Variability in Outcomes for Patients with Intermediate-risk Prostate Cancer (Gleason Score 7, International Society of Urological Pathology Gleason Group 2–3) and Implications for Risk Stratification: A Systematic Review

Context: Optimal management for patients with intermediate-risk (IR) prostate cancer (PCa) remains controversial. Clinical metrics provide guidance on appropriate management options. Objective: To report estimates for clinically relevant outcomes in men with IR PCa based on clinical and pathological features. Evidence acquisition: PubMed and programs from key 2015 uro-oncology congresses were searched using the terms “intermediate”, “Gleason 3 + 4”, “Gleason 4 + 3”, “active surveillance”, “treatment”, “adverse pathology”, AND “prostate cancer.” Articles meeting prespecified criteria were retrieved. Bibliographies were scanned for additional relevant references. Evidence synthesis: Men with IR PCa have a wide range of predicted clinically relevant outcomes. Within the IR category, estimate ranges for adverse surgical pathology and 5-yr disease progression are 15–64% and 21–91%, respectively. Clinical parameters and predictive nomograms refine these estimates, but do not uniformly differentiate favorable and unfavorable IR PCa. Variations in study design and data quality in source manuscripts mandate caution in interpreting results. Conclusions: Outcomes in IR PCa are heterogeneous. Refinements in personalized risk assessment are needed to better select IR PCa patients for surveillance. Patient summary: Current and future risk stratification tools may provide additional information to identify men with intermediate-risk prostate cancer who may consider active surveillance. Decision-making in intermediate-risk prostate cancer is challenging owing to substantial heterogeneity for outcomes reported in the literature. Existing clinical parameters provide guidance; novel modalities are needed to further optimize management of men with intermediate-risk prostate cancer.