A recent study has revealed that men diagnosed with “Grade Group one” (GG1) prostate cancer might face higher risks than previously indicated by biopsy results. The research, led by Weill Cornell Medicine, University Hospitals Cleveland, and Case Western University, suggests that relying solely on biopsy grades can underestimate the disease’s severity, potentially misclassifying individuals who could benefit from more definitive treatments such as surgery or radiation.
The study, published on July 31 in JAMA Oncology, highlights that biopsies, which sample small areas of the prostate, may miss more advanced cancer cells, leading to an incomplete assessment. Researchers found that one in six men with GG1 cancer actually had intermediate- or high-risk cancer when other clinical factors were considered alongside biopsy results.
Reevaluating the “Low Risk” Label
Co-senior author Dr. Bashir Al Hussein, an assistant professor of urology and population health sciences at Weill Cornell Medicine, emphasized the importance of accurate risk assessment. “We don’t want to miss aggressive cancers that initially present as Grade Group One on biopsy,” he stated. “Such underestimation of risk could lead to undertreatment and poor outcomes.”
The study’s findings could influence ongoing discussions about whether to remove the cancer label from GG1 tumors. Dr. Jonathan Shoag, another co-senior author and associate professor of urology at Case Western Reserve University, warned against such changes. “There is a misunderstanding that ‘low grade’ and ‘low risk’ are the same. Here, we show clearly that they are not,” he explained. “Attempts to rename GG1 are misguided as many patients with GG1 cancers on biopsy have substantial risks of their cancers causing pain and suffering over their lifetime if untreated.”
Data-Driven Insights
The research team utilized data from the National Cancer Institute’s Surveillance, Epidemiology and End Results Program, covering 2010 to 2020. “This is real-world, contemporary data representing all men diagnosed with prostate cancer across the United States,” Al Hussein noted. The dataset included approximately 300,000 men with localized prostate cancer, of which about 117,000 were categorized as GG1 based on biopsy results.
Traditionally, GG1 is associated with a low risk of progression to metastasis and is often managed with active surveillance, including regular blood tests for prostate-specific antigen (PSA), additional biopsies, and MRI scans. However, increasing PSA levels can indicate cancer progression, prompting further investigation.
“Our data show that up to 30% of patients who were diagnosed with GG1 but were in the higher risk category underwent active surveillance, which means they were potentially undertreated,” Al Hussein said.
Implications for Clinical Practice
Understanding how cancer classification correlates with clinical outcomes is crucial, especially as some physicians advocate for removing the “cancer” label from GG1 prostate cancer to reduce anxiety and unnecessary treatment. They argue that most GG1 tumors grow slowly and rarely spread or cause harm. However, the study advises against a one-size-fits-all approach.
“There has been an unfortunate conflation of several different terms by some of my colleagues who are trying to rename GG1 cancer,” explained Shoag. “One is that biopsy GG1 and prostatectomy GG1 are similar, but they are not. As clinicians, we must make decisions based on each patient and his biopsy results in that context.”
Future Directions and Patient Counseling
Dr. Neal Arvind Patel, the study’s first author and an assistant professor of clinical urology, stressed the need for a deeper understanding of the biology of low-grade tumors. “A subset of men with low-grade tumors has adverse clinical features that are associated with worse cancer outcomes. We need to better understand this biology, which could help clinicians improve prognosis,” he said.
Al Hussein highlighted the importance of patient education. “We need to find a better way to inform patients about their prognosis when they have GG1 prostate cancer with adverse clinical features,” he said. “As physicians, the responsibility falls on us to educate patients and provide them with the information they need to understand their diagnosis and decide on the best approach for treatment, while continuing to advocate for active surveillance for those who are indeed low risk.”
This research received support from The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust. The findings underscore the complexity of prostate cancer diagnosis and the necessity for nuanced approaches to treatment and patient counseling.
