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Gleason 3+3=6 is NOT “Not Cancer”
It’s not aggressive and may never need treatment – but then again, it might.

“Don’t worry about Gleason 3+3=6 (Grade Group 1)!  It’s harmless!  We shouldn’t even call it cancer!  In fact, let’s call it IDLE (indolent lesion of epithelial origin)!”

Many patients have heard reassurances like these, and yes, if you have to have prostate cancer, Gleason 6 is the best kind to have.

But wait: Let’s not call it “not cancer,” says Johns Hopkins urologic pathologist Jonathan Epstein, M.D.  “There are some very good reasons to keep the cancer designation for Grade Group 1.”  Epstein should know; he is the originator of the Grade Group system of prostate cancer grading, a system that has been adopted worldwide.

Gleason Score and Grade Group The “grade” of your cancer refers to how abnormal the cells look under a microscope, which in turn is linked to how aggressive the cancer is. Higher grade means more aggressive. There are two grading systems for prostate cancer. Gleason scores are assigned as 6-10. The newer Grade Group system is assigned as 1-5. Gleason 6 and Grade Group 1 are simply two equivalent ways of describing the least-aggressive type of prostate cancer. Read more here.

“Under the microscope,” he explains, “Grade Group 1 [Gleason 6] cancer has some of the same behaviors as higher-grade cancer.”  Even though it is not aggressive, it can still “invade nerves, go out of the prostate, and rarely, can invade the seminal vesicles.  Molecularly, it has many of the hallmarks associated with higher-grade cancer, and has certain features that you do not see in benign prostate glands.”

So why are some doctors downplaying Gleason 6 cancer?  The thinking here, Epstein explains, is that “if you remove the cancer label, it could reduce unnecessary treatment of low-grade disease,” and ease the uncertainty for men on active surveillance living with a cancer diagnosis.  For some men, this is very stressful: “In the Johns Hopkins active surveillance program, 8 percent of men undergo definitive therapy – even though they still qualify for active surveillance.”  They just don’t want a cancer diagnosis hanging over their heads.

Another problem: approximately 20-35 percent of men who are diagnosed with Gleason 6 cancer who have a prostatectomy actually turn out to have higher-grade cancer in their prostate.  “It was just missed during the biopsy.  Each biopsy needle samples 1/10,000th of the prostate.  Even with 14 to 16 cores, you’re still sampling only a tiny fraction of what’s there,” says Epstein.  “If we had a crystal ball or could look at the prostate with some other imaging or molecular test, and see that all a patient had was pure Gleason 6, I would feel more comfortable saying we should potentially change the name.”

Epstein worries that if men believe they don’t have cancer, they won’t feel a strong need to get regular follow-up monitoring.  “If you tell a man that he doesn’t have cancer, yet you’re telling him you want to see him every year and get a repeat biopsy multiple times, he may think, ‘It’s not cancer, so why do I have to keep coming back?  I’m fine!’”  And then, if he stops regular follow-up monitoring, “potentially, his cancer could progress and that would be missed.”  One more thing, Epstein warns: “The excellent prognosis of treated Grade Group 1 [Gleason 6] cancer is not the same if it is called noncancer and is not treated.”

Finally, a name change may not even be that meaningful today, Epstein continues.  “Grade Group 1 is more intuitive to patients as lowest-grade cancer.  With greater acceptance of active surveillance, patients are understanding that not all cancers are the same, that not everyone needs treatment right away – or ever – and that low-grade cancer can be followed carefully and safely.”

Gleason Score and Grade Group The “grade” of your cancer refers to how abnormal the cells look under a microscope, which in turn is linked to how aggressive the cancer is. Higher grade means more aggressive. There are two grading systems for prostate cancer. Gleason scores are assigned as 6-10. The newer Grade Group system is assigned as 1-5. Gleason 6 and Grade Group 1 are simply two equivalent ways of describing the least-aggressive type of prostate cancer. Read more here.
Janet Worthington
Janet Farrar Worthington is an award-winning science writer and has written and edited numerous health publications and contributed to several other medical books. In addition to writing on medicine, Janet also writes about her family, her former life on a farm in Virginia, her desire to own more chickens, and whichever dog is eyeing the dinner dish.

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