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Which treatment is best to treat your prostate cancer may not be the best thing for you. Know your options and the pros and cons of each. A word to the wise is sufficient. A second opinion is rarely a bad idea. JM
What is a Gleason score?
Last reviewed: Thu 25 May 2017
The Gleason score is also used to determine how aggressive the cancer is and what the best course of treatment will be.
Contents of this article:
What is a Gleason score?
The Gleason score measures the progress of a cancer cell from normal to tumorous.
The Gleason score is a grading system devised in the 1960s by a pathologist called Donald Gleason.
Gleason worked out that cancerous cells fall into five differentt patterns, as they change from normal cells to tumorous cells. As a result, he determined they could be scored on a scale of 1 to 5.
The cells that score a 1 or 2 are considered to be low-grade tumor cells. These tend to look similar to normal cells.
Cells closest to 5 are considered high-grade. In comparison to the lower grade cells, they have mutated so much that they no longer look like normal cells.
How is the Gleason score worked out?
The Gleason score is determined by the results of the biopsy.
During a biopsy, the doctor takes tissue samples from different areas of the prostate. Several samples are taken, as cancer is not always present in all parts of the prostate.
After examining the samples under a microscope, the doctor finds the two areas that have the most cancer cells. The Gleason score is assigned to each of these areas, separately. Each is given a score of between 1 and 5. These are then added together to give a combined score, often referred to as the Gleason sum.
In most cases, the Gleason score is based on the two areas described above that make up most of the cancerous tissue.
However, there are some exceptions to the way scores are worked out.
When a biopsy sample has either a lot of high-grade cancer cells or shows three different types of grades, the Gleason score is modified to reflect how aggressive the cancer is deemed to be.
What do the results mean?
When a doctor tells a person what their Gleason score is, it will be between 2 and 10. Although it is not always the case, the higher the score, the more aggressive the cancer tends to be. Typically, lower scores indicate less aggressive cancers.
In most cases, scores range between 6 and 10. Biopsy samples that score 1 or 2 are not used very often because they are not usually the predominant areas of cancer.
A Gleason score of 6 is usually the lowest score possible. Prostate cancer with a score of 6 is described as well-differentiated or low-grade. This means the cancer is more likely to grow and spread slowly.
Scores between 8 and 10 are referred to as poorly differentiated or high-grade. In these cases, the cancer is likely to spread and grow quickly. Scores of 9 and 10 are twice as likely to grow and spread quickly as a score of 8.
In the case of a score of 7, the results could be one of two ways:
- 3 + 4 = 7
- 4 + 3 = 7
This distinction indicates how aggressive the tumor is. Scores of 3 + 4 typically have a good outlook. A score of 4 + 3 is more likely to grow and spread compared to the 3 + 4 score, but it is less likely to grow and spread than a score of 8.
In some cases, a person may receive multiple Gleason scores. This is because the grade may vary between samples within the same tumor or between two or more tumors. In these cases, the doctor is likely to use the highest score as the guide for treatment.
Other ways to measure prostate cancer
The Gleason scale is very important for doctors when they decide the best treatment options. However, there are some additional factors and groupings to assist them.
Some additional considerations include:
There are other factors which help determine the treatment plan for prostate cancer, including blood PSA levels and biopsy results.
- results of a rectal exam
- the blood PSA level of the individual
- the results of imaging tests
- the number of biopsy samples that contain cancer
- whether the cancer has spread beyond the prostate
- how much of each tissue sample is made up of cancer
- whether cancer is found on both sides of the prostate
More recently, researchers have determined additional groupings, called grade groups. These grade groups help address some of the problems with the Gleason system.
Currently, the lowest Gleason score that is given is a 6. In theory, however, the Gleason grades range from 2 to 10.
The lowest reported score of a 6 leads some people to think their cancer is in the middle of the grade scale. As a result, they are more likely to worry and to want treatment right away.
As described above, the Gleason scores are most often divided into only three groups: 6, 7, and 8-10.
These groupings are not entirely accurate since the Gleason score of 7 is made up of two grades, 3+4 and 4+3. Within this group, a 4+3 is a worse outlook than a 3+4.
Similarly, Gleason scores of 9 or 10 have a worse outlook than a Gleason score of 8, despite being in the same group.
The newer groupings are more understandable for the individual being treated and more accurate in terms of outlook and treatment.
The following is a breakdown of the new groups. A score of 1 is considered best and a score of 5 is considered worst.
- grade group 1 = Gleason 6 (or less)
- 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
How does a Gleason score affect treatment?
The Gleason score and similar groupings help a doctor give an outlook and treatment plan to an individual. This information and other factors are then used together to guide the treatment decisions.
For lower Gleason scores, treatment is likely to consist of:
- active surveillance, where someone’s age and overall health help determine when their cancer is treated
- radical prostatectomy surgery to remove the prostate
- radiation therapy
For higher Gleason scores and more advanced stages of cancer, treatment may consist of a combination of the following:
More advanced cancers may be treated with surgery, radiation therapy, or chemotherapy.
- radical prostatectomy
- brachytherapy only
- external beam radiation only
- brachytherapy and external beam radiation
- involvement in a clinical trial of newer treatments
- active surveillance
- hormone therapy
- surgery to treat symptoms of the cancer
Brachytherapy is a form of radiation therapy, where radiation is administered to the prostate by placing small radioactive seeds directly into the prostate. It is also referred to as internal radiation therapy.
External beam radiation involves the use of a machine that focuses beams of radiation onto the prostate from outside of the body.
People with prostate cancer will be able to discuss their treatment options with their doctor to decide the best ones for them.
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This is a real scenario and shows the complexity of managing certain situations about the prostate. Part of the problem is the common misconceptions about the prostate and prostate cancer. As well all the things you read in the paper or hear on TV about new studies showing that the PSA is unreliable and is used too often by Urologists and in turn resulting in too many men being biopsied and then subsequently being treated…and subsequently as a result negatively affecting their lives with incontinence and impotence.
So imagine you are in the exam room with your doctor in the above situation and your urologist is walking you through the fine line of doing just the right amount of tests or procedures to determine if you have prostate cancer. The bottom line is that if you have cancer and this is found out a year after your office visit…you’d be quite disappointed and probably mad…probable the word “lawyer” may come to mind.
As Bart Simpson said when asked his thoughts on “why does increasing military might and expenditures on weaponry actually act a deterrent to war?”
Bart had wrongly been put in a genius class because the test scores of a brilliant student had been attributed to him. He said, “Well.. I guess you’re damned if you do and damned if you don’t!”
So…in the conundrum I’ve described in the title of this post…the issues-
- The two negative biopsies performed five years ago were negative however that was five years ago and things change. Just because a patient says, “But I have had a biopsy before and it was okay. Isn’t that enough?” Well a lot can happen or change in five years. Yes you didn’t have it then but that was then and this is now.
- There is the issue of prostate cancer being in unusual places in the prostate that is not a easily sampled on a biopsy. If you look at a picture of a prostate the part that is examined by the urologist on a rectal exam is the posterior lobe of the prostate. This does not examine the inner or anterior aspect of the prostate. The exam is a good exam and necessary but does not evaluate the “entire gland.”
- Now you throw in the drug Proscar or generic name Finasteride. Five years ago the biopsies were negative and the PSA then was 15. Now the PSA is 13. The patient concludes that- I have had two negative biopsies and now my PSA is less than five years ago. Well Proscar lowers the PSA by about 50%. So off the Proscar this patient’s PSA could well be 20.
- The patient stops going to the Urologist because his family doctor is doing the PSA now and it is less than five years ago but the family doctor and the patient are looking at a PSA that hasn’t changed appreciably and “stay the course.”
- The PSA being the same or lower is not better. The Proscar is “masking” the true value.
- So the feeling is that all is well with this patient. Well to the urologist who sees this patient…he is concerned. He also has to explain the above and put out there that some other sort of evaluation must be done to be sure the Proscar isn’t deceiving everyone.
- If the patient for whatever reason goes back to the urologist, the urologist will note the scenario above and recommend doing something to update the situation and hopefully show that there is indeed no prostate cancer. Again sitting on this situation and the patient is found to have an aggressive form of prostate cancer because it has been allowed to smolder undetected because of the masking effect of the Proscar…well that is a problem for all. I would think the urologist would found potentially at fault.
- Again remember in the back drop…all the misconceptions that prostate cancer is the slow growing type and that people don’t die of it. And of course the old standby by the male not wanting a rectal exam or another biopsy, “I don’t have any symptoms.”
- The channel that the male voids through is well away from the posterior aspect of the prostate and so for there to urinary symptoms the cancer would have to be extensive to cause voiding symptoms. In other words when found it is too late.
How about this added to the above scenario? The patient has seen the urologist and has had the two negative biopsies and his PSA is stable on the Proscar (which actually is worrisome..it should be half). The family doctor gets the PSA, and it is unchanged. The family doctor says to the patient, “I’ll leave your prostate exam to your urologist.” The patient however has not seen his urologist for five years. Uh oh! Do you see the perfect storm brewing…yes quite the opportunity for the late diagnosis of prostate cancer due to numerous factors and misconceptions on several layers. Of note in the above situation…the urologist is out of the loop. The patient has stopped going to him and being “checked up” by the family guy.
This is like in baseball the center fielder and the right fielder are both approaching a fly ball. The center fielder yells as they both close in on the ball, one in which it looks like both could catch but both struggling to get there. The center fielder says, “I got it.” The right fielder backs off, the center fielder realizes that he will not be able to get to the ball and then yells, “You take it.” The ball falls safely between the two fielders. Just as too many chefs spoil the soup so too it can be said of doctors “I got it, you take it” type arrangement in which things fall through the proverbial cracks of patient care.
So one day on the blood work of the family doctor the PSA does go up. “Hmmmm, your PSA is going up. Have you been seeing your urologist? You haven’t? Well it may time to go back to him and let him evaluate these numbers.” The doctor then remembers that the patient is on the Proscar. He becomes concerned.
The family doctor remembers the warnings that pop up on his medical record screen regarding patient’s taking Proscar: Proscar does not cause prostate cancer if prostate cancer is found in a patient taking Proscar it is further along and more aggressive, i.e. the “masking effect” in lowering the PSA delays the diagnosis.
The patient is now back with his urologist after five years and the options are discussed.
- Of course now a rectal exam is done after five years of not checking it.
- You could do another biopsy
- You could do a prostate MRI
- You could do various PSAs that predict the chances of a positive biopsy
If another biopsy is done it may be negative but it may not. And this is not a situation the patient, the family doctor or the urologist wants to be in.
Summary-Negative biopsies, being on Proscar, reluctant male patients not wanting to be messed with, misconceptions about prostate cancer, misunderstandings of the family doctor thinking the urologist is more involved in the care of a patient than the urologist actually is-all create a perfect storm of the late diagnosis of prostate cancer.
As my mother would say, “A word to the wise is sufficient”
The apple ain’t got nothing on the tomato!
Article Reviewed: Lycopene Inhibits Disease Progression in Patients With Benign Prostate Hyperplasia. Schwarz S, Obermuller-Jevic UC, et al: J Nutr; 2008; 138 (January): 49-53.