Predicting risk for Gleason score upgrades in non-surgical patients


The ability to predict risk for Gleason score upgrading in patients who have any form of treatment other than radical prostatectomy can be important, because it may help treating physicians and their patients to optimize first-line therapy.

Budäus et al. have developed a new nomogram that can be used to predict risk for Gleason score upgrading (GSU) from a biopsy-based Gleason score of 6 to a pathologic Gleason score of 7 or higher in patients undergoing radical prostatectomy (RP) who also meet criteria for treatment with low-dose-rate brachytherapy (Gleason score 6, PSA ≤ 10 ng/ml, clinical stage ≤ T2a, and prostate volume ≤ 50 ml). They have also compared the performance of this new nomogram to that of an older, existing nomogram for prediction of GSU in this specific group of patients.

The key information about this study are as follows:

  • The analysis was based on data from 414 patients who met the criteria described above and who had all received an initial 10-core prostate biopsy.
  • The overall rate of GSU was 35.5 percent.
  • When applied to candidates for low-dose-rate brachytherapy, the new nomogram had an accuracy of 70.8 percent compared to an accuracy of 65.8 percent for the older, existing nomogram.
  • The new nomogram was substantially better at predicting GSU than either the assumption that no patient is upgraded or the older, existing nomogram when subjected to decision curve analysis.

The authors conclude only that their new nomogram might improve selection of appropriate patients for low-dose-rate brachytherapy by excluding patients with an increased probability of GSU.

The “New” Prostate Cancer InfoLink considers that the potential to evaluate risk for Gleason score upgrading in any patient who is undergoing a form of treatment other than radical prostatectomy is important. It would be helpful if we had access to a series of well-constructed, accurate, on-line, “plug and play” nomograms that could be used to assess such risk for patients considering all the widely-used forms of non-surgical, first-line management of localized prostate cancer — most particularly active surveillance, high- and low-dose-rate brachytherapy, the various types of external beam radiation therapy (including proton beam radiation), and high-intensity focused ultasound. The data generated by Budäus and colleagues can, of course, be used to project such risk with for any patient who meets their original criteria (Gleason 6, PSA ≤ 10 ng/ml, clinical stage ≤ T2a, prostate volume ≤ 50 ml). The accuracy with which it can be used to project such risk unless the original biopsy was a 10-core biopsy is open to question. It would be helpful if any such nomogram could project risk for GSU with an accuracy or more like 80 percent than 70 percent, and perhaps we can evolve to that level of accuracy over time.

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