Gleason score 6 adenocarcinoma: should it be labeled as cancer?

Overtreatment of low-grade prostate cancer (Gleason score 6) is a recognized problem today, with systematic prostate gland sampling triggered by prostate-specific antigen (PSA) measurements. The extent to which overtreatment is caused by fear of death resulting from cancer, fear of litigation from undertreatment, and misaligned incentives that reimburse more for treating rather than monitoring when appropriate is not known. Nevertheless, fear of death resulting from cancer likely plays some role, and removing the label “cancer” could reduce unnecessary treatment of low-grade disease. On the other hand, undertreatment of prostate cancer and a missed opportunity for cure in those who could benefit is a real risk of relabeling a cancer as noncancer. We have decided on an alternative modification of the Gleason scoring system and herein present the arguments for and against removing the label of cancer from Gleason 6 tumors. We believe that our alternative approach may help: one, ensure that patients receive the proper counseling/treatment; two, reduce the risk of overtreatment and its associated harms; and three, improve shared decision making.