Gleason 6 Prostate Cancer

 Howard Wolinsky

It starts with the PSA blood test. If it rises above 4, you might have prostate cancer. The next diagnostic step is a digital rectal exam. Then you move on to an MRI and probably a biopsy, where they take a dozen samples from around the prostate. Pathology looks at the tissue samples and delivers a Gleason verdict.

The Gleason number tell you how aggressive your cancer is. The numbers start at 6 and go up to 10. A reading of 6 indicates your cancer has a low risk of spreading, and the standard approach is to go on active surveillance. What this means is that you don’t do anything to the cancer. You sit back and monitor it. In fact, undergoing treatments now to “cure” your cancer could be detrimental to your health. Three-quarters of Gleason 6 men never need any treatment, and they die in old age of something else. 

Active surveillance involves getting a PSA blood test every three or six months, or every year, depending on how nervous you are as a patient, with a digital exam every year, and an MRI and a biopsy now and then to make sure there’s no new growth. The timing is determined by you and your doctor.

A Gleason score of 7 or higher will either send you for surgical removal or radiation and hormone therapy.

Many of the details in this post come from Howard Wolkinsky’s insightful August 1st Substack post on The Active Surveillor, which does a wonderful job of explaining the Gleason 6 world. He says there are new thoughts about stopping the diagnostic tests after five years if there’s been no development of your Gleason 6 cancer, rather than continuing with yearly scans and biopsies for the rest of your life. This is Dr. Michael Leapman’s idea, and he works at the Yale Cancer Center. 

Biopsies, by the way, are not fun. They are uncomfortable because the urologist shoots a dozen needles into your prostate to collect tissue samples, either going through your perineum or rectal wall, and you feel pain and discomfort for a couple of days. There is also the risk of a serious infection, although this is low.

Dr. Leapman “wants to safely reduce testing,” and is hopeful that future genomic tests will be able to tell which Gleason 6 men are likely to develop serious prostate cancer and need to continue to be monitored, and which men don’t have to endure the physical and emotional trauma of each next diagnostic test.

Howard adds a however. As men go from “young old to old old,” prostate cancer “still needs to be monitored to avoid the Biden Effect of stopping in your young 70s only to find in your 80s you have symptoms and a Gleason 9.”

I don’t know how often Biden had PSA tests done, or if his doctors stopped doing the test when he reached the age of 70, 72, or 75. In May 2025, when he was 82, Biden was having urinary problems, went in to find out what was going on, and was diagnosed with Gleason 9, Stage 4, metastatic cancer. 

Dr. David Shusterman, a urologist at NY Urology said that just finding prostate cancer at a Gleason 9 is “pretty much unheard of in this day and age of medicine,” because it takes five to ten years to develop. This timeline would suggest that Biden’s cancer began growing right after his last PSA test. Dr. Peter Nelson, though, an oncologist at Fred Hutchinson Cancer Center, suggests that it’s possible his cancer progressed over a 2-3 year time frame.

Let me toss my personal experience into the ring. My primary physician runs the PSA test as part of my annual physical. Every year my PSA had been normal. Then, over the course of one year in my late 60s, my PSA took off, and I was diagnosed with Gleason 9 cancer. I had no symptoms of a problem. 

If your cancer is aggressive, it can explode like this. If you don’t catch it in time, it will become metastatic before you know it’s a problem, and then you’ll be fending off death. 

Howard says “Active Surveillance is no longer a rigid protocol. It’s a negotiation. A partnership. A long game where the rules loosen as the years go by.”

If your doctor says you have a Gleason 6 but doesn’t tell you that it has a low-risk of developing into something serious, or doesn’t suggest that you start Active Surveillance, bring this up. If your doctor says you need surgical removal right away, look for a different doctor. 

It’s a shock when you’re told you have cancer. If you’re a Gleason 6, knowing that you don’t have to do anything right now hoses down the edge of a hayfield that has just caught fire.

© 2026 Mark Liebenow