Low Risk Prostate Cancer Gleason Score

What Is A Normal Gleason Score For Prostate Cancer

Your Gleason score doesn’t rank potential ranges like ranges set for elevated PSA tests. Instead, providers break Gleason scores into three categories:

• Gleason 6 or lower: The cells look similar to healthy cells, which is called well differentiated.
• Gleason 7: The cells look somewhat similar to healthy cells, which is called moderately differentiated.
• Gleason 8, 9 or 10: The cells look very different from healthy cells, which is called poorly differentiated or undifferentiated.

What are grade groups?

Healthcare providers established grade groups to clarify the Gleason score system. Those grade groups are:

• Grade Group 1 = Gleason 6 .
• Grade Group 2 = Gleason 3+4=7.
• Grade Group 3 = Gleason 4+3=7.
• Grade Group 4 = Gleason 8.
• Grade Group 5 = Gleason 9-10.

Active Surveillance For Prostate Cancer

If diagnosed with localized prostate cancer , disease management can take many forms, depending on the risk category of disease. Patients with low-grade, slow-growing tumors confined to the prostate gland may consider active surveillance. This involves monitoring prostate cancer in its localized stage until your doctor feels that further treatment is needed to halt the disease at a curable stage.

According to the American Society of Clinical Oncology, patients with low-risk, low-grade disease can consider active surveillance. It may also be an option for patients with a Gleason score of 7. Patients within these categories may choose to postpone prostate cancer treatment because of its associated risks and side effects.

Understanding Your Pathology Report: Prostate Cancer

When your prostate was biopsied, the samples taken were studied under the microscope by a specialized doctor with many years of training called a pathologist. The pathologist sends your doctor a report that gives a diagnosis for each sample taken. Information in this report will be used to help manage your care. The questions and answers that follow are meant to help you understand medical language you might find in the pathology report from your prostate biopsy.

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Active Surveillance Testing Schedule

Medical experts offer various recommendations regarding frequency of testing and when to start treatment during active surveillance. The American Society of Clinical Oncology recommends the following periodic evaluations while under active surveillance for prostate cancer:

• PSA testing every three to six months

• A digital rectal exam at least once a year

• A prostate biopsy at least every two to five years

If test results or symptoms indicate the cancer is progressing, treatment is recommended with the intention of curing the disease.

What Is A Risk Group

Evaluating the results of treatment can be done in multiple ways. Patient can be evaluated using a single characteristic such as the stage, the grade or the PSA. For example, all Stage T1c patients could be evaluated. However, the problem with this is that favorable prognosis patients can be lumped in with poorer prognosis patients. For example if your cancer was staged T1c and has a low grade, you wouldnt want patients with high grade included in the analysis. You want to know how patients like you do after treatment.Multiple studies have indicated that patients with slightly different characteristics can be organized into groups that have similar outcomess. For example a Low Risk patient with a T1c, Gleason Score 6 cancer and a PSA of 5 will behave very similarly to a patient with a T2a, Gleason Score 6 and PSA of 8. By grouping patients with similar results, large numbers of patients can be analyzed for the results of a treatment. By grouping these patients, we are able to compare the success of any treatment regimen.

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The Sum Of Two Numbers

The pathologist assigns two separate grades to the two predominant cancer cell patterns in the prostate tissue sample. They determine the first number by observing the area where the prostate cancer cells are most prominent. The second number, or secondary grade, relates to the area where the cells are almost as prominent.

These two numbers added together produce the total Gleason score, which is a number between 2 and 10. A higher score means the cancer is more likely to spread.

When you discuss your Gleason score with your doctor, ask about both the primary and secondary grade numbers. A Gleason score of 7 can be derived from differing primary and secondary grades, for example 3 and 4, or 4 and 3. This can be significant because a primary grade of 3 indicates that the predominant cancer area is less aggressive than the secondary area. The reverse is true if the score results from a primary grade of 4 and secondary grade of 3.

Active Surveillance For Gleason 6 Cancer

Per the Cancer Care Ontario guideline,1 active surveillance for patients with Gleason 6 disease should include:

• PSA testing every 3 to 6 months
• Annual digital rectal exam
• 12- to 14-core confirmatory transrectal ultrasound biopsy, including anterior-directed cores, within 6 to 12 months of starting surveillance, and then a serial biopsy every 3 to 5 years thereafter

REFERENCES

1. Chen RC, Rumble RB, Loblaw DA, et al: Active surveillance for the management of localized prostate cancer : American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 32:2182-2190, 2016.

2. Cooperberg MR, Broering JM, Carroll PR: Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol 28:1117-1123, 2010.

3. Loeb S, Folkvaljon Y, Curnyn C, et al: Uptake of active surveillance for very low-risk prostate cancer in Sweden. JAMA Oncol 3:1393-1398, 2016.

4. American Cancer Society: Key statistics for prostate cancer. Available at www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Accessed June 26, 2018.

5. Morash C, Tey R, Agbassi C, et al: Active surveillance for the management of localized prostate cancer. Available at www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/2286. Accessed June 26, 2018.

6. Hamdy FC, Donovan JL, Lane JA, et al: 10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 375:1415-1424, 2016.

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Dropping Psa Score With Gleason Score Of 7

How can a PSA drop with a Gleason score of 7? The biopsy showed that the cancer had attacked the nerves. Should I consider monitor with this situation?

Hi Cayandray,Good question regarding the relationship between PSA and Gleason score. Im tagging fellow members to see what they may add this conversation.

You may also be interested in joining these discussions on Connect:

prostate cancer treatment choices Prostate cancer treated with Leuprolide Why did you choose brachytherapy for prostate cancer

Have you had any treatment for prostate cancer or have been on active surveillance ?

Hi Cayandray,Good question regarding the relationship between PSA and Gleason score. Im tagging fellow members to see what they may add this conversation.

You may also be interested in joining these discussions on Connect:

prostate cancer treatment choices Prostate cancer treated with Leuprolide Why did you choose brachytherapy for prostate cancer

Have you had any treatment for prostate cancer or have been on active surveillance ?

You may also be interested in joining these discussions on Connect:

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Watchful Waiting Vs Active Surveillance

To understand your choices, he explained, its key to know the difference between the two options for men if they do not seek immediate treatmentwatchful waiting and active surveillance.

While both strategies entail not being treated immediately, they are very different. The goal ofwatchful waiting isnt to cure or even treat the disease. Its not a good option for men with low-riskcancer. Its generally for men who, because of advanced age or a medical condition, are likely to die from something else before prostate cancer becomes a mortal threat. If the disease causes symptoms such as pain, these are managed, but the goal isnt cure.

Men with low-risk cancer, on the other hand, are good candidates for active surveillance. The goal here is to cure the cancerif it needs treatment at all. In many cases, these cancers dont even progress, so they dont really need treatmentand may never need treatment. With active surveillance, Dr. Hu explained, treatment is deferred until the time that there is evidence that the disease is progressing.

Current guidelines recommend active surveillance for most men with low-risk prostate cancer.

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The Gleason Grading System

Screening for prostate cancer involves the prostate-specific antigen test and a digital rectal exam. If results are suspect, your doctor may recommend a prostate biopsythe only way to confirm the diagnosis.

During a prostate biopsy, a urologist uses a small needle to remove tissue samples from different parts of the prostate. These samplesalso called coresare then sent to a pathologist so they can review each one under a microscope.

The pathologist uses a pattern scale, developed by Donald Gleason, MD, PhD in 1966, to give each sample a grade from 1 to 5. Grade 1 cells are well-differentiated and look like normal tissue. Grade 5 cells, on the other hand, are poorly differentiated or even unrecognizable from normal tissue.

Your Gleason score is the sum of the two numbers that represent the most common types of tissue found in your biopsy. The first number in the equation is the most common grade present, the second number is the second most common grade. For example, if seven of your cores are grade 5 and five are grade 4, your Gleason score would be 5+4, or a Gleason 9.

Today, pathologists typically only flag tissue samples that are grade 3 or higher, making 6 the lowest Gleason score.

In 2014, a revised grading system for prostate cancercalled Grade Groupswas established. This system builds on the Gleason scoring system and breaks prostate cancer into five groups based on risk. This can help make it easier to understand the Gleason score scale.

How Is A Gleason Score Determined

Dr. Gleason graded prostate cancer cells based on how closely they resembled normal cells. This ranged from Grade 1 to Grade 5 . After a patient had been diagnosed with prostate cancer, Dr. Gleason would analyze the two most common cell patterns in the patients tissue sample, assign each of them a grade and then combine those grades to come up with a total Gleason score.

In other words, to calculate a prostate cancer patients Gleason score, a pathologist must:

For example, if a pathologist grades a prostate cancer patients primary cell pattern as a 3 and their secondary cell pattern as a 4, then the patients Gleason score would be a 7.

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How Is Active Surveillance Done

Although the protocol can vary, recommendations for active surveillance generally call for routine PSA tests and prostate biopsies to check for any indication that the cancer might be growing.

For example, patients at Montefiore Health System in New York City get a PSA test every 36 months, at least initially, and an MRI-guided biopsy a year after diagnosis, said Kara Watts, M.D., a urologist at the hospital who specializes in treating prostate cancer but was not involved in the study.

After the initial PSA tests and biopsy, how often they are performed depends largely on the patients particular situation, Dr. Watts explained.

We have a flexible protocol, particularly for people at both ends of the spectrum, she continued. For a man in his 70s and a life expectancy of 510 years , she said, additional PSA tests or biopsies may only be conducted every few years or only if he has symptoms. An otherwise healthy man in his 50s, on the other hand, will usually continue to have PSA tests and MRI-guided biopsies on a schedule similar to the initial protocol.

At the NIH Clinical Center, where Dr. Parnes sees patients, in addition to routine PSA testing, MRI-guided biopsies are used to help inform decisions around whether to pursue active surveillance and as part of the surveillance protocol.

Gene And Protein Tests For Prostate Cancer

For men with prostate cancer that is localized , a major issue is that its often hard to tell how quickly the cancer is likely to grow and spread. This can make it hard to decide if the cancer needs to be treated right away, as well as which types of treatment might be good options.

Some types of lab tests, known as genomic, molecular, or proteomic tests, can be used along with other information to help better predict how quickly a prostate cancer might grow or spread, and as a result, help decide what treatment options might be best and when they should be given. These tests look at which genes or proteins are active inside the prostate cancer cells. Examples of such tests include:

These tests continue to be studied to find more areas where they can be useful in prostate cancer risk and treatment decisions.

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Tools To Help You Decide

The Predict Prostate tool can help you decide between monitoring and more radical treatment. It is for men whose prostate cancer hasnt spread.

It cant tell you exactly what is going to happen in the future, but it gives you an idea about the differences in survival between the different treatment options. The tool works less well for men with a very high PSA or those with a fast growing or large tumour.

To be able to use the tool you need to know the following about your cancer:

by Wolters Kluwer Health

Men undergoing active surveillance for prostate cancer have very low rates one percent or lessof cancer spread or death from prostate cancer, according to a recent study published in The Journal of Urology, an official journal of the American Urological Association .

In the long-term, active surveillance is a safe and viable option for men with low-risk and carefully selected intermediate-risk prostate cancer, according to the report by senior author Peter R. Carroll, MD, MPH, of University of California, San Francisco and colleagues.

During active surveillance, prostate cancer is carefully monitored for signs of progression through regular prostate-specific antigen screening, prostate exams, imaging and repeat biopsies. If symptoms develop, or if tests indicate the cancer is more aggressive, active treatment such as surgery or radiation may be warranted.

New data on outcomes of active surveillance

Explore further

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Understanding Prostate Cancers Progression

To determine the appropriate treatment, doctors need to know how far the cancer has progressed, or its stage. A pathologist, the doctor trained in analyzing cells taken during a prostate biopsy, will provide two starting pointsthe cancers grade and Gleason score.

• Cancer grade: When the pathologist looks at prostate cancer cells, the most common type of cells will get a grade of 3 to 5. The area of cancer cells in the prostate will also be graded. The higher the grade, the more abnormal the cells.
• Gleason score: The two grades will be added together to get a Gleason score. This score tells doctors how likely the cancer is to grow and spread.

After a biopsy confirms prostate cancer, the patient may undergo additional tests to see whether it has spread through the blood or lymph nodes to other parts of the body. These tests are usually imaging studies and may include a bone scan,positron emission tomography scan or computed tomography scan.

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I Have Heard That Other Factors May Be Included When Evaluating Treatment

Yes, other factors such as the number of biopsies and the presence of Gleason Score 7 versus a Gleason Score may influence the treatment decision. The number of + biopsies is also strongly predictive of outcomes but not typically part of the risk grouping systems. An example would be a person with a multiple + biopsies Gleason 7. His cancer would be considered a High Intermediate Risk and require a combination of External Beam and radiation while another patient with only a few + biopsies could be a Low Intermediate Risk patient and be a good candidate for an implant alone. These factors should be discussed with you doctor.

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Often Prostate Cancer Is Low

Many prostate cancers are found with a PSA blood test. Often these cancers are low-risk. This means:

• The tumor is small.
• It is contained within the prostate.
• It is probably growing so slowly that it will not become life-threatening.

Usually a man with low-risk prostate cancer dies of something else, even if he doesnt get treatment.

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Prostate Cancer: Stages Grades And Treatment

Cancer stage refers to the size of the tumor and whether or not it has spread to other parts of the body prostate cancer is staged using the TNM system. Cancer grade refers to how quickly the cancer cells will grow and spread prostate cancer is graded using the Gleason score. Treatment of prostate cancer is based on a combination of age, life expectancy, and personal preferences, in addition to cancer grade and stage. In general, the higher the grade or stage, the more likely it is that the cancer will spread.

Renaming Gleason Score 6 Tumors As Noncancer Would Result In Medical Liability

Undoubtedly, renaming Gleason score 6 tumors as benign lesions would risk medical liability for pathologists and urologists.25 Pathologists could be liable for underdiagnosing cancer, leading to a delay in diagnosis. Currently, medical liability is virtually unheard of for a pathologist who undergrades a carcinoma. Although the issue is one of semantics, the change in diagnosis from noncancer to cancer would seem to be more significant than one of grade change in a carcinoma, especially to a lay jury. Similarly, some urologists would be liable if they did not treat a tumor that was later discovered to be incurable.

There is a precedent for retaining the term carcinoma for tumors that are indolent. For example, squamous cell carcinoma of the skin is a common tumor that like low-grade prostate carcinoma is morphologically carcinoma yet has a negligible risk of mortality. Patients are reassured about the typically benign clinical course of this tumor and consequently not overly concerned when diagnosed with carcinoma, accepting conservative treatment. Rather than avoid the term carcinoma, patients and physicians need to be educated about the indolent behavior of Gleason score 6 tumors and alternatives to immediate treatment.

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