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October 6, 2004

Natural History of Early Localized Prostate Cancer—Reply

JAMA. 2004;292(13):1549-1550. doi:10.1001/jama.292.13.1549-c

In Reply: Drs Osborn and Chodak consider Gleason histopathologic grading to be a “more accurate predictor of prognosis” than cytological assessment of differentiation. The implication of “accurate” is far from clear in this context. It could vary from the statistical precision of an effect estimate (such as 20-year survival) to the reliability of the factor or its performance in distinguishing fatal from nonfatal cancerous tumors (sensitivity, specificity, or predictive value). Prognostic factors do not exist in a vacuum; their purpose is to guide clinical management. Although the Gleason score conveys significant prognostic information, it is not obvious that a dichotomous clinical decision is better guided by the Gleason score with 10 discreet levels than by the 3 discreet categories of differentiation. In our data, degree of differentiation distinguishes groups with an almost 50-fold difference in risk of death from prostate cancer.1

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