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A Contemporary Prostate Cancer Grading System: A Validated Alternative to the Gleason Score.

  • Epstein, Jonathan I1
  • Zelefsky, Michael J2
  • Sjoberg, Daniel D2
  • Nelson, Joel B3
  • Egevad, Lars4
  • Magi-Galluzzi, Cristina5
  • Vickers, Andrew J2
  • Parwani, Anil V3
  • Reuter, Victor E2
  • Fine, Samson W2
  • Eastham, James A2
  • Wiklund, Peter4
  • Han, Misop6
  • Reddy, Chandana A5
  • Ciezki, Jay P5
  • Nyberg, Tommy4
  • Klein, Eric A5
  • 1 The Johns Hopkins Medical Institutions, Baltimore, MD, USA. Electronic address: [email protected]
  • 2 Memorial Sloan Kettering Cancer Center, New York, NY, USA.
  • 3 University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
  • 4 Karolinska Institute, Stockholm, Sweden. , (Sweden)
  • 5 Cleveland Clinic, Cleveland, OH, USA.
  • 6 The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Published Article
European urology
Publication Date
Mar 01, 2016
DOI: 10.1016/j.eururo.2015.06.046
PMID: 26166626


Despite revisions in 2005 and 2014, the Gleason prostate cancer (PCa) grading system still has major deficiencies. Combining of Gleason scores into a three-tiered grouping (6, 7, 8-10) is used most frequently for prognostic and therapeutic purposes. The lowest score, assigned 6, may be misunderstood as a cancer in the middle of the grading scale, and 3+4=7 and 4+3=7 are often considered the same prognostic group. To verify that a new grading system accurately produces a smaller number of grades with the most significant prognostic differences, using multi-institutional and multimodal therapy data. Between 2005 and 2014, 20,845 consecutive men were treated by radical prostatectomy at five academic institutions; 5501 men were treated with radiotherapy at two academic institutions. Outcome was based on biochemical recurrence (BCR). The log-rank test assessed univariable differences in BCR by Gleason score. Separate univariable and multivariable Cox proportional hazards used four possible categorizations of Gleason scores. In the surgery cohort, we found large differences in recurrence rates between both Gleason 3+4 versus 4+3 and Gleason 8 versus 9. The hazard ratios relative to Gleason score 6 were 1.9, 5.1, 8.0, and 11.7 for Gleason scores 3+4, 4+3, 8, and 9-10, respectively. These differences were attenuated in the radiotherapy cohort as a whole due to increased adjuvant or neoadjuvant hormones for patients with high-grade disease but were clearly seen in patients undergoing radiotherapy only. A five-grade group system had the highest prognostic discrimination for all cohorts on both univariable and multivariable analysis. The major limitation was the unavoidable use of prostate-specific antigen BCR as an end point as opposed to cancer-related death. The new PCa grading system has these benefits: more accurate grade stratification than current systems, simplified grading system of five grades, and lowest grade is 1, as opposed to 6, with the potential to reduce overtreatment of PCa. We looked at outcomes for prostate cancer (PCa) treated with radical prostatectomy or radiation therapy and validated a new grading system with more accurate grade stratification than current systems, including a simplified grading system of five grades and a lowest grade is 1, as opposed to 6, with the potential to reduce overtreatment of PCa. Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.

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