Additional Director, Urology, Fortis Hospital, Shalimar Bagh, New Delhi
Part 4 of 8 in Prostate Cancer: Diagnosis and Latest Treatment Guidelines
Gleason Score and Risk Stratification in Prostate Cancer
May 5, 2024
Once prostate cancer is confirmed, it is graded and staged to decide on the right treatment intent and intensity.
Gleason score and the four stages
The Gleason score, from biopsy, ranges from 5 to 10; a score above 7 indicates a more aggressive cancer. There are four clinical stages: stage one is non-palpable, detected only incidentally (via PSA or during unrelated prostate surgery); stage two is palpable but confined to the prostate; stages three and four extend beyond the prostate into surrounding structures.
Risk stratification
The European Association of Urology risk-stratifies patients into low, intermediate and high risk using three parameters together: PSA level, Gleason score, and the clinical (digital rectal exam) stage. Low-risk disease has a PSA under 10, a Gleason score under 7, and disease confined to the prostate on examination; risk rises as any of these three parameters worsens.
This article is based on a Jivo Masterclass session conducted by Dr. Anurag Puri, Additional Director, Urology, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Anurag Puri taught doctors across Africa on May 5, 2024.
FROM THE LIVE Q&A
Moderator
Is there a specific disease stage for which robotic treatment is used?
Dr. Anurag Puri
Robotic radical prostatectomy is used for low-risk and intermediate-risk disease, and can be used for high-risk disease too, provided the lymph nodes are not involved, in which case it is combined with an extended lymph node dissection. If the lymph nodes are already positive, radical surgery is not performed.
Frequently Asked Questions
Should a PSA test be sent for all patients with BPH?▼
It is not mandatory as routine screening, but a baseline PSA is checked before starting an anti-androgen such as dutasteride, which is commonly prescribed for BPH.
What is the benefit of alfuzosin in the symptomatic management of BPH, and is there a newer drug?▼
Alfuzosin is a commonly used drug that relieves the urinary symptoms of BPH. Silodosin is a newer, more potent alternative. Alfuzosin is generally preferred in younger, sexually active men, while silodosin is preferred in older patients because of its sexual side-effect profile.
Is there really no treatment available for prostate cancer above the age of 80?▼
That is not the case. Between the ages of 80 and 90, up to 80% of men are found to harbour some focus of prostate cancer, but most die of other causes rather than the cancer itself. Because it is often a low-risk, indolent disease in this age group, treatment is sometimes deliberately avoided if the patient is asymptomatic.
Does declining male sexual performance with age relate to atherosclerotic changes in penile vessels? Is there a better urological explanation?▼
Yes - this is generally due to atherosclerosis: as blood vessels narrow with age, blood supply to the penis decreases, and this reduced blood flow is the main driver of declining sexual performance.
What are the principles of prostate cancer management, the survival rates by stage, and can advanced disease be managed locally?▼
Management is decided by the disease's staging and parameters: PSA level, Gleason score, and clinical stage on digital rectal examination. Survival rates vary sharply by stage - low-risk, early disease has close to a 100% cure rate, and even metastatic (stage four) patients now have meaningfully better life expectancy with appropriate treatment than with many other stage-four cancers.
What is the Gleason score?▼
A histopathological grading from biopsy, ranging from 5 to 10; a score above 7 indicates more aggressive cancer.
How is prostate cancer risk-stratified?▼
Using three parameters together: PSA level, Gleason score, and clinical stage on digital rectal examination, to classify disease as low, intermediate or high risk.
In This Series: Prostate Cancer: Diagnosis and Latest Treatment Guidelines
- 1.Prostate Cancer
- 2.Prostate Cancer Risk Factors and How It Presents
- 3.Diagnosing Prostate Cancer: PSA, Biopsy and Staging
- 4.Gleason Score and Risk Stratification in Prostate Cancer
- 5.Prostate Cancer Treatment: From Active Surveillance to Robotic Surgery
- 6.Advanced and Hormone-Resistant Prostate Cancer Management
- 7.Managing BPH: Medications and When Size Doesn't Matter
- 8.When to Refer a Prostate Cancer Patient for Treatment Abroad