Long-term outcomes of men stratified by 4Kscore: a retrospective analysis

Accurately distinguishing men with clinically significant prostate cancer (csCaP) from those with indolent disease remains challenging. Biomarkers such as the 4Kscore enhance risk stratification and guide biopsy decisions. This study assessed the long-term prognostic value of the 4Kscore, evaluating its ability to predict clinical and oncological outcomes.

We retrospectively reviewed men who underwent 4Kscore testing prior to prostate cancer evaluation with long-term follow-up (median 7.3 years). Patients were categorized as low risk (≤5), intermediate risk (5.1-20), or high risk (≥20.1) based on their 4Kscore. Long-term clinical and oncologic outcomes were analyzed across risk groups.

A total of 113 patients were included: 33% low risk, 34% intermediate risk, and 33% high risk. The majority of patients (95%) had MRI at baseline (within 6 months prior or after the 4K score test). During a long-term follow-up (median 7.3 years), csCaP occurred in 19%, 46%, and 65% of the respective groups. No high-grade cancers (≥ GG4) occurred in the low-risk group, whereas such cancers occurred in both the intermediate- and high-risk groups. Compared with low-risk patients, the high-risk group demonstrated a 6-fold increased likelihood of csCaP (HR = 6.95; 95% CI: 2.14-22.73; p = 0.0013) and 4.4-fold higher risk of Grade Group ≥4 disease (HR = 4.43; 95% CI: 2.11-9.09; p < 0.001). No cases of metastasis or prostate cancer-specific mortality occurred among low-risk patients, whereas all such events arose in the intermediate and high-risk groups.

The 4Kscore provides durable long-term prognostic value for prostate cancer risk assessment. A low 4Kscore identifies men at minimal risk, supporting biopsy deferral and reduced overtreatment. Higher scores predict csCaP, aggressive disease, and adverse pathology and outcomes, confirming the 4Kscore's continued relevance for personalized management in the MRI era.