PLANS

Risk Stratification

This plan is formulated from AUA guidelines, Michigan Urologic Surgery Improvement Collective (MUSIC),
Very Low Risk
PSA <10 ng/ml AND Grade Group 1 AND clinical stage T1-T2a AND <34% of biopsy cores positive AND no core with >50% involved, AND PSA density <0.15 ng/ml/cc

Recommend no imaging and AS
Active Surveillance
Low Risk
PSA <10 ng/ml AND Grade Group 1 AND clinical stage T1-T2a


AS preferable for most
If AS, counsel increased risk of metastasis and consider MRI fusion biopsy
Consider offering RP or RT if PSA density > 0.15, BMI >35, African American race, strong family history and extensive Gleason 6 cancer on systematic biopsy cores
Consider genomic tests if AS and if PSA density > 0.15, BMI >35, African American race, strong family history and extensive Gleason 6 cancer on systematic biopsy cores
Intermediate Risk: Favorable 
Grade group 1 (with PSA 10 to <20
Grade group 2 with PSA <10


Recommend RP or RT + ADT
May consider cryotherapy
May consider AS in select patients (small volume, <10% gleason 4), get MRI fusion biopsy & communicate higher risk of metastasis
If life expectancy ≤ 5 yrs, recommend observation or watchful waiting
Intermediate Risk: Unfavorable
Grade group 2 w/ PSA 10 to <20
Grade group 2 with T2b or T2c
Grade group 3 w/ PSA <20

Consider CT or MRI and bone scan
Recommend RP or RT + ADT
May consider cryotherapy
If life expectancy ≤ 5 yrs, recommend observation or watchful waiting
High Risk
PSA >20 ng/ml
Grade group 4 or 5
T3

Needs CT or MRI and bone scan
Recommend RP or RT + ADT
Watchful waiting only asymptomatic men with ≤5 yr life expectancy
No primary ADT unless limited LE and symptoms
Consider genetic referral if strong fam hx of breast, ovarian, pancreatic, other gastrointestinal tumors, lymphoma
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Risk stratification for localized prostate cancer (1)
In low risk, surgical and radiation treatments do not improve survival at 10 years vs. AS, does reduce disease progression and development of metastatic disease shown in PIVOT (10% versus 5%) and PROTECT (6% versus 2%).  AS for intermediate risk has higher rate of metastasis (2,3) 
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MUSIC Life Expectancy Calculator (4)
  1. ​​​AUA Gudielines.Viewed May 10, 2018. http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)
  2. Hamdy FC, Donovan JL, Lane JA et al: 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375:1415. PROTECT TRIAL
  3. Wilt TJ, Brawer MK, Jones KM: Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367:203. PIVOT TRIAL
  4. MUSIC 
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