ÖZET

Risk stratification system according to risk factors that are baseline PSA, biopsy Gleason score and tumor category popularized by D’Amico et al include a low, intermediate and high risk group. However, many of the pre-treatment risk stratification schemes assess risk of biochemical recurrence rather than risks of clinically significant recurrent disease.

It is evident from a number of studies that PSA recurrence often does not predict clinically significant recurrent disease or a need for further treatment. Only a minority of patients with PSA failure will die of prostate cancer. Risk should be understood as significant probability of progressive, symptomatic disease or death from prostate cancer.

Tumor category has become relatively less important as a prognostic factor because most patients diagnosed today have nonpalpable disease as result of increased PSA screening and the follow-on stage migration toward earlier stage disease. Concomitant with stage migration, median PSA at presentation has also decreased, such that PSA greater than 10 ng/ml at diagnosis has become uncommon. Moreover, benign prostatic hyperplasia increases serum PSA and it is commonly seen in men of prostate cancer bearing age. Therefore, the prognostic significance of any single PSA value below 10 ng/ml is becoming more limited.

Despite decreasing PSA values at presentation the information obtained from serial PSA values in the form of PSA velocity has been shown to be significantly associated with tumor stage, grade, time to PSA failure and time to prostate cancer specific mortality following RP.

Although treatment in patients with high risk clinically localized prostate cancer remains controversial, there is gradually more a consensus as to how they should be classified and how they should not be treated.