An Automated, Pathologist-free Gleason Grade Stratifies Disease-free Interval Comparably to Expert Grading from a Single Out-of-distribution Slide

Automated Gleason grading now matches expert pathologists on the cohorts where systems are developed and tuned, but deployment-relevant gaps remain: whether an automated grade, applied without site-specific tuning or pathologist oversight, stratifies outcome comparably to expert grading on slides from unseen institutions and in cross-specimen applications. We tested this for disease-free interval (DFI), a curated recurrence endpoint. A production gland-level prostate diagnostic (PathTools Prostate v11.0) was applied frozen and uncalibrated to 298 diagnostic whole-slide images from 274 TCGA-PRAD radical-prostatectomy patients, a cohort outside its development distribution and needle-core-biopsy training data, contributed by 25 source sites under heterogeneous digitization; tissue was detected automatically with no expert region annotation. From the output we derived an ISUP grade group and continuous high-grade content, and evaluated each grade as a standalone predictor of DFI (24 events) by Harrell’s c-index with 95% bootstrap confidence intervals, a paired between-method bootstrap, and Kaplan-Meier curves with the log-rank test. The automated grade reproduced the clinical grade group at quadratic-weighted κ = 0.62 (95% CI 0.53–0.70; 48% exact, 86% within one group), within the expert inter-observer range. As the sole predictor it stratified recurrence (log-rank p = 0.022; c-index 0.69, 95% CI 0.58–0.79), and the continuous high-grade fraction was robustly prognostic (hazard ratio 1.37 per SD, p = 0.029; c-index 0.71, 0.61–0.81). Standalone discrimination was not statistically separable from the clinical grade (c-index 0.78, 0.69–0.86; paired Δ c-index spanning zero), and in a joint model the automated grade added nothing beyond it, consistent with both measuring a shared morphological axis. From a single out-of-distribution slide with no pathologist oversight, the automated grade provides standalone recurrence stratification not statistically separable from whole-gland expert grading, demonstrating robust generalizability beyond training data; reported as a continuous high-grade fraction, it offers reproducible, expert-free, grade-equivalent risk stratification for harmonizing large archival or genomically-profiled cohorts.