title: Staging for prostate cancer: time to incorporate pretreatment prostate-specific antigen and Gleason score?
abstract: BACKGROUND
  The American Joint Committee on Cancer (AJCC) staging system for prostate cancer is based primarily based on clinical tumor (T) classification. In this article, the authors summarize arguments for incorporating additional pretreatment parameters and creating a new staging system for prostate cancer.
  
  
  METHODS
  Men with localized prostate cancer who received treatment with external beam radiation alone were analyzed using the 1997 AJCC staging system compared with a system that included pretreatment prostate-specific antigen (pPSA) level and Gleason score (GS). Multivariate analyses using a Cox proportional-hazards model were carried out to evaluate T classification, GS, and pPSA as predictors of overall survival (OS), disease-specific survival (DSS), and freedom from PSA failure (FFPF). RESULTS.: Based on pretreatment characteristics in a series of contemporary patients, only 0.6% of patients were classified with AJCC stage I disease, 16.0% were classified with AJCC stage III disease, and 83.4% were classified with AJCC stage II disease. Multivariate analyses indicated the independent statistical significance of T classification, GS, and pPSA in predicting OS, DSS, and FFPF (model chi-square value, P < .0001 for each). Using these 3 predictors, subsets of patients who had similar outcomes were combined to provide examples of the insensitivity of the AJCC system for predicting outcomes. Incorporating pPSA and GS allowed the identification of differences in OS, DSS, and FFPF for subsets of patients with AJCC stage II disease (P < .0001, P = .005, and P < .0001, respectively).
  
  
  CONCLUSIONS
  The current AJCC staging system does not divide contemporary patients with prostate cancer into prognostic subgroups and does not identify patients who have comparable biochemical control and survival. The AJCC staging system for prostate cancer should be changed to incorporate pPSA, GS, and risk stratification.
authors.affiliation: Department of Radiation Oncology, University of California San Francisco Comprehensive Cancer Center, University of California San Francisco, San Francisco, California 94143-1708, USA. roach@radonc17.ucsf.edu
authors.forename: Mack
authors.initials: M
authors.lastname: Roach
authors.forename: Vivian
authors.initials: V
authors.lastname: Weinberg
authors.forename: Howard
authors.initials: H
authors.lastname: Sandler
authors.forename: Ian
authors.initials: I
authors.lastname: Thompson
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use; D003131:Combined Modality Therapy; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D009367:Neoplasm Staging / Q000379:methods* / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000145:classification / Q000473:pathology* / Q000628:therapy; D011878:Radiotherapy / Q000379:methods; D015203:Reproducibility of Results; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis
chemical_list: D018931:Antineoplastic Agents, Hormonal; D017430:Prostate-Specific Antigen