The Gleason score shows how abnormal prostate cancer cells look under a microscope and how quickly the cancer is likely to grow and spread [1]. A pathologist gives the two main cell patterns a grade from 3 to 5, and adding them, for example "3+4=7", gives the Gleason score, which ranges from 6 to 10 [1]. Today these scores are summarised in five "Grade Groups": Grade Group 1 (Gleason 6) is the lowest risk and often needs only regular monitoring, and Grade Group 5 (Gleason 9 and 10) is the highest risk and needs stronger treatment [2, 5].
Key points
- The Gleason score is the sum of two numbers and ranges from 6 to 10; the higher it is, the faster the cancer is likely to grow [1].
- Because 6 is the lowest score given today, "Gleason 6" means the lowest-risk prostate cancer, not a medium one; this is why the scores have been simplified into five "Grade Groups" [2].
- Gleason 7 comes in two kinds: 3+4 (Grade Group 2) and 4+3 (Grade Group 3). In 4+3 the higher-risk part is larger, and the chance of the disease coming back after surgery is about three times that of 3+4 [3].
- Most men with Gleason 6 do not need treatment straight away; regular monitoring with PSA tests, MRI and repeat biopsies is the standard choice [5].
- The Gleason score alone does not decide how the illness will go: PSA, the size and spread of the tumour, your age and your general health also matter when choosing treatment [1, 5]. Even in the highest-risk group, most men who receive standard treatment do not die of prostate cancer [12].
How is the Gleason score worked out?
After a prostate biopsy, a pathologist (a doctor who specialises in examining tissue) looks at the samples under a microscope and finds the two main patterns in which the cancer cells are arranged [1]. Each pattern is given a grade from 3 to 5: 3 looks most like healthy prostate tissue and 5 looks the most abnormal [1].
- Pattern 3: small but separate, well-formed glands; lower risk [2]
- Pattern 4: glands that are fused together, poorly formed or sieve-like (cribriform); higher risk [2]
- Pattern 5: cells that no longer form glands and grow as solid sheets or cords; the most aggressive [2]
The first number is the pattern that makes up most of the cancer, and the second number is the next most common pattern. Adding the two numbers gives the Gleason score. For example, if most of the cancer is pattern 3 and a smaller part is pattern 4, the score is written "3+4=7" [1]. The same score may also appear on the report as "Gleason 7/10" or "Gleason score 7" [1].
The Gleason score is a kind of cancer "grade"; grade is not the same as stage. Read more: What is cancer grade? Grade versus stage
Grade Groups 1 to 5: a simple Gleason score chart
In 2014, pathology experts from 19 countries agreed to summarise Gleason scores in five "Grade Groups". One reason was that hearing "Gleason 6 out of 10" frightened patients for no good reason, when 6 is in fact the lowest score given today [2]. On a pathology report you will usually see the Grade Group written as "Grade Group" or "ISUP" next to the Gleason score [2].
| Gleason score | Grade Group | What it means | What usually happens |
|---|---|---|---|
| 3+3=6 | Grade Group 1 | Lowest risk; the cells look most like healthy tissue [1, 2] | Regular monitoring instead of immediate treatment [5] |
| 3+4=7 | Grade Group 2 | Intermediate risk, towards the favourable side; most of the cancer is pattern 3 [1, 2] | Surgery or radiotherapy; in some men with a small amount of cancer, regular monitoring [5] |
| 4+3=7 | Grade Group 3 | Intermediate risk, towards the unfavourable side; most of the cancer is pattern 4 [2, 3] | Treatment; regular monitoring is not suitable [5] |
| 8 (4+4, 3+5 or 5+3) | Grade Group 4 | High risk [2] | Radiotherapy with long-term hormone therapy, or surgery in selected patients [5] |
| 9 or 10 (4+5, 5+4 or 5+5) | Grade Group 5 | Highest risk [2] | Combined, more intensive treatment [5, 9] |
The Grade Group is only one of the factors; your doctor considers it together with the PSA and the stage of the tumour.
These groups really do point to different futures. In a large study of more than 20,000 men who had surgery, five years after the operation the PSA stayed low in almost all men in Grade Group 1; this was the case for about 6 in 10 men in Grade Group 3 and about 1 in 4 men in Grade Group 5 [3]. This study measured the PSA rising again, not deaths from cancer [3]. In another study of more than 300,000 men in the United States, the risk of dying of prostate cancer roughly doubled with each higher Grade Group [4].
What does a Gleason score of 3+3=6 mean? Is Gleason 6 dangerous?
Gleason 6 (Grade Group 1) is the lowest-risk prostate cancer [1, 2]. In a review of more than 14,000 prostate operations at four large centres, when the samples were carefully re-examined, not a single true Gleason 6 cancer had reached the lymph nodes [8].
This is why the European guideline recommends "regular monitoring" (active surveillance) for men with low-risk cancer who are expected to live more than 10 more years [5]: a PSA test at least every 6 months, a prostate examination, and a repeat biopsy (with or without MRI) every 2 to 3 years [5]. If the cancer grows or the score goes up, treatment aimed at curing the cancer is offered [7].
In a large monitoring programme in the United States of about 1,300 men with low-risk cancer, almost nobody had died of prostate cancer after up to 15 years [7]. About half of these men were treated within the first 10 years; treatment was offered when a later biopsy showed a higher score or more cancer [7]. In a large study in the United Kingdom, where most men had low-risk cancer, deaths from prostate cancer after 15 years were low and almost the same in the monitoring, surgery and radiotherapy groups; however, spread of the cancer was about twice as common in the monitoring group as in the other two groups [6]. So regular monitoring means having your tests on time.
Gleason score 7 (3+4 vs 4+3): what is the difference?
Both add up to 7, but they are not the same [2]. In 3+4 most of the cancer is the lower-risk pattern 3 and a smaller part is pattern 4; in 4+3 it is the other way round [1]. In the large surgery study, the chance of the PSA rising again was about three times higher with 4+3 than with 3+4 [3].
Gleason 3+4 (Grade Group 2) is usually treated with surgery or radiotherapy. But if the pattern 4 part is very small (less than a tenth of the cancer), the PSA is below 10, the tumour is small and cancer was found in 3 samples or fewer, the European guideline also accepts regular monitoring as an option, provided the patient accepts that the risk of spread may be higher [5].
Gleason 4+3 (Grade Group 3) is not suitable for regular monitoring and usually needs treatment [5]. If your pathology report contains the word "cribriform" (sieve-like) or "intraductal", this is also a sign of more aggressive behaviour, and regular monitoring is not recommended, even when the score is 3+4 [2, 5].
What do Gleason 8, 9 and 10 mean? Life expectancy with a Gleason score of 9 or 10
A score of 8 to 10 (Grade Groups 4 and 5) means the cancer is high risk and more likely to grow and spread [1, 2]. But this score does not mean the cancer has spread. Imaging is needed to find out whether the cancer has reached anywhere else; a PSMA PET scan is the most sensitive test [5]. Read more: What is a bone scan, and what do the results mean? and What is a PET scan?
If the cancer has not spread, the aim of treatment is to get rid of it completely: usually radiotherapy with 2 to 3 years of hormone therapy, or surgery in selected patients [5]. In a study of about 1,800 men with Gleason 9 or 10, five years after treatment about 9 in 10 men had not died of prostate cancer. In those who had external radiotherapy plus radioactive implants placed in the prostate (brachytherapy) and hormone therapy, the results were even better [9].
A large study in Sweden estimated that, even in the highest-risk group, men who receive standard treatment are more likely, over 30 years, to die of other causes than of prostate cancer [12]. Each person's life expectancy also depends on age, other illnesses, the PSA and the imaging results; talk this through with your own doctor. If the cancer has spread, read: Treatment of prostate cancer that has spread.
The Gleason score and the choice of treatment
Your doctor puts the Gleason score together with the PSA and the stage of the tumour (its size on examination and MRI) and places the disease in one of the "risk groups": low, intermediate or high [5]. Treatment is chosen according to this risk group, your age, any other illnesses and your own wishes [1, 5].
- See your risk group with the prostate cancer risk group tool.
- Read about treatment at each stage on the prostate cancer page, and about the chance of cure in Is prostate cancer curable?
- Read about how each treatment affects erections and bladder control: Sex, erections and bladder control after prostate cancer treatment.
Perineural invasion in prostate cancer and other terms on a prostate biopsy report
| Term on the pathology report | What it means | Why it matters |
|---|---|---|
| Gleason score and Grade Group | The Gleason score and the Grade Group | The most important sign of how serious the cancer is [1, 2] |
| % pattern 4 | How much of the cancer is the higher-risk pattern 4 | In Gleason 3+4, if it is small, regular monitoring may be possible [5] |
| Number of positive cores and percentage of each core involved | How many of the tissue samples contained cancer, and how much of each sample it took up | A sign of how much cancer there is; important when choosing between monitoring and treatment [5, 7] |
| Perineural invasion | Cancer cells were seen around the tiny nerve fibres of the prostate | It does not mean the cancer has spread; it goes with a somewhat higher chance of the PSA rising again after surgery [11] |
| Cribriform pattern | Cancer glands full of tiny holes, like a sieve; a type of pattern 4 | More aggressive behaviour; regular monitoring is not recommended [2, 5] |
| Intraductal carcinoma | Cancer cells have grown inside the ducts of the prostate | Almost always found together with a more aggressive cancer; regular monitoring is not recommended [2, 5] |
Perineural invasion is fairly common in prostate biopsies [11]. In studies, men whose biopsy showed perineural invasion were somewhat more likely to have their PSA rise again after surgery [11]; your doctor takes this into account too when choosing treatment. Read what the other terms on a pathology report mean in How to read a pathology report.
Can the Gleason score change after surgery?
Yes, sometimes. A needle biopsy takes only a few thin strips of the prostate, but after surgery the pathologist sees the whole prostate [10]. In a review of more than 7,600 men, more than 1 in 3 of those who had Gleason 6 on biopsy were given a higher score after surgery. With Gleason 3+4, the score stayed the same in half of the men, and in the rest it went up or down in roughly equal numbers [10].
During regular monitoring, a later biopsy sometimes also shows a higher score; in the US monitoring programme, about 1 in 4 men had a higher score within 10 years [7]. This is why MRI and repeat biopsies matter during regular monitoring [5]. Worried about having a biopsy? Read: What is a biopsy?
Frequently asked questions
Is a Gleason score of 7 dangerous?
Gleason 7 means a medium-grade cancer [1], and 4+3 is more serious than 3+4 [3]. These cancers are usually treated with surgery or radiotherapy, with the aim of getting rid of the cancer completely [5]. In a large UK study in which more than a third of the men had intermediate- or high-risk cancer, fewer than 3 in 100 men had died of prostate cancer after 15 years [6].
I have Gleason 9: what is my life expectancy?
It depends on your age and general health, your PSA, and whether the cancer has spread. In a study of men with Gleason 9 or 10 whose cancer had not spread, five years after treatment about 9 in 10 men had not died of prostate cancer [9]. See the section “What do Gleason 8, 9 and 10 mean? Life expectancy with a Gleason score of 9 or 10”, and talk to your doctor about your own situation. Read more: What does 5-year survival mean?
Is Gleason 3+3 really cancer? Do I need an operation?
How is the Gleason score different from the PSA?
PSA is a blood test that measures a protein made by the prostate. The Gleason score comes from looking at the cancer tissue itself under a microscope [1]. Your doctor uses both, together with the size of the tumour, to work out the risk group [5]. Read more: Does a high PSA mean prostate cancer?
Does Gleason 10 mean the cancer has spread?
Not necessarily. The Gleason score tells you how aggressive the cells are, not how far the cancer has reached; spread is shown by the "stage", which is worked out with imaging [1, 5]. Read more: What are the stages of cancer?
Why does my report say "Grade Group" or "ISUP"?
Since 2014, Gleason scores have been summarised in five ISUP Grade Groups, and the World Health Organization has adopted them as well. The Grade Group is usually written next to the Gleason score, for example "Gleason 3+3=6 (Grade Group 1)" [2].
Related pages
Definitions, outcomes by Grade Group and active surveillance criteria (for doctors)
For physicians
ISUP 2014 (adopted by WHO 2016). Grade Group 1: Gleason ≤6; 2: 3+4=7; 3: 4+3=7; 4: 8; 5: 9–10. Pattern 4 includes cribriform, glomeruloid, fused and poorly formed glands; unequivocal comedonecrosis, even if focal, is pattern 5; intraductal carcinoma without invasive carcinoma is not assigned a grade [2]. In a multi-institutional validation (20,845 radical prostatectomies and 5501 radiotherapy patients), hazard ratios for biochemical recurrence relative to Gleason 6 were 1.9, 5.1, 8.0 and 11.7 for 3+4, 4+3, 8 and 9–10, and 5-year biochemical recurrence-free survival by prostatectomy grade was 96%, 88%, 63%, 48% and 26% [3]. In SEER (331,320 patients, 2006–2012), the adjusted HR for prostate cancer-specific mortality after prostatectomy relative to Grade Group 1 was 1.13 (95% CI 0.83–1.54) for Grade Group 2, 1.87 (1.33–2.65) for Grade Group 3, 5.03 (3.59–7.06) for Grade Group 4 and 10.92 (8.03–14.84) for Grade Group 5 [4].
Grade Group 1 and active surveillance. Of 14,123 totally embedded prostatectomies with pelvic lymph node dissection, 22 were N+, and all 19 reviewed cases had a higher grade on review [8]. In the Johns Hopkins cohort (1298 men with favourable-risk disease, median follow-up 5 years), cancer-specific and metastasis-free survival at 15 years were 99.9% and 99.4%; the cumulative incidence of grade reclassification was 26% (10 years) and 31% (15 years), and of curative treatment 50% and 57% [7]. In ProtecT (1643 men, median follow-up 15 years; PSA-based active monitoring), prostate cancer-specific death was 3.1% with monitoring, 2.2% with prostatectomy and 2.9% with radiotherapy (P=0.53), and metastases occurred in 9.4%, 4.7% and 5.0% [6].
EAU 2026. Low risk with life expectancy over 10 years: active surveillance (strong). Selected ISUP 2, e.g. less than 10% pattern 4, PSA below 10 ng/mL, ≤cT2a, low disease extent on imaging and ≤3 positive ISUP 2 cores with ≤50% involvement per core: active surveillance, accepting the potentially higher risk of metastatic progression (weak). ISUP 3, and cribriform or intraductal histology on biopsy: excluded from active surveillance (strong). Follow-up: PSA at least every 6 months, DRE, and repeat biopsy with or without MRI every 2 to 3 years. High-risk localised disease: IMRT/VMAT with IGRT (76–78 Gy, or 60 Gy in 20 fractions, or 70 Gy in 28 fractions) with 2 to 3 years of ADT, or RP in selected patients [5].
Gleason 9–10 and long-term outcomes. In a retrospective cohort of 1809 patients from 12 centres (2000–2013), adjusted 5-year prostate cancer-specific mortality was 12% after RP, 13% after EBRT with ADT and 3% after EBRT with a brachytherapy boost plus ADT (HR 0.38 and 0.41 in favour of EBRT+BT), and 5-year distant metastasis 24%, 24% and 8% [9]. In the Swedish national register (62,839 men treated according to NCCN), simulated 30-year prostate cancer-specific mortality ranged from 12% (low risk) to 30% (very high risk), against 77% to 63% for death from other causes [12].
Grade change and PNI. In 7643 prostatectomies, 36.3% of biopsy Gleason 5–6 cases were upgraded; half of biopsy 3+4 cases matched at surgery, as did 58% of Gleason 9–10 [10]. The prevalence of PNI on biopsy was 7% to 33%, and it was associated with biochemical recurrence after RP (systematic review of 18 studies with 14,855 patients; pooled multivariable HR from 4 studies 1.57; 95% CI 1.28–1.93) [11].
Related cancer types
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References
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This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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