Dr D’Amico on the Nuances of a Low Gleason Score in Localized Prostate Cancer

Anthony V. D'Amico, MD, PhD, professor of radiation oncology, Harvard Medical School, chief, Genitourinary Radiation Oncology, Dana-Farber Cancer Institute, discusses Gleason score interpretation in the management of localized prostate cancer.

D’Amico highlights an ongoing debate in the field regarding whether a Gleason score of 6 should be labeled as "benign" when reported by pathologists. Although some clinicians propose not disclosing Gleason 6 to patients, viewing it as a non-aggressive form unlikely to impact patient outcomes, D’Amico expresses significant concern about this approach, noting that a Gleason score of 6 is not homogeneous.

Although clinical guidelines suggest that a Gleason score of 6 identified incidentally at autopsy usually reflects a small, clinically insignificant tumor with limited impact on patient outcomes, D'Amico suggests that in clinical practice, the presentation of Gleason 6 is more variable.

He cautions that the observation of multiple positive biopsy cores, rising prostate-specific antigen (PSA) levels, or features like perineural invasion may indicate a more aggressive disease that is not fully captured by Gleason score alone.

D’Amico warns that labeling such cases of a Gleason score of 6 as "benign" may mislead clinicians and patients, potentially resulting in missed opportunities for timely intervention and, ultimately, curative treatment. He emphasizes the importance of assessing the full clinical context, including tumor volume, biopsy characteristics, PSA kinetics, and other histopathological findings, rather than relying solely on Gleason score.

Treatment considerations for patients with localized prostate cancer should be tailored to each individual, taking into account not only their Gleason score but also the broader clinical context, including tumor volume, PSA kinetics, imaging findings, and patient comorbidities, he says. This comprehensive approach ensures that management decisions are aligned with the specific characteristics of the disease and the patient’s overall health, optimizing the balance between treatment efficacy and quality of life, D’Amico explains.

D’Amico concludes that careful stratification of Gleason score 6 cases is essential to determine the most appropriate management strategy, ranging from active surveillance to definitive therapy, ensuring that patients receive an optimal balance of treatment intensity and preservation of quality of life.