Originally published 2/4/2016
When we posted the blog below, the new ISUP grading system was not yet widely used, but it is now standard to report biopsy results as a Grade Group (GG) score. As explained below, using the traditional Gleason score (sum of 2 numbers, both Gleason 3+4 = 7 and Gleason 4+3 = 7 were labeled intermediate risk. The new GG system differentiates the risk level:
| Traditional Gleason score | GG score) | Risk level |
| 3+4 = 7 | Grade group 2 | Favorable intermediate risk |
| 4+3 = 7 | Grade group 3 | Unfavorable intermediate risk |
Using the new system, Active Surveillance (AS) is typically recommended only for patients in GG 1 (Gleason 3+3 = 6) whereas patients with GG 2 are recommended for active treatment (though some experts believe that with today’s improved diagnostics, some GG 2 patients may go on AS if monitored diligently).[i] Thus, carefully qualified GG 2 patients may consider focal therapy. However, since GG 3 patients have unfavorable risk PCa due to the higher proportion of Gleason pattern 4 disease, they are never candidates for AS. A 2024 review of published literature examined data on the safety and effectiveness of focal therapy for GG 3 patients with low volume, localized PCa as a way to control the cancer while avoiding the side effect risks of radical treatment. They concluded that, for carefully qualified patients, focal treatment may be “… a good option for patients with localized low volume GG 3 prostate cancer without compromising cancer survival and preserving quality of life.”[ii] Our expert team at the Sperling Prostate Center can provide in-depth, precision diagnostics to determine if a patient with low volume GG 3 PCa is a candidate for focal therapy.
The strategy of using active surveillance (AS) is increasingly recommended to low-risk prostate cancer (PCa) patients as a way to avoid or delay overtreatment. This is a new way of thinking; before the New Millennium, PCa was assumed to be multi-focal and most men with more than 10 years of life expectancy were hurried into surgery or radiation. Today’s terminology includes words that might have been meaningless a decade ago, e.g. indolent cancer, very low risk disease, and focal disease are all consistent with the growing movement toward AS.
The American Urological Association states:
A program of active surveillance has two goals: (1) to provide definitive treatment for men with localized cancers that are likely to progress and (2) to reduce the risk of treatment-related complications for men with cancers that are not likely to progress.[iii]
The AUA guidelines for PCa treatment suggest that AS is a good management strategy for patients with lower risk patients (low PSA, Gleason score and tumor stage). However, many patients with Gleason 3 + 4 or 4 + 3, considered to be intermediate risk, are choosing to go on AS. One study found that almost 9% of them start on AS despite questions about the safety and wisdom of this choice.[iv] According to the article, “the majority of AS protocols worldwide exclude men with GS4 cancers [Gleason score with at least one pattern 4] unless their life expectancy is limited.”
At the Sperling Prostate Center, we respect the right of each patient to make his own treatment decision. We also recognize that international guidelines strongly favor AS for low-risk patients, so for those with intermediate-risk PCa who are leaning toward AS we highly recommend having a baseline 3T multiparametric MRI (mpMRI) with results interpreted by an expert radiologist such as we do, and subsequently being monitored by more frequent (every 6-9 months) 3T mpMRI scans.
We have an even better solution for intermediate-risk patients who are considering AS and also have one or two tumors: focal therapy. The Sperling Prostate Center offers the three most advanced technologies:
- Focal laser ablation (FLA) is a minimally invasive outpatient procedure that safely and accurately destroys PCa with minimal to no risk of side effects. Insertion of a laser fiber is guided to the tumor core by real-time MRI; special thermometry tracks temperature changes to assure that the tumor is completely destroyed, along with a safety margin of surrounding tissue.
- Transurethral Ultrasound Ablation of the Prostate (TULSA-PRO) is an “inside out” delivery of sonic energy via the urethra. Mapping and destroying the tumor are guided by real-time MRI. It is noninvasive and uses no incisions or radiation.
- MRI-Guided Focused Ultrasound (Exablate) is a noninvasive targeted treatment that applies MRI-guided sonic energy from outside the body while the patient lies on the MRI table. All three precise treatment approaches spare healthy tissue, thus preserving both continence (100%) and potency (approaching 100%) for our patients.
Why is focal therapy a preferred solution for qualified patients? Knowing that it is the natural history of Gleason 4 PCa to progress, focal treatment is an attractive alternative to Active Surveillance because it offers the potential of permanent cancer control. In addition, thanks to continual monitoring as occurs with AS and all other PCa treatments, any new cancer activity is detected very early when all future treatment options are still possible. If you or a loved one has been diagnosed with PCa that includes Gleason pattern 4, call our Center for a free consultation to find out how we can help.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] i Pekala KR, Bergengren O, Eastham JA, Carlsson SV. Active surveillance should be considered for select men with Grade Group 2 prostate cancer. BMC Urol. 2023 Sep 30;23(1):152.
[ii] Pressler L, Pressler M. Focal Therapy in Grade Group 3 Prostate Cancer. Curr Urol Rep. 2024 Jul 2.
[iii] https://www.auanet.org/education/guidelines/prostate-cancer.cfm
[iv] Sathianathen NJ, Murphy D, van den Bergh R, Lawrentchuk N. Gleason pattern 4, Active Surveillance No More. BJU international. 2015 Sep 21 [Epub ahead of print]
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
