Should we really consider Gleason 6 prostate cancer?

Taunton, UK There is no doubt that prostate cancer kills, but only a minority of men who are given this diagnosis, die from prostate cancer. In the developed world we are now overdiagnosing and, more importantly, overtreating prostate cancer, a fact for which we will be criticized in generations to come. As well-intentioned urologists, we should have no trouble in justifying our radical therapy for pathologically moderate to high grade, Gleason 7 – 10 cancers. Despite the opinions of some urological luddites, careful active surveillance is slowly becoming the standard for Gleason 6, particularly for those with low volume disease associated with low serum PSA values, however, many patients with Gleason 6 still receive radical treatment. We (and others) would like to hypothesize, at least for the sake of discussion, that Gleason 6 pattern prostate pathology is not in itself a lethal prostate cancer, but rather can be associated with a higher risk of potentially lethal prostate cancer (e.g. Gleason 7 or higher) or, alternatively, is a precursor to such prostate cancer. This change in thinking would mean that patients with Gleason 6 scores would not be labelled with a ‘ lethal ’ cancer diagnosis and would be less anxious about the appropriate treatment plan of active surveillance. Many patients drop out of active surveillance and pursue radical treatment, not because of rising PSA levels, biopsy results or other forms of disease progression, but because of anxiety. There may be less morbidity (and cost) if patients were not given the ‘ cancer-label ’ until they had Gleason 7 disease. Certainly high volume Gleason 6 disease warrants concern, closer follow-up or perhaps pre-emptive therapy.