Digital pathology-based artificial intelligence algorithms in prostate cancer: inside the 'black box'

Artificial intelligence (AI) algorithms leveraging digital pathology slides are currently transforming the way urological cancers are diagnosed and graded, and they add additional prognostic, predictive and molecular subtyping information beyond traditional pathological risk stratification. This review explores recent advances in histopathology-based AI systems for prostate cancer. We examine how these algorithms perform relative to pathologists for tumour diagnosis and grading, and the ways in which they surpass pathologists with respect to reducing inter-observer variability and providing quantified tumour metrics. We particularly focus on prognostic algorithms that have been benchmarked against 'gold standard' patient outcomes such as metastasis or death, and we highlight the emerging role of digital pathology-enabled AI for predicting response to therapy or underlying tumour molecular alteration status. Finally, we touch on the advantages of, and barriers to, implementation of digital pathology and histopathology-based AI algorithms in clinical practice. Through this synthesis of current literature, we underscore the emerging potential of AI for standardising pathological assessment, guiding clinical management, and improving patient outcomes in prostate cancer.