Hearing the words “you have prostate cancer” is one of the most frightening moments in a man’s life. But often, that fear is quickly followed by a sense of relief when the doctor adds, “Fortunately, it’s low-risk.”
Historically, clinical guidelines have offered a reassuring path for these cases. For men diagnosed with Gleason Grade Group 1 (GG1) prostate cancer, the standard recommendation is usually “active surveillance.” Instead of rushing into surgery or radiation, we simply monitor the cancer closely to make sure it isn’t growing.
But as our imaging technology and genetic testing become more advanced, the urologic oncology community is realizing something critical: not all “low-risk” diagnoses are truly low-risk.
In our latest peer-reviewed study, published in the August 2026 issue of Current Problems in Cancer, my colleagues and I challenged the baseline assumptions of low-risk prostate cancer. We wanted to know: Are we inadvertently under-treating a subset of men whose cancer harbors hidden, aggressive features?
The Study: Looking Closer at the Data
To find out, our team—including researchers from Palmetto General Hospital and the International Robotic Institute for Prostate Cancer—conducted a detailed review of 874 men who underwent an MRI-fusion prostate biopsy.
We specifically focused on men who were officially diagnosed with “low-risk” (GG1) prostate cancer but ultimately chose to undergo robotic surgery to remove their prostate (a robotic radical prostatectomy).
By looking at their prostate tissue after it was removed, we could compare the actual cancer to their initial biopsy results. We were looking for “pathological upgrading”—instances where the cancer was actually much more aggressive than the initial biopsy suggested.
The Hidden Red Flags
Our research uncovered a vital insight: the number of positive biopsy cores a patient had did not impact their risk of having a more aggressive cancer.
Instead, the real danger lies in a specific combination of warning signs. We discovered that men with “low-risk” GG1 prostate cancer are significantly more likely to have aggressive disease hiding in the prostate if they have any of the following clinical red flags:
- Elevated PSA Levels: A PSA level greater than 6 ng/dL.
- Highly Suspicious MRI Results: A “PIRADS 5” lesion detected on a multiparametric MRI.
- Abnormal Physical Exam: Irregularities found during a digital rectal exam (DRE).
- High Biomarker Scores: An MPS2.0 test score greater than 8.1%.
- Cellular Warning Signs: The presence of atypical cells (ASAP) or intraductal carcinoma (IDC) on the initial biopsy.
If any of these specific predictors are present, the patient’s risk profile shifts entirely. The standard “low-risk” label is no longer safe to rely on.
What This Means for Patients
If you have been diagnosed with low-risk prostate cancer, do not simply accept “active surveillance” without looking at the complete picture. Ask your urologist about your MRI results, your exact PSA numbers, and whether advanced biomarker testing (like the MPS2.0 score) makes sense for you. If you have any of the red flags listed above, active surveillance may not be the safest choice, and early intervention should be heavily considered. Expert, personalized counseling is your best tool for survival.
What This Means for Clinicians
As urologists and oncologists, we can no longer afford to view all GG1 diagnoses through a uniform lens. We must integrate novel urinary biomarkers, advanced imaging, and nuanced biopsy data into our risk stratification. Patients who present with these unique risk factors require a highly tailored approach, and we must explicitly counsel them on their unique risk of pathological upgrading.
By refining our diagnostic criteria, we can ensure that every single patient receives the precise, proactive treatment they truly need to achieve the best possible outcome.
Dr. Shirin Razdan is a Urologic Oncologist and Robotic Surgeon based at Miami Robotic Surgery. This research was conducted in collaboration with Ali Fathollahi, Alexandre Armache, and Sanjay Razdan. Read the full abstract and publication in the August 2026 edition of Current Problems in Cancer.
