Kim DW, Chen MH, Wu J, et al. - The present study was performed to explore prostate‐specific antigen levels of ≤ 4 and > 4 ng/ml and risk of prostate cancer‐specific mortality in men with biopsy gleason score 9 to 10 prostate cancer.Researchers enrolled 17,632 men with clinical T1-4 prostate cancer (PC) with a biopsy Gleason score (GS) of 6 to 10 who had undergone radical prostatectomy at a single academic center between February 25, 1992, and February 25, 2016. They used Multivariable Fine and Gray regressions to assess the risk of prostate cancer–specific mortality with an interaction model evaluating the prognostic significance of prostate-specific antigen (PSA) ≤ 4 ng/mL vs PSA > 4 ng/mL among men with PC with a biopsy GS of 9 to 10 versus ≤ 8, with adjustments made for the time-dependent use of adjuvant and/or salvage radiation therapy and androgen deprivation therapy in addition to known PC prognostic factors. This study’s findings demonstrate that some men with PSA ≤ 4 ng/mL and a biopsy GS of 9 to 10 may have pathologic or genetic variants that make them less amenable to a cure with current standards of care. Moreover, additional workup evaluating for small cell, neuroendocrine, and genetic variants should be considered.