Gleason 3+4 Prostate Cancer? Think Twice Before Active Surveillance

There’s a lot of enthusiasm about Active Surveillance (AS) for prostate cancer (PCa) patients with low or very low risk disease. In fact, many doctors are even discussion AS with their patients who have a Gleason 3+4 tumor; however, much controversy exists over the question of whether AS is a safe option for these patients. A new Johns Hopkins paper, based on a study of 6700+ men from 2005-2016 who chose immediate prostatectomy after biopsy, suggests men with Gleason 3+4 PCa should think twice.[i]

Key definitions

The respected urology and pathology departments at Johns Hopkins have established many of today’s diagnostic and treatment criteria for PCa. Here are the definitions they used for this report:

  • Very low-risk (VLR) PCa – Stage T1c, PSA (PSAD) density <0.15, <50% cancer in any biopsy core
  • Low-risk (LR) PCa – Stage <T2a, PSA level <10.
  • Low-volume intermediate-risk (LVIR) PCa – 1-2 biopsy cores with Gleason 3+4 disease, PSA level <20
  • Adverse pathologic features – Examination of the post-surgery prostate specimen finds previously undetected Gleason 4+3 disease and/or other adverse features. This means the PCa is now “upgraded” to a more aggressive cancer.
  • Objective of the study – To determine if there is a subgroup of LVIR cases who are appropriate for AS, and if so, which clinical factors indicate they have favorable, minimal risk Gleason 3+4

Study findings

The team’s analysis revealed the following rates of adverse pathology for each risk level:

Risk Level Adverse pathology rate
VLR PCa (1264 patients) 4.7% (60 patients)
LR PCa (4849 patients) 5.8% (280 patients)
LVIR PCa (608 patients) 24.7% (105 patients)

They found no clear way to identify the Gleason 3+4 patients for whom AS is a safe bet. The team notes that this has important implications for LVIR patients considering AS.

Important takeaway message about AS

From our viewpoint at the Sperling Prostate Center, AS is a good thing for the right patient. This Johns Hopkins study shows the diagnostic inadequacy of the TRUS biopsy to determine who those men are.

Who wants to wake up from radical prostatectomy only to learn that the cancer was worse than originally thought? The fact is, at the time of surgery, nearly 25% of study patients with Gleason 3+4 cancer were harboring more dangerous disease than their doctors found using TRUS biopsy.

We have to ask, what if these men had undergone a 3T multiparametric MRI scan before they had a biopsy? And, if the 3T mpMRI had picked up significant lesions, what would an in-bore MRI-guided targeted biopsy have found? Many published studies have shown that real-time MRI-guided biopsies are superior over TRUS biopsies at detecting significant cancer (Gleason 3+4 or 4+3) using fewer needles.

At our Center, we support AS patients by offering

  • The most accurate imaging to detect significant disease
  • The most precise biopsy method, superior to fusion-guided biopsy, for accurate diagnosis
  • A monitoring protocol using PSA (and its variants) plus periodic 3T mpMRI scans to pick up any cancer changes as early as possible, to facilitate decision-making at each step along the way.

If you have a suspiciously high or rising PSA, we highly recommend having a 3T mpMRI prostate scan as soon as possible. It’s the first and most important step toward the most trustworthy diagnosis to help you make the best treatment or AS decision. Contact the Sperling Prostate Center for more information.


[i] Patel HD, Tosoian JJ, Carter HB, Epstein JI. Adverse Pathologic Findings for Men Electing Immediate Radical Prostatectomy: Defining a Favorable Intermediate-Risk Group. JAMA Oncol. 2017 Jul 13. doi: 10.1001/jamaoncol.2017.1879. [Epub ahead of print]