What is the management approach for a patient with a Gleason score of 6 (Gleason grading system)?

From the Guidelines

Active surveillance is the recommended management approach for patients with Gleason score 6 prostate cancer, as it allows for the avoidance of treatment-related side effects while maintaining the option for intervention if the cancer progresses. This approach is supported by the most recent and highest quality study, which found that active surveillance is a safe and effective management strategy for patients with low-risk prostate cancer 1. The study, published in 2022, found that active surveillance was associated with a low risk of prostate cancer-specific mortality and a high quality of life, making it an attractive option for patients with Gleason score 6 cancer.

Key Components of Active Surveillance

• Regular PSA blood tests every 3-6 months
• Digital rectal examinations annually
• Repeat prostate biopsies every 1-3 years to monitor for disease progression
• Patient counseling and education on the risks and benefits of active surveillance

Benefits of Active Surveillance

• Avoidance of treatment-related side effects, such as urinary incontinence and erectile dysfunction
• Maintenance of quality of life and normal activities
• Avoidance of unnecessary treatment of small indolent cancers
• Decreased initial costs

Patient Selection for Active Surveillance

• Patients with low-risk prostate cancer, including those with Gleason score 6
• Patients with a life expectancy of 10-15 years or more
• Patients who are willing and able to undergo regular monitoring and follow-up
• Patients who prefer to avoid treatment-related side effects and maintain their quality of life

Monitoring and Follow-up

• Regular PSA blood tests and digital rectal examinations
• Repeat prostate biopsies every 1-3 years
• Patient counseling and education on the risks and benefits of active surveillance
• Trigger points for intervention, such as an increase in PSA level or Gleason score, should be discussed with the patient and monitored closely 1.

From the Research

Gleason Score 6 Management

• The management of Gleason score 6 prostate cancer is a complex issue, with various treatment options available, including watchful waiting, active surveillance, and brachytherapy 2.
• A study published in 2007 found that 34% of patients with low-risk prostate cancer were upgraded to high-grade disease, and that prostate-specific antigen (PSA) level and pathologist expertise were predictive of upgrading 2.
• Another study published in 2021 found that higher pretreatment PSA was independently associated with increased risks of Gleason score upgrading and adverse pathologic features at prostatectomy, and that flexible modeling of the relationship between PSA and each outcome did not support dichotomization at a threshold of 10 ng/ml 3.
• The use of PSA, Gleason score, and digital rectal examination in staging patients with newly diagnosed prostate cancer has been studied, and it has been found that patients with a PSA greater than 25 ng/mL, a Gleason score greater than 6, and a positive DRE should undergo further staging studies 4.
• The concept of Gleason score 6 as a "benign variant" has been discussed, with some arguing that it represents a low malignant subgroup that may not require aggressive treatment 5.
• A recent study published in 2025 found that the percentage of pattern 4 was not statistically correlated with upgrading or downgrading on confirmatory biopsy in patients with Grade Group 2 prostate cancer, and that patients with GG2 PCa should not be excluded from active surveillance solely because of grade 4 > 10% when other parameters are otherwise favorable 6.

Treatment Options

• Watchful waiting, active surveillance, and brachytherapy are treatment options for patients with Gleason score 6 prostate cancer 2.
• Active surveillance is a viable option for patients with low-risk prostate cancer, but it requires careful monitoring and regular follow-up 3.
• The decision to pursue treatment should be based on individual patient characteristics, including PSA level, Gleason score, and digital rectal examination results 4.

Risk Stratification

• Risk stratification is critical in determining the best course of treatment for patients with Gleason score 6 prostate cancer 2.
• PSA level, Gleason score, and digital rectal examination results are important factors in risk stratification 4.
• The use of nomograms and other predictive tools can help physicians identify patients who are at high risk of upgrading or adverse pathologic features 2, 3.