Article Text

Download PDFPDF
Use of the ISUP e-learning module improves interrater reliability in prostate cancer grading
  1. Rachel N Flach1,
  2. Lars Egevad2,
  3. Martin Eklund3,
  4. Theodorus H van der Kwast4,
  5. Brett Delahunt5,
  6. Hemamali Samaratunga6,
  7. Britt B M Suelmann7,
  8. Peter-Paul M Willemse1,
  9. Richard P Meijer1,
  10. Paul J van Diest8
  1. 1Department of Oncological Urology, UMC Utrecht, Utrecht, The Netherlands
  2. 2Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
  3. 3Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
  4. 4Pathology, Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
  5. 5Pathology and Molecular Medicine, University of Otago, Dunedin, New Zealand
  6. 6Aquesta Uropathology and University of Queensland, Brisbane, Queensland, Australia
  7. 7Department of Medical Oncology, UMC Utrecht, Utrecht, The Netherlands
  8. 8Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
  1. Correspondence to Professor Paul J van Diest; p.j.vandiest{at}


Aims Prostate cancer (PCa) grading is an important prognostic parameter, but is subject to considerable observer variation. Previous studies have shown that interobserver variability decreases after participants were trained using an e-learning module. However, since the publication of these studies, grading of PCa has been enhanced by adopting the International Society of Urological Pathology (ISUP) 2014 grading classification. This study investigates the effect of training on interobserver variability of PCa grading, using the ISUP Education web e-learning on Gleason grading.

Methods The ISUP Education Prostate Test B Module was distributed among Dutch pathologists. The module uses images graded by the ISUP consensus panel consisting of 24 expert uropathologists. Participants graded the same 10 images before and after e-learning. We included those who completed the tests before and after training. We evaluated variation in PCa grading in a fully crossed study design, using linearly weighted kappa values for each pathologist, comparing them to other pathologists and to the ISUP consensus panel. We analysed the improvement in median weighted kappas before and after training, using Wilcoxon’s signed rank-test.

Results We included 42 pathologists. Inter-rater reliability between pathologists improved from 0.70 before training to 0.74 after training (p=0.01). When compared with the ISUP consensus panel, five pathologists improved significantly, whereas the kappa of one pathologist was significantly lower after training. All pathologists who improved significantly, graded with less than substantial agreement before training.

Conclusions ISUP Prostate Test B e-learning reduces variability in PCa grading. E-learning is a cost-effective method for standardisation of pathology.

  • Education, Medical
  • Urologic Neoplasms

Data availability statement

Data are available on reasonable request.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Data availability statement

Data are available on reasonable request.

View Full Text


  • Handling editor Runjan Chetty.

  • Contributors Conceptualisation: RF and PJvD; Methodology: ME; Formal analysis and investigation: RF and ME; Writing-original draft preparation: RF; Writing-review and editing: all authors; Funding acquisition: PJvD, RPM and BBS; Resources: LE; Supervision: PJvD. Guarantor: PJvD

  • Funding This research was funded by Quality Foundation of the Dutch Associaton of Medical Specialists (SKMS), Astellas Pharma an Pfizer B.V.

  • Competing interests PJvD received research grants from Quality Foundation of the Dutch Associaton of Medical Specialists (SKMS). RPM received a research grant from Astellas Pharma B.V. BBS received a research grant from Pfizer BV. THvdK receives a consulting fee from Google Inc.

  • Provenance and peer review Not commissioned; externally peer reviewed.