A debate is developing over whether to rename Grade Group 1 (GG1) prostate cancer. Proponents argue that clinical decisions based on the grading often ignore other key diagnostic factors, such as PSA. Physicians might also conflate low-grade disease (GG1) with low-risk disease, which can mislead patients. The dispute inspired research led by Weill Cornell Medicine, which discovered that one in six men diagnosed with GG1 prostate cancer is later found to have intermediate- or high-risk disease once other clinical features are considered.
Here, we speak with Bashir Al Hussein, Assistant Professor of Urology and Population Health Sciences, and co-senior author of this study, about what this research means for prostate cancer diagnostics.
Did you face any challenges during your research, and if so, how did you overcome them?
A key challenge was designing a study with enough breadth and rigor to address the research question: Do cancer-specific outcomes of individuals with grade group 1 prostate cancer on biopsy differ based on validated risk stratification? We overcame this by collaborating with multiple institutions and using population-based data, which strengthened the reliability and generalizability of our findings.
What were the main outcomes of your study – did anything surprise you?
In a contemporary cohort of 299,746 men, nearly 1 in 6 with GG1 prostate cancer actually had non–low-risk disease. These men showed higher rates of adverse pathology at surgery and greater prostate cancer–specific mortality compared with those who truly had GG1 low-risk disease. While this aligns with clinical experience, it highlights the risk of misleading patients if they are told they do not have cancer.
Given the ongoing debate over whether GG1 should be labeled as “cancer,” how do your findings inform that discussion from a diagnostic and pathology standpoint?
Our findings highlight key distinctions. Firstly, biopsy GG1 is not the same as GG1 found at prostatectomy, which often underpins the argument that these cancers do not metastasize. And second, despite advances such as targeted MRI biopsies, many men with biopsy GG1 still harbor more aggressive disease. For these reasons, we believe it is problematic to suggest these men do not have cancer, and greater emphasis should be placed on incorporating additional adverse features into risk assessment.
This distinction should be made by the clinician, not the laboratory team. However, laboratories may also report the patient’s risk according to national guidelines alongside the biopsy histology.
What role do histopathology and ancillary testing play in identifying GG1 patients who may actually harbor more aggressive disease?
These tools show promise in identifying aggressive disease that may be missed at biopsy. When combined with imaging findings and clinical features such as PSA, they can support more individualized risk stratification and improve patient counseling. Their utility, however, is limited by under-sampling at biopsy. Ancillary tests may add value, but they cannot fully overcome the challenge of missing more aggressive disease.
What’s next for this research?
Our goal is to refine risk stratification for men with GG1 disease, providing clearer prognostic information and guiding patients toward the most appropriate management strategies.
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