There continues to be a vigorous debate about the merits of reclassifying Gleason Grade Group 1 (GG1) as something other than cancer. The rationale for such a change is based on the perception that GG1 never causes harm and that there is significant overtreatment. The sentiment behind the proposed change in designation is sound; if we knew a patient had GG1 cancer and the patient had no risk of progression, there would be no reason to monitor and treat. Unfortunately, in 2023 we know that many patients with biopsy-proven GG1 harbor higher-grade elements, that there is a risk of progression to higher-grade disease, and that there likely would be unintended consequences of changing nomenclature that would hamper care.

First, a high percentage of patients with GG1 have grade reclassification on repeat biopsy. The key point is that even men with very low-risk disease, close to 15%, will have higher grade on subsequent biopsy.¹ As a result, a change to a noncancer designation would likely result in no alteration in the need for active surveillance since all patients with low risk need to be monitored to ensure no clinical progression. Why change the designation if there is no change in care?

Second, the grade of the tumor as GG1 is not the sole factor that should be considered in treatment decisions. Tumor volume, clinical stage, imaging, genetic background, and genomic testing can all impact on decision to treat.^2-5 For example, PIRADS (Prostate Imaging Reporting and Data System) 4 and 5 are associated with upgrading and therefore have been integrated into decision-making. Should a patient with a PIRADS 5 GG1 tumor on biopsy be told they don’t have cancer? Should a patient with BRCA2 germline mutations not be treated? Patients should be risk stratified using more than just Gleason score.

Third, removing the label of cancer in men with GG1 cancer on biopsy will make it challenging to ensure close follow-up. While patients with optimal insurance will likely not be affected by a change in terminology, those with policies that are less robust may fall into a trap where follow-up is curtailed when GG1 is renamed noncancer, resulting in financial toxicity. This is particularly an issue in underserved communities. Currently, patients already fail to follow up for active surveillance. Analysis of SEER (Surveillance, Epidemiology, and End Results) data demonstrated that close to 40% of all men and 60% of Black men with low-risk prostate cancer failed to follow surveillance strategies.⁶ It is logical and expected that renaming GG1 as not cancer will lead to less compliance with follow-up.

Fourth, there is concern that defining GG1 as noncancer could paradoxically lead to more treatment. Pathologists may be wary of a noncancer diagnosis if the patient is not going to be managed closely. Consciously or unconsciously, borderline cases could be upgraded. The result is more treatment in men who could be safely followed.

In summary, there is strong rationale for retaining the cancer designation for GG1 prostate cancer. The arguments for renaming GG1 prostate cancer primarily revolved around protecting the patient from overtreatment. This argument is weakened over time with greater acceptance of active surveillance. While there is widespread agreement that some prostate cancer is of no threat to the patient, the underlying clinical challenge is how to identify those patients and how to minimize treatment. Simply relabeling GG1 as a benign condition is not going to address this conundrum.