disease.

For men with Gleason ≥8 prostate cancer and negative staging studies (historically a CT or MRI and bone scan; more recently a PSMA PET/CT scan), the two main options for treatment are radiotherapy or radical prostatectomy (surgery). Those who choose radiotherapy should be given ADT during and after treatment for 18-24 months. This is based on trials that show an improvement in survival when combining radiotherapy and ADT.

Men with Gleason ≥8 prostate cancer may also opt for radical prostatectomy (surgical removal of the prostate). For the most part, these will be younger men with Gleason 4 + 4 disease who may still benefit from surgery.

In all cases of radical prostatectomy for Gleason ≥8 prostate cancer, pelvic lymph node testing should be done to help stage the prostate cancer. It is important to know that there is about a 30%-50% chance that men with Gleason ≥8 prostate cancer who choose primary robotic prostatectomy may need salvage radiotherapy after surgery. This most often is needed in cases of persistent PSA right after surgery or increasing PSA in the months after surgery.

Understanding the details of your prostate cancer and how they affect the way your cancer might behave is an important step toward choosing the right treatment for you. As you move forward, look for articles about other tests you may need and details on treatment options before you decide on treatment.

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