What is the best management approach for a patient with low-grade prostate cancer, Gleason score GG1, and involvement of the Left Medial Lobe, Left Lateral Apex, and Left Medial Apex, as shown on a Transrectal Ultrasound (TRUS) biopsy?

Management of Gleason Grade Group 1 (GG1) Prostate Cancer

Active surveillance is the preferred management strategy for your patient with Gleason Grade Group 1 (GG1) prostate cancer involving the left medial lobe, left lateral apex, and left medial apex. 1

Risk Stratification

Your patient falls into the low-risk category based on:

• Gleason score ≤6 (GG1) 1
• Assuming PSA <10 ng/mL and clinical stage T1-T2a (typical for TRUS biopsy-detected disease) 1

The NCCN Guidelines explicitly state that for low-risk prostate cancer with life expectancy ≥10 years, active surveillance is the recommended initial approach. 1

Why Active Surveillance is Preferred

Active surveillance avoids overtreatment of indolent disease while maintaining the option for curative intervention if progression occurs. 1, 2

Key supporting evidence:

• Cancer-specific mortality with active surveillance is only 3% at 10-15 years for low-risk disease 3
• GG1 disease lacks common genetic aberrancies of aggressive cancer and has minimal metastatic potential 3
• Approximately 30% of patients initially classified as low-risk will be upgraded on subsequent biopsies, representing either sampling error or true progression—this is why surveillance is "active" rather than passive 3, 4

Active Surveillance Protocol

Implement the following standardized monitoring schedule:

Serial PSA Testing

• Measure PSA every 3-6 months 3
• Rising PSA velocity may indicate progression requiring intervention 1

Digital Rectal Examination

• Perform DRE every 6-12 months 3
• Any change in DRE findings (new nodules, induration, asymmetry) warrants immediate repeat biopsy 5

Repeat Prostate Biopsy

• First repeat biopsy within 12-18 months of diagnosis 3, 4
• Subsequent biopsies annually or as clinically indicated 1
• Obtain minimum 10-12 cores from peripheral and transition zones 6
• 81% of upgrades occur by the second repeat biopsy, suggesting early upgrades represent initial sampling error 4

Consider MRI-Targeted Biopsy

• Multiparametric MRI can identify high-value targets missed on systematic TRUS biopsy 1
• MRI-targeted biopsy is increasingly used to supplement systematic biopsy during surveillance 1
• Negative MRI is a favorable prognostic finding, with only 9% of such patients reclassified to higher-risk disease 1

Triggers for Definitive Treatment

Switch from active surveillance to radical treatment (surgery or radiation) if any of the following occur:

• Grade reclassification to Gleason ≥7 (GG2 or higher) on repeat biopsy 1, 2, 3
• Increase in tumor volume (>50% core involvement or >3 cores positive) 1
• PSA doubling time <3 years 3
• Clinical stage progression detected by DRE 1
• Patient preference for definitive treatment due to anxiety 3

Treatment Options if Progression Occurs

If surveillance biopsies reveal progression to intermediate-risk disease (Gleason 3+4=7), treatment options include:

• Radical prostatectomy with pelvic lymph node dissection if predicted nodal involvement ≥2% 1
• External beam radiation therapy ± 4-6 months androgen deprivation therapy 1
• Brachytherapy for favorable intermediate-risk features 1

For select patients with low-volume Gleason 3+4=7, continued active surveillance may be considered, though this is controversial 2

Critical Pitfalls to Avoid

Do not offer primary androgen deprivation therapy alone—it does not improve survival in localized disease and is explicitly not recommended. 1

Do not use cryotherapy or other ablative therapies as routine primary treatment—lack of long-term comparative data with surgery or radiation. 1

Do not skip repeat biopsies—approximately 30% of patients harbor higher-grade cancer unrepresented on initial biopsy, and systematic rebiopsy is essential for detecting progression. 3, 7

Do not order bone scan or CT staging for low-risk disease—imaging is not indicated unless intermediate or high-risk features are present. 1

Patient Counseling Points

• GG1 is morphologically and molecularly cancer, but has extremely low metastatic potential when properly selected for surveillance 8
• Active surveillance is not "doing nothing"—it requires disciplined adherence to monitoring protocol 3
• Treatment can be curative if initiated when progression is detected, provided the patient remains a surgical/radiation candidate 1, 7
• Quality of life is preserved by avoiding immediate treatment-related complications (erectile dysfunction, urinary incontinence, bowel toxicity) 2, 3