Understanding the Gleason Scale
Gleason Scale Prostate Cancer In the diagnosis and management of prostate cancer, the Gleason Scale is a crucial tool used to assess the aggressiveness of the disease. It is a grading system that assigns a Gleason Score to prostate cancer based on the appearance of tumor cells under a microscope. Understanding the Gleason Scale and its significance can help both patients and healthcare professionals make informed decisions regarding treatment options and prognosis.
The Prostate Cancer Grading System
The Gleason Scale, named after pathologist Dr. Donald Gleason, uses a grading system ranging from 2 to 10 to classify prostate cancer. The grading is determined by assessing the tumor’s glandular architecture and cellular abnormalities. The higher the Gleason Score, the more aggressive the cancer is likely to be, indicating a higher risk of spreading beyond the prostate.
The Gleason Score is calculated by adding the two most predominant Gleason grades seen in the tissue sample. Each grade is based on the microscopic patterns observed, ranging from 1 (well-differentiated) to 5 (poorly-differentiated). The combination of the two grades determines the Gleason Score, with scores of 6 or lower indicating low-grade (less aggressive) cancer, and scores of 7 or higher suggesting higher-grade (more aggressive) cancer.
Significance of the Gleason Score
The Gleason Score plays a crucial role in guiding treatment decisions and determining the prognosis for prostate cancer patients. It helps healthcare professionals understand the potential for the cancer to grow and spread, aiding in the selection of appropriate treatment approaches. Additionally, the Gleason Score is an essential factor in staging the cancer, which further assists in determining the extent of the disease and developing a comprehensive treatment plan.
A higher Gleason Score is associated with a greater likelihood of the cancer spreading beyond the prostate, potentially impacting treatment options and outcomes. Conversely, a lower Gleason Score suggests a lower risk of aggressive cancer behavior and may indicate a better prognosis. Understanding the Gleason Score allows patients and their healthcare providers to tailor treatment plans based on the individual characteristics of the cancer, leading to more personalized and effective care.
Prostate Cancer Diagnosis
In order to diagnose prostate cancer, a comprehensive diagnostic process is employed, which includes various techniques and tests. The goal of these diagnostic measures is to determine the presence and severity of the disease. One of the key tools used in diagnosing prostate cancer is the Gleason Scale, which plays a vital role in assessing the aggressiveness of the cancer cells.
Prostate cancer diagnosis typically involves:
- Medical history and physical examination
- Prostate-specific antigen (PSA) blood test
- Imaging tests such as ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scan
- Prostate biopsy
The Gleason Score, derived from the Gleason Scale, is an essential component of the diagnostic process. It determines the grade of the cancer based on the appearance of tumor cells under a microscope. The Gleason Score ranges from 2 to 10, with a higher score indicating a higher likelihood of aggressive cancer.
The Gleason Score is determined by assessing the two most prevalent patterns of cancer cells present in a tissue sample obtained from a biopsy. Each pattern is assigned a grade ranging from 1 to 5, and the sum of these two grades produces the Gleason Score. For example, a Gleason Score of 3+4=7 indicates that the cancer is primarily composed of grade 3 cells with some grade 4 cells.
Knowing the Gleason Score helps healthcare professionals develop an appropriate treatment plan and predict the potential behavior of the cancer. Understanding the diagnostic process and the significance of the Gleason Scale empowers patients to make informed decisions about their healthcare.
Staging Prostate Cancer
Prostate cancer staging is a crucial aspect of understanding the extent and progression of the disease. Staging provides valuable information for treatment planning and prognosis. One key factor in prostate cancer staging is the Gleason Grade, which helps assess the aggressiveness of the cancer.
Gleason Grade and Staging
The Gleason Grade is determined by examining prostate tissue samples under a microscope. This grading system assigns a score based on how the cancer cells look and behave. The Gleason Score, ranging from 2 to 10, is calculated by adding the primary Gleason Grade (most common pattern) and the secondary Gleason Grade (second-most common pattern).
The Gleason Grade, along with other factors such as tumor size and spread, is used to determine the stage of prostate cancer. The most commonly used staging system is the TNM system, which categorizes tumors based on their size (T), lymph node involvement (N), and metastasis (M).
Prostate Cancer Stages
The staging of prostate cancer ranges from localized (confined to the prostate gland) to advanced (spread to distant organs). Here are the stages of prostate cancer:
| Stage | Description |
|---|---|
| T1 | The cancer is not detectable by a physical examination or imaging tests, but may be found incidentally during surgery for another condition. |
| T2 | The cancer is confined to the prostate gland and can be felt during a physical examination. |
| T3 | The cancer has spread beyond the prostate gland, possibly invading nearby tissues or organs. |
| T4 | The cancer has spread to nearby structures, such as the bladder, rectum, or pelvic wall. |
| N+ | The cancer has spread to nearby lymph nodes. |
| M1 | The cancer has metastasized to distant organs, such as the bones, liver, or lungs. |
The stage of prostate cancer plays a crucial role in determining appropriate treatment options and predicting outcomes. Early-stage cancers are more likely to be treated with localized therapies, such as surgery or radiation, while advanced-stage cancers may require systemic treatment options, such as hormone therapy or chemotherapy.
Understanding the staging of prostate cancer, in conjunction with the Gleason Grade, provides vital information for developing an individualized treatment plan and improving patient outcomes.
Understanding Gleason Grades
When it comes to diagnosing and treating prostate cancer, understanding Gleason Grades is crucial. Gleason Grades are assigned based on the Gleason Score, a system used to assess the aggressiveness and behavior of prostate cancer cells. The Gleason Score is determined by analyzing tissue samples obtained through biopsy.
The grading system includes scores ranging from 6 to 10, with higher scores indicating more aggressive cancer. Gleason Grades help healthcare professionals and patients make informed treatment decisions, providing insights into the potential outcomes and long-term prognosis.
Each Gleason Grade corresponds to different patterns observed in the tumor cells under a microscope. The two most dominant patterns are assigned individual scores, which are then combined to determine the Gleason Score. For example, a Gleason Score of 7 may consist of a primary pattern score of 3 and a secondary pattern score of 4.
Here is a brief overview of the Gleason Grades and their corresponding Gleason Scores:
| Gleason Grade | Gleason Score |
|---|---|
| Grade 1 | 2-4 |
| Grade 2 | 3-4 |
| Grade 3 | 4-6 |
| Grade 4 | 7-8 |
| Grade 5 | 9-10 |
It is important to note that higher Gleason Scores indicate a more aggressive form of prostate cancer. The Gleason Grade assists healthcare professionals in determining the appropriate treatment strategy, helping to improve patient outcomes.
Understanding Gleason Grades empowers patients to actively participate in their treatment journey, enabling them to ask informed questions and make personalized decisions in collaboration with their healthcare team. By comprehending the significance of the Gleason Score and its corresponding Gleason Grade, individuals can gain a clearer understanding of the nature of their prostate cancer and the potential treatment options available.
Decoding Gleason Patterns
In the diagnosis of prostate cancer, understanding the different Gleason Patterns is crucial for predicting the behavior of the disease. Pathologists play a key role in this process, as they analyze tissue samples to identify these patterns and assign scores that aid in prognosis and treatment planning.
The Gleason Patterns represent the microscopic appearance of tumor cells under a microscope. They range from Pattern 1, which indicates well-differentiated cells resembling normal prostate tissue, to Pattern 5, which represents poorly differentiated cells that may be more aggressive.
Each tissue sample is examined and assigned two Gleason Patterns, representing the two most prevalent patterns observed. These patterns are then combined to form the Gleason Score, which ranges from 2 to 10. A higher score indicates a higher likelihood of aggressive cancer.
Here is an overview of the Gleason Patterns and their characteristics:
- Gleason Pattern 1: Well-differentiated cells resembling normal prostate tissue.
- Gleason Pattern 2: Slightly abnormal cells with subtle changes.
- Gleason Pattern 3: Cells with moderate abnormalities and more disorganized growth.
- Gleason Pattern 4: Cells with significant abnormalities and less gland-like structure.
- Gleason Pattern 5: Highly irregular and poorly differentiated cells.
The Gleason Patterns play a crucial role in determining the prognosis and treatment options for patients with prostate cancer. Higher Gleason Scores and patterns are associated with a higher risk of cancer progression and may warrant more aggressive treatment.
A clear understanding of the Gleason Patterns allows physicians to make informed decisions about the best course of treatment for each patient. It helps to develop personalized treatment plans that consider the aggressiveness of the disease, patient preferences, and overall health.
By decoding the Gleason Patterns, pathologists and healthcare professionals can provide patients with valuable information about their prostate cancer diagnosis and guide them towards the most optimal treatment options.
Prostate Cancer Prognosis
Prostate cancer prognosis plays a crucial role in determining the outlook and treatment options for patients. One of the key factors considered in predicting prognosis is the Gleason Score. This scoring system, named after pathologist Donald F. Gleason, evaluates the aggressiveness of prostate cancer based on the microscopic appearance of tumor cells.
The Gleason Score ranges from 2 to 10, with lower scores indicating cancer cells that closely resemble normal prostate tissue and higher scores representing more abnormal, aggressive cells. A high Gleason Score suggests an increased likelihood of cancer spread beyond the prostate gland.
Research has established a clear correlation between higher Gleason Scores and a poorer prognosis. A higher score indicates a higher risk of disease progression, recurrence, and metastasis. Patients with lower Gleason Scores tend to have better treatment outcomes and longer survival rates.
It’s important to note that prognosis is not solely determined by the Gleason Score. Other factors, such as the stage of cancer, PSA levels, and overall health, are taken into consideration by healthcare professionals when assessing a patient’s prognosis and recommending suitable treatment options.
Survival Rates by Gleason Score
| Gleason Score | 5-Year Survival Rate | 10-Year Survival Rate |
|---|---|---|
| 6 or lower | Nearly 100% | Over 90% |
| 7 | Approximately 93% | Over 70% |
| 8 or higher | Varies depending on stage and other factors | Varies depending on stage and other factors |
These survival rates are estimates and may vary based on individual patient characteristics and other factors. It’s essential to consult with a healthcare professional to accurately understand the prognosis and discuss personalized treatment options.
Next, we will explore how the Gleason Score is interpreted in the pathology report and its significance in guiding treatment decisions.
Interpreting the Pathology Report
When it comes to diagnosing prostate cancer, the pathology report plays a crucial role. It provides valuable information about the tumor’s characteristics and the Gleason Score, which is a key factor in determining treatment options. Understanding how to interpret the pathology report is essential for making informed decisions about prostate cancer diagnosis and treatment.
The pathology report contains several important components that help guide medical professionals in assessing the severity and aggressiveness of the cancer. One of the key elements is the Gleason Score, which is a grading system used to classify tumor cells based on their appearance under a microscope.
The Gleason Score ranges from 6 to 10 and is derived from two primary Gleason Patterns. Each Gleason Pattern represents a different cancer cell growth pattern, and the combination of these patterns determines the overall Gleason Score. The higher the Gleason Score, the more aggressive the cancer is likely to be.
To illustrate the significance of the Gleason Score, here is an example:
| Gleason Pattern | Grade | Percentage of Tumor |
|---|---|---|
| 3 | 3 | 10% |
| 4 | 4 | 90% |
Based on the above example, the Gleason Score would be 7 (3 + 4 = 7). This information helps the healthcare team understand the stage and aggressiveness of the cancer, allowing them to recommend appropriate treatment options.
It is important to note that each pathology report may have additional details and information specific to the patient’s case. Pathologists carefully analyze tissue samples and provide a comprehensive report that outlines important factors such as tumor size, extent of involvement, and presence of any additional markers or anomalies.
Interpreting the pathology report, particularly the Gleason Score, is best done with the guidance of a healthcare professional. They can explain the implications of the report and discuss suitable treatment options based on the specific findings.
By understanding the pathology report and the significance of the Gleason Score, patients and their loved ones can actively participate in the decision-making process and ensure they receive appropriate care for prostate cancer.
Treatment Options for Gleason Scale Prostate Cancer
When it comes to treating Gleason Scale Prostate Cancer, there are several options available. The most appropriate treatment approach depends on various factors, including the patient’s overall health, the stage of the cancer, and the Gleason Score. Here, we explore the different treatment modalities commonly used for Gleason Scale Prostate Cancer.
Surgery
Surgical intervention, such as radical prostatectomy, involves the removal of the prostate gland and surrounding tissues. It is often recommended for localized prostate cancer with a low to intermediate Gleason Score. Surgery aims to remove the cancerous cells and prevent the spread of the disease. However, it may be associated with potential risks and side effects, including erectile dysfunction and urinary incontinence.
Radiation Therapy
Radiation therapy uses high-energy X-rays or other types of radiation to destroy cancer cells. It can be delivered externally or internally. External beam radiation therapy targets the prostate from outside the body, while brachytherapy involves the placement of radioactive sources directly into the prostate. Radiation therapy is commonly used for localized prostate cancer with varying Gleason Scores. Potential side effects may include urinary issues, bowel problems, and erectile dysfunction.
Hormone Therapy
Hormone therapy, also known as androgen deprivation therapy (ADT), aims to reduce the levels of male hormones (androgens) that can fuel the growth of prostate cancer cells. It is often used in combination with other treatments, such as radiation therapy or surgery. Hormone therapy may be recommended for locally advanced or metastatic prostate cancer, including cases with higher Gleason Scores. Side effects may include hot flashes, loss of libido, and osteoporosis.
Other Treatment Modalities
In addition to surgery, radiation therapy, and hormone therapy, there are other treatment options available for Gleason Scale Prostate Cancer. These may include:
- Chemotherapy: Administering drugs that kill cancer cells throughout the body. It is commonly used for advanced or metastatic prostate cancer.
- Immunotherapy: Stimulating the body’s immune system to recognize and destroy cancer cells.
- Targeted therapy: Using drugs that specifically target certain proteins or molecular pathways involved in cancer growth.
- Watchful waiting or active surveillance: Monitoring the cancer closely without immediate treatment, especially for older patients or those with low-risk disease.
It’s important to note that treatment decisions should be made in consultation with a healthcare professional, considering individual factors and preferences. The goal is to choose the most effective and suitable treatment approach based on the patient’s unique circumstances.
| Treatment Modality | Indications | Potential Side Effects |
|---|---|---|
| Surgery (Radical Prostatectomy) | Local disease with low to intermediate Gleason Scores | Erectile dysfunction, urinary incontinence |
| Radiation Therapy (External beam or Brachytherapy) | Localized disease with varying Gleason Scores | Urinary issues, bowel problems, erectile dysfunction |
| Hormone Therapy (Androgen Deprivation Therapy) | Locally advanced or metastatic disease, higher Gleason Scores | Hot flashes, loss of libido, osteoporosis |
| Chemotherapy | Advanced or metastatic disease | Nausea, fatigue, hair loss, decreased blood cell count |
| Immunotherapy | Advanced or metastatic disease | Flu-like symptoms, skin reactions, fatigue |
| Targeted Therapy | Potential applications in various stages of the disease, depending on specific targets | Varies depending on the drug |
| Watchful Waiting or Active Surveillance | Older patients or low-risk disease | Regular monitoring, potential risk of disease progression |
It’s crucial for patients to have open and honest discussions with their healthcare team to fully understand the potential benefits, risks, and side effects associated with each treatment option. By considering the Gleason Score and other factors, individuals can make informed decisions regarding their prostate cancer treatment journey.
Personalized Treatment Approaches
When it comes to treating Gleason Scale Prostate Cancer, a one-size-fits-all approach simply doesn’t work. Each patient is unique, and their specific Gleason Score, overall health, and other factors must be taken into account to determine the most suitable treatment plan.
Personalized treatment approaches for prostate cancer involve tailoring the treatment to individual patients’ needs and characteristics. This ensures that the chosen treatment is not only effective but also minimizes potential side effects.
Following a thorough assessment, the healthcare team will consider various factors in developing a personalized treatment plan:
- Gleason Score: The Gleason Score plays a crucial role in determining the aggressiveness of the cancer. A higher score indicates a more aggressive form of prostate cancer, which may require more intensive treatment.
- Overall Health: The patient’s overall health is an essential consideration when selecting a treatment approach. Factors such as age, existing medical conditions, and functional abilities can influence treatment decisions.
- Tumor Stage and Spread: Assessing the stage and spread of the tumor helps determine the appropriate treatment. This information is typically obtained through imaging tests and further helps in planning the treatment strategy.
- Patient Preferences: Patients’ preferences, beliefs, and goals should be taken into account when deciding on treatment options. Open communication between the healthcare team and the patient is key to ensuring that the chosen treatment aligns with the patient’s priorities.
The table below provides an overview of the various treatment options that may be considered based on the personalized characteristics of the patient:
| Treatment Options | Description |
|---|---|
| Surgery | Removal of the prostate gland and surrounding tissue. Common surgical procedures include radical prostatectomy and robot-assisted laparoscopic prostatectomy. |
| Radiation Therapy | Using high-energy beams or radioactive substances to destroy cancer cells. External beam radiation therapy and brachytherapy are common radiation treatment approaches. |
| Hormone Therapy | Lowering testosterone levels, as prostate cancer growth is often dependent on this hormone. Hormone therapy may involve medications or surgical removal of the testicles (orchidectomy). |
| Active Surveillance | Monitoring the cancer closely without immediate treatment. This approach is suitable for patients with low-risk prostate cancer and a slow-growing tumor. |
| Chemotherapy | Using medications to kill cancer cells or slow their growth. Chemotherapy is typically recommended for advanced or metastatic prostate cancer. |
It is important to note that the treatment options listed here are not exhaustive, and new therapies may become available as research progresses. Each treatment option has its own advantages and potential side effects, which should be thoroughly discussed with the healthcare team.
By incorporating the patient’s Gleason Score and considering their overall health and preferences, personalized treatment approaches offer the best chance for successful outcomes in Gleason Scale Prostate Cancer.
Advances in Gleason Scale Prostate Cancer Research
Significant advancements are being made in the field of Gleason Scale Prostate Cancer research, paving the way for improved diagnosis, staging, and treatment options for patients. Ongoing studies and emerging discoveries are revolutionizing our understanding of this complex disease, offering hope for better outcomes and quality of life.
New Diagnostic Techniques
Innovative diagnostic techniques are being developed and refined to enhance the accuracy and reliability of Gleason Scale Prostate Cancer diagnosis. These include advanced imaging technologies, such as multiparametric magnetic resonance imaging (mpMRI), which provides detailed images of the prostate, aiding in the detection and characterization of tumors.
Precision Medicine Approaches
Researchers are exploring precision medicine approaches that aim to tailor treatment plans based on an individual’s unique tumor characteristics and genetic profile. By understanding the specific molecular alterations driving prostate cancer growth, targeted therapies can be developed to effectively combat the disease while minimizing side effects.
Immunotherapies and Immunomodulators
Immunotherapies and immunomodulators, which harness the power of the immune system to fight cancer cells, are showing promise in Gleason Scale Prostate Cancer research. These innovative treatments aim to boost the body’s natural immune response, helping to eliminate cancer cells and prevent disease progression.
Advancements in Minimally Invasive Surgery
Minimally invasive surgical techniques, such as robotic-assisted prostatectomy, are continually evolving to improve surgical outcomes, reduce complications, and enhance patient recovery. These advancements enable surgeons to perform precise and targeted removal of cancerous tissue, while minimizing damage to surrounding healthy tissues.
Targeted Radiation Therapies
New developments in radiation therapy are revolutionizing the treatment landscape for Gleason Scale Prostate Cancer. Techniques such as intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT) allow for more precise and targeted delivery of radiation, minimizing damage to nearby healthy tissues and reducing side effects.
Prostate Cancer Vaccines
Researchers are exploring the potential of prostate cancer vaccines to stimulate the immune system to recognize and destroy cancer cells. Vaccines targeting specific prostate cancer antigens hold promise for preventing cancer recurrence and improving long-term survival rates.
These advancements in Gleason Scale Prostate Cancer research offer hope for improved outcomes and quality of life for patients. Continued efforts in research and collaboration among scientists, clinicians, and patients will be vital in translating these discoveries into clinical practice and ultimately making a significant impact in the fight against prostate cancer.
Importance of Regular Prostate Cancer Screening
Regular prostate cancer screening plays a crucial role in the early detection and diagnosis of this potentially life-threatening disease. By undergoing routine screenings, individuals can significantly increase their chances of identifying prostate cancer at its earliest stages, when treatment options are most effective.
Prostate cancer screening typically involves a combination of two tests: the prostate-specific antigen (PSA) blood test and the digital rectal exam (DRE). The PSA test measures the level of PSA in the blood, which can be elevated in the presence of prostate cancer. The DRE, performed by a healthcare professional, involves the manual examination of the prostate gland for abnormalities or irregularities.
While prostate cancer screening has proven benefits, it also presents certain challenges. The PSA test, for example, may result in false-positive or false-negative results, leading to unnecessary anxiety or missed diagnoses. It is important to consult with a healthcare professional to determine the appropriate screening interval and discuss the potential risks and benefits based on individual factors and family history.
Regular prostate cancer screening, particularly for individuals at higher risk, such as those with a family history of the disease or of African American descent, can help identify prostate cancer at its earliest stages when treatment is most effective. By prioritizing regular screenings and engaging in open conversations with healthcare providers, individuals can take proactive steps towards managing their health and well-being.
FAQ
What is the Gleason Scale Prostate Cancer?
The Gleason Scale Prostate Cancer is a grading system used to evaluate the aggressiveness and prognosis of prostate cancer. It involves analyzing the microscopic appearance of tumor cells in a prostate biopsy or surgical specimen.
How does the Gleason Scale work?
The Gleason Scale assigns a Gleason Score to prostate cancer based on the patterns observed under a microscope. The score ranges from 2 to 10, with higher scores indicating more aggressive cancer. It helps determine the appropriate treatment options and guides the prognosis.
How is prostate cancer diagnosed using the Gleason Scale?
Prostate cancer is diagnosed using the Gleason Scale through a biopsy. During the biopsy, small tissue samples are obtained from the prostate gland and examined under a microscope. The pattern and extent of tumor cells help assign a Gleason Score and subsequently determine the presence and severity of cancer.
What is the role of the Gleason Grade in prostate cancer staging?
The Gleason Grade, determined by the Gleason Score, plays a significant role in staging prostate cancer. It helps classify the cancer into different stages, such as localized or advanced, based on the aggressiveness of the tumor. Staging assists in treatment planning and predicting the disease's spread and prognosis.
What are Gleason Grades and how are they assigned?
Gleason Grades represent the different patterns observed in prostate cancer cells. Pathologists assign Gleason Grades based on the predominant and secondary patterns present in the tissue sample. The patterns range from 1 to 5, with a higher grade indicating more abnormal and aggressive cells.
What are Gleason Patterns?
Gleason Patterns refer to the specific architectural appearances of tumor cells seen under a microscope. They help classify prostate cancer into various grades (Gleason Grades) and guide treatment decisions. The combination of Gleason Patterns determines the overall Gleason Score.
How does the Gleason Score impact the prognosis of prostate cancer?
The Gleason Score is a strong predictor of prostate cancer prognosis. Higher Gleason Scores indicate more aggressive cancer, which may have a higher chance of spreading and a poorer prognosis. Lower scores suggest less aggressive cancer with better treatment outcomes and chances of survival.
How can the pathology report with a Gleason Score be interpreted?
The pathology report provides important information about the Gleason Score. It includes the primary and secondary grades, as well as the overall Gleason Score. It also describes the percentage of each pattern observed. Consulting with a healthcare professional can help interpret the report accurately and understand the implications for further treatment decisions.
What are the treatment options for Gleason Scale Prostate Cancer?
Treatment options for Gleason Scale Prostate Cancer include surgery (prostatectomy), radiation therapy, hormone therapy, and active surveillance. The choice of treatment depends on various factors, including the Gleason Score, cancer stage, age, overall health, and patient preferences.
Why is personalized treatment important for Gleason Scale Prostate Cancer?
Personalized treatment approaches are crucial for Gleason Scale Prostate Cancer because each patient's condition is unique. Considering the patient's specific Gleason Score, overall health, and other factors helps tailor the treatment plan to maximize effectiveness and minimize side effects.
What are the recent advances in Gleason Scale Prostate Cancer research?
Ongoing research in Gleason Scale Prostate Cancer focuses on improving diagnostic techniques, refining treatment options, and developing targeted therapies. Studies are investigating new biomarkers, genetic testing, and immunotherapies. These advancements aim to enhance early detection, increase treatment precision, and improve outcomes.
Why is regular prostate cancer screening important?
Regular prostate cancer screening is crucial as it enables the early detection of the disease when treatment outcomes are generally better. It involves tests such as the prostate-specific antigen (PSA) blood test and digital rectal exams. Discussing screening options with a healthcare professional can help determine the best approach based on individual risk factors and preferences.
