Biopsy Gleason pattern 4 burden refines preoperative risk stratification in prostate cancer.

The cohort was racially and ethnically diverse (76% Black or Hispanic/Latino).

Adverse surgical pathology occurred in 38% of patients and 17% experienced biochemical recurrence within 3 years of surgery.

Adverse surgical pathology risk rose 15% per 2-millimeter increase in total length of pattern 4 on biopsy.

Among risk stratification models, the P4RS demonstrated the highest discrimination (concordance index 0.728).