Doubling our precision of risk stratification in early prostate cancer: too good to be true?

It is difficult to over-estimate the enormity of the revolution involved in transitioning away from an organ-based system of care in prostate cancer (prostatectomy or radiotherapy to prostate cancer of any grade, number, location or volume) to one in which the target condition is defined and verified, and then subsequently treated with a margin. Since Hugh Hampton-Young undertook the first radical prostatectomy more than 100 years ago, an organ-based system of care has been the only plausible strategy for men with early-stage prostate cancer. This is because our risk stratification methods could certainly tell us who had prostate cancer when it was indeed identified, but they could not tell us with any degree of precision how much cancer was present (number of foci and volume of cancer), what grade it was and where within the prostate the cancer resided. Surgery or radiotherapy to the whole gland, it was thought, was a reasonable mitigation (at the cost of over-treatment in a significant proportion of men) to the systematic underestimation of risk to the patient. The degree to which our attempts at risk stratification failed our patients was emphasized in a recent UK report that showed an increase of >50% in histological grade (the most important determinant of risk) at radical prostatectomy compared with the risk the patient was told at the time of diagnosis [1]. ‘Upgrading’ is an inverse measure of the quality of our risk stratification.