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Mr John Smith is a 59-year-old man referred for evaluation with recently diagnosed clinical stage T1c prostate cancer. On a routine insurance examination his prostate-specific antigen (PSA) was noted to be 6.3 ng/ml. This prompted a referral to a urologist, who examined the patient and suggested that he undergo a prostate biopsy. His digital rectal examination (DRE) demonstrated a 30-g soft prostate without any discrete nodules. A 12-core transrectal ultrasound (TRUS) biopsy demonstrated Gleason 3 + 3 prostate cancer in 2 out of 12 cores (both right-sided) with a total cancer volume of 20% in each of the cores. He is an otherwise healthy and active businessman. He has mild lower urinary tract symptoms (AUASS 7) and no complaints of erectile dysfunction (SHIM 22). He now presents with his wife for a second opinion regarding treatment options.

Counselling the newly diagnosed prostate cancer patient is one of the more formidable tasks in urology. Patients often desire an active or collaborative role in treatment decision-making [1]. As a result, the healthcare provider is expected to translate and individualize the seemingly endless and often contradictory clinical data that have emerged about this disease over the last 25 years. Uncertainty related to the variable natural history of prostate cancer, the high prevalence of autopsy prostate cancer and the lack of any clear-cut advantage of one treatment modality over another are recurring themes that characterize these data and create a sense of frustration for clinicians. More importantly, the diagnosis of prostate cancer may create distress for as many as 50% of patients, who are faced with complex and controversial decisions that may dramatically alter their quality of life (QOL) [2]. Moreover, men often initially believe that their sexual function will be terminated and are distressed over their partner’s reaction, whereas the partner is often initially less concerned with the quality of life outcomes and more interested in curing the disease [3].

Risk stratification of patients with prostate cancer assists in the selection of patients who are candidates for treatment with curative intent. In addition to providing prognostic information for the individual, it also may provide insight into the urgency with which treatment is instituted. Traditionally, urologists have relied upon serum prostate-specific antigen (PSA), biopsy Gleason score and DRE to predict the final pathological stage at the time of radical prostatectomy. More recently, nomograms have been developed and validated using large cohorts of patients that attempt to predict the biochemical recurrence 5 and 10 years after radical prostatectomy in those patients with clinically localized disease. Despite this, the accuracy of these nomograms falls short of perfect, with concordance indices between 0.68 and 0.84 [4–8]. Moreover, there is evidence that they are even less accurate for that group of low-risk patients based upon favourable PSA, Gleason score and clinical stage [7].

Recently, the utilization of the triad of the ...

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