Treatment Options for Prostate Cancer with Gleason Score 6
Active surveillance is the recommended first-line approach for patients with Gleason score 6 prostate cancer, particularly for those meeting very low-risk or low-risk criteria, as it provides excellent disease-specific survival while avoiding unnecessary treatment-related side effects.
Risk Stratification for Gleason 6 Prostate Cancer
Gleason 6 prostate cancer typically falls into two risk categories:
Very Low Risk
- T1c clinical stage
- PSA <10 ng/mL
- <3 positive biopsy cores with ≤50% cancer in any core
- PSA density <0.15 ng/mL/g 1
Low Risk
- T1-T2a clinical stage
- Gleason score 6
- PSA <10 ng/mL 1
Active Surveillance Protocol
Active surveillance involves structured monitoring with the intent to intervene if the cancer shows signs of progression. The recommended protocol includes:
- PSA testing every 3-6 months
- Digital rectal examination (DRE) every 12 months
- Repeat prostate biopsy at 1 year after diagnosis and then every 3-5 years 1
The Canadian protocol for active surveillance has demonstrated excellent outcomes with:
- 99.2% patient survival at 8 years
- Only about 25% of patients requiring intervention during follow-up 1
Criteria for Intervention During Active Surveillance
Intervention should be considered if:
- PSA doubling time is less than 3 years
- Progression to Gleason score 7 or higher on repeat biopsy
- Increase in tumor volume on biopsy 1
Alternative Treatment Options
For patients who are not candidates for or decline active surveillance, the following options may be considered:
Radical Prostatectomy
- Provides definitive treatment but associated with significant side effects
- Erectile dysfunction occurs in approximately 80% of patients
- Urinary leakage affects about 49% of patients 1
Radiation Therapy
- External beam radiotherapy using conformal techniques (minimum 70 Gy)
- Brachytherapy (permanent seed implants)
- Associated with less urinary morbidity and erectile dysfunction than surgery 1
Outcomes and Quality of Life Considerations
Despite treatment-related adverse effects:
- Less than 5% of patients report dissatisfaction with treatment
- More than 90% of patients say they would make the same decision again 1
For active surveillance:
- Disease-specific survival rate of 99% at 8-10 years 2
- Avoids treatment-related side effects
- Patients show favorable levels of anxiety and distress 1
Important Considerations and Pitfalls
Undersampling Risk: Approximately 30% of men diagnosed with low-risk disease may harbor higher-grade cancer that was missed on initial biopsy 3, 4. This underscores the importance of the confirmatory biopsy at 1 year.
Patient Selection: Age and comorbidities should factor into decision-making. Active surveillance is particularly appropriate for men with limited life expectancy (<10 years) 1.
Molecular Progression: A small percentage of Gleason 6 cancers may have molecular alterations that can lead to progression to more aggressive disease 2, 4. Regular monitoring is essential to identify these cases early.
Patient Anxiety: Contrary to concerns, studies show that men on active surveillance do not experience higher rates of anxiety or depression compared to those undergoing immediate treatment 1.
Active surveillance represents the optimal balance between overtreatment (radical therapy for all) and undertreatment (watchful waiting with palliative therapy only) for patients with Gleason 6 prostate cancer 5.