The introduction of prostate-specific antigen (PSA) into the paradigm of early detection has resulted in a stage migration towards more localized, and curable, prostate cancers. This has led, however, to an unfortunate trend to over-diagnosis and over-treatment of biologically insignificant disease. One challenge we face in the modern PSA era is to differentiate men who have disease destined to progress and cause morbidity/mortality from those who will not require immediate, or possibly even delayed, therapeutic intervention. Researchers are attempting to develop a prognostic marker of some type — via molecular, biochemical, imaging and other routes — that will be able to meet this challenge.

Once patients undergo radical intervention for what is thought to be significant cancer, a second challenge is how to predict, preoperatively, which of these men carry a higher risk of developing postoperative recurrence. The current standard of practice is to combine possible predictive factors to broadly “risk stratify”, piecing together preoperative clinicopathologic factors that may suggest the likelihood of recurrence after surgery and the possible need for adjuvant therapies.

This paper reviews the application of preoperative clinical information to determine postoperative risk. We assess different schemas of risk stratification of men with prostate cancer that will give urologists and oncologists the most useful and practical information to plan pre- and post-treatment care.