Why Dr. Gleason’s 60-Year-Old Drawings Still Matter Today
When I meet with patients in my Fort Worth office to discuss a new prostate cancer diagnosis after a prostate biopsy, the first thing we discuss is the Gleason Score. Patients often ask about what where this name comes from, and why we still use it in the age of genetic testing.
The History of the Patterns
About 60 years ago, a pathologist named Dr. Donald Gleason was looking at prostate cancer cells under a microscope. He didn’t have the genetic sequencing tools we have today at Texas Health Harris Methodist, but he had a keen eye for patterns.
He noticed that prostate cells grow in specific structures called glands. He graded these patterns from 1 to 5 based on how organized they looked. In the mid-1960s, he sat down with statisticians to look at the data from his first 280 patients. The correlation was undeniable. He didn’t just see different-looking cells; he saw a direct link between those “pictures” and how long the patients lived!
Patients with highly organized glands (Patterns 1 and 2) almost never died from their prostate cancer, so he called those glands “normal”, and patterns 3, 4, and 5 as “cancer” with 3 being the lowest grade (slowest growing), and 5 being the highest grade (most aggressive).
How the Math Works (3+4 is not equal to 4+3)
Because cancer isn’t always uniform, Dr. Gleason would look for the two most common patterns in a sample.
- The Primary Pattern: What he saw the most of.
- The Secondary Pattern: The next most common.
If he saw a lot of 3 and a little bit of 4, the score would be 3+4=7.
If he saw mostly 4 and a little bit of 3, it would be 4+3=7. While they both add up to seven, as a surgeon, I view a 4+3 as a more aggressive disease that requires closer attention.
60 years later, Gleason grade grouping still remains the strongest independent predictor of whether a patient will eventually die of prostate cancer.
It’s Not Just the Grade – It’s the Patient
I tell my patients that the Gleason Score is a vital tool, but it isn’t the “end-all, be-all” for treatment. We have to look at the context of your life.
- The 87-year-old: lets say a patient is 87 years old, with heart disease, COPD, and diabetes, (a combination I call “one foot in the grave”) even a high-grade 5+4 cancer might not be his biggest threat. In this case, the risks of aggressive treatment often outweigh the benefits.
- The 55-year-old: If a relatively young patient has a “3+4” cancer, they have a long life expectancy ahead of them. That cancer has decades to grow and spread, so we are much more likely to recommend an aggressive approach, such as robotic-assisted surgery, to protect their future.
In urologic oncology, we don’t just treat the biopsy report; we treat the person. Whether we choose active surveillance or robotic surgery, the goal is to match the treatment to your specific life stage and health. You can explore more about these pathways on our prostate cancer patient education page.
Sohrab Arora, MD, MS, MCh
Urologic Oncology & Robotic Surgery
Texas Health Harris Methodist, Fort Worth