Medical Records Abstraction

Medical Abstraction Protocol — For Baseline PCaP

Medical Records Abstraction Protocol — For HCaP-NC visits 1-3 years

Appendix 3. PCaP essential variables

  1. Gleason grades and sums (scores) are recorded from the subject's medical record. If no Gleason sum is reported in the diagnostic biopsy table, Gleone, Gletwo and Glesum are missing. Note that for most subjects who had a prostatectomy, a second set of Gleason grades and sum is also available.
  2. The Gleason grades and sum are reported as indicated in a medical record. These are: the 1° Gleason grade or pattern (assigned to the most predominant histologic pattern in the sample and listed first), the 2° Gleason grade or pattern (assigned to the second most predominant histologic pattern in the sample and listed second) and the Gleason sum or score (the sum of the 1° and 2° Gleason grades, which may sometimes be the only value listed). The primary grade is the first pattern of the sum. If there are more than one positive sites, the pattern with highest Gleason sum is reported. If the sums are the same, the one with the higher primary grade is reported. For example, if someone has three positive sites: 3+3=6, 3+4=7, and 4+3=7, the Gleason 4+3=7 is reported and the 4 is the primary. See Medical Records Abstraction Manual of Procedures for more information.

  3. The PSA range of 365 days prior to diagnosis was set by the PCaP investigators.