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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

Second, with respect to the appropriateness of generalizing our . . . [Full Text of this Article]

Jan-Erik Johansson, MD, PhD
jan-erik.johansson@orebroll.se

Ove Andrén, MD; Swen-Olof Andersson, MD, PhD; Anders Magnusson, BSc
Örebro University Hospital and
Center for Assessment of Medical Technology
Örebro, Sweden

Paul W. Dickman, PhD
Karolinska Institute
Stockholm, Sweden

Lars Holmberg, MD, PhD
Regional Oncologic Center
University Hospital
Uppsala, Sweden

Hans-Olov Adami, MD, PhD
Karolinska Institute
Stockholm, Sweden
Harvard School of Public Health
Boston, Mass

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