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A phenomenon described by several previous investigators — an upward drift in assigned Gleason grade to prostate cancer — is elegantly addressed in the article by Albertsen and colleagues in this issue of the Journal (1). The authors asked the question: are prostate cancers currently more aggressive, or are we just labeling them as more aggressive? Comparing initial biopsy Gleason grades from a decade ago with a contemporary Gleason grade assessment of the same samples, the authors made two important observations. First, there was a substantial shift to higher tumor grades with contemporary evaluation. Second, when survival was stratifi ed by Gleason score, all groups of patients appeared to have improved outcomes, merely by rereading of the biopsy slides and the assignment of a new, contemporary Gleason score. A similar phenomenon could be the Will Rogers effect, a term that was fi rst coined by Feinstein and colleagues (2) ; this phenomenon is also known as stage migration (3). An alternative term could be grade infl ation, a term that acknowledges the national trend of higher grades, especially in university-level education. Like the observations of Albertsen et al. regarding Gleason grades, an analysis of grades given at the university level in the United States that does not control for year of graduation would suggest that we, as a nation, have increasingly brilliant college students. To our knowledge, the fi rst person to use this term for prostate cancer was Barnett Kramer, MD, MPH, the editor of the Journal of the National Cancer Institute. What is the cause of grade infl ation in prostate cancer? A recent change in the accepted protocol for reporting of biopsy grade may be partially responsible. Prostate cancer is usually multi-focal, with prostatectomy specimens often harboring six to eight discrete tumors of various grades. Prostate biopsy, performed to " map " the gland, can thus identify several different tumors. Gleason scoring, which identifi es fi ve patterns of decreasing differentiation and increasing aggressiveness, assigns a fi rst number to the predominant pattern in a biopsy core and, if there is another pattern present, a second number to the second most common pattern (e.g., 3 + 3). Increasingly, more than two patterns are identifi ed in prostate biopsy samples, and some clinicians have suggested reporting a tertiary score (4). However, in recognition of the fact that the most aggressive tumor found in a prostate biopsy, even if …

Stage Migration and Grade Inflation in Prostate Cancer: Will Rogers Meets Garrison Keillor