A pathologist examines your biopsy tissue under a microscope and assigns a pattern number (3, 4, or 5) based on how abnormal the cells look and how much they have lost normal glandular architecture. The two most common patterns are added together to give the Gleason score. For example, 3+4=7 means the dominant pattern is relatively well-organized (pattern 3) with a smaller component of more disorganized cells (pattern 4). Read more in our complete Gleason score guide.

Both equal 7, but 4+3 carries meaningfully higher risk because the dominant (most prevalent) pattern is the more aggressive one. This is exactly why the modern Grade Group system separates them: 3+4 = Grade Group 2 (favorable intermediate), while 4+3 = Grade Group 3 (unfavorable intermediate). This distinction genuinely changes treatment recommendations. For more on biopsy interpretation, see our prostate biopsy preparation guide.

Technically yes — but Gleason 6 (Grade Group 1) behaves so indolently that many leading experts argue it should be reclassified entirely. It has a near-zero rate of metastasis when confined within the prostate. Most men with Gleason 6 are managed with active surveillance rather than immediate treatment — avoiding surgery and radiation side effects entirely while maintaining close monitoring. This is not denial; it is evidence-based medicine.

Your urologist combines your Gleason score with your PSA level and clinical stage (from digital rectal examination and imaging) to determine your overall risk group using a system like D’Amico criteria. This risk group — not the Gleason score alone — drives the treatment recommendation. Options range from active surveillance for low-risk disease all the way to radical prostatectomy, radiation therapy, or combined multimodal approaches for high-risk disease. See our full Gleason score article for a detailed treatment pathway breakdown.

Your original biopsy score does not change, but a subsequent biopsy may show a different — often higher — grade, called “upgrading.” About 30–40% of men on active surveillance experience upgrading on a repeat biopsy. This is one reason regular surveillance biopsies and MRI monitoring are essential if you are on an observation pathway. Upgrading does not mean the cancer was missed; it often reflects improved sampling on the second biopsy.