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Case history

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Image not available. A 52-year-old white man attended his local GP surgery following the death of his father from metastatic prostate cancer. He wished to discuss prostate cancer screening. He denied any urinary symptoms, had no medical history of note and was not prescribed any medications. He was married and worked as a self-employed construction engineer. Following a discussion with his GP he requested to have his prostate-specific antigen (PSA) level checked and agreed to a digital rectal examination (DRE). The DRE was normal, but the PSA level was raised at 10 ng/ml. The patient was informed and referred to a urologist through the suspected cancer pathway.

At his initial urology appointment, he was counselled on the risks and benefits of a prostate biopsy and agreed to proceed. An MRI demonstrated stage T2a disease with no gross pelvic lymphadenopathy. His biopsy revealed a Gleason 3+4 adenocarcinoma involving two out of five cores from the left lobe of the prostate, with a maximum single core involvement of 20%. The man was grouped into the intermediate-risk group according to the D'Amico risk criteria.1 A discussion regarding the future management plan was held including the risks and benefits of each treatment option. His options included active surveillance, low-dose brachytherapy, radical prostatectomy or radical external beam radiotherapy in combination with 6 months of androgen deprivation therapy.

Whilst being aware of the potential for progression of his cancer, he chose active surveillance as his primary treatment option, citing the basis for his choice on the potential for interference with his occupation, finances and sex life. A surveillance plan was made for PSA measurements every 3 months, with a rise of 1 ng/ml/year, or an increase in volume or grade at 1 year re-biopsy, as a trigger for reconsideration of active intervention, based on the latest NICE guidelines.2

Why is risk stratification important and how do we currently risk stratify patients with localized disease at diagnosis?

What proportion of men on active surveillance progress to active treatment?

Given the difficultly in deciding between treatment options, are there any precision medicine 'tools' available to help guide decision making?

What would be a potential treatment algorithm for such a tool?

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Why is risk stratification important and how do we currently risk stratify patients with localized disease at diagnosis?

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Localized prostate cancer encompasses a spectrum of disease, spanning from the more aggressive cancer that will lead directly to patient death, to the more indolent that may never cause the patient any harm.3 According to the latest NICE guidance,2 it is estimated that, in the UK, 65% of cases are discovered at stage I-II. The challenges are to confidently identify those with clinically significant disease who require immediate intervention and to avoid overtreatment of those with indolent disease.3 This challenge is particularly important with the ever more frequent diagnosis in asymptomatic men given the availability of PSA testing.4

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