What should a clinician obtain prior to treating favorable intermediate risk prostate cancer?

Pre-Treatment Assessment for Favorable Intermediate Risk Prostate Cancer

Clinicians should consider cross-sectional imaging (CT or MRI) and bone scan prior to treating favorable intermediate risk prostate cancer, particularly for those with unfavorable intermediate risk features. 1

Risk Stratification Assessment

Before initiating treatment for favorable intermediate risk prostate cancer, clinicians should obtain:

• Complete risk stratification parameters including clinical stage, pathologic grade (Gleason score/Grade Group), PSA level, and assessment of comorbidity-adjusted life expectancy 2
• Consideration of PSA density, tumor volume, and percentage of Gleason pattern 4 disease on biopsy to help distinguish truly favorable intermediate risk patients 1
• Family history assessment, particularly for patients with strong family history of specific cancers (breast, ovarian, pancreatic, gastrointestinal tumors, lymphoma) who may benefit from genetic counseling 1

Imaging Studies

• Cross-sectional imaging (CT or MRI) and bone scan should be considered, particularly for patients with unfavorable intermediate risk features 1
• MRI can provide additional information about local disease extent and may help identify patients who are appropriate candidates for active surveillance versus definitive treatment 1

Treatment Planning Considerations

Prior to treatment, clinicians should discuss and document:

• All appropriate treatment options including active surveillance, radiation therapy, and radical prostatectomy for favorable intermediate risk patients 1
• The increased risk of disease progression with active surveillance compared to definitive treatment (22.9 per 1,000 person-years vs 8.9-9.0 per 1,000 person-years) 1
• The increased risk of metastatic disease with active surveillance (6.3 per 1,000 person-years vs 2.4-3.0 per 1,000 person-years) 1
• Information about radiation therapy options, noting that favorable intermediate risk prostate cancer can be treated with radiation alone, though evidence is less robust than for combining radiotherapy with ADT 1

Special Considerations

• For patients considering focal therapy or HIFU, clinicians must inform them that these interventions are not standard care options due to lack of comparative outcome evidence 1
• For patients with limited life expectancy (≤5 years), watchful waiting rather than definitive treatment should be recommended 1
• For patients considering active surveillance, assessment of factors that may predict reclassification is important, including PSA density, tumor volume, and percentage of Gleason pattern 4 1

Clinical Pitfalls to Avoid

• Failing to distinguish between favorable and unfavorable intermediate risk disease, as these subgroups have significantly different outcomes and treatment recommendations 3, 4
• Recommending active surveillance without thorough assessment of risk factors that may predict disease progression 4
• Neglecting to consider life expectancy and comorbidities when recommending treatment options 1
• Recommending non-standard treatments like HIFU or focal therapy without informing patients about the lack of comparative outcome evidence 1

By following this structured approach to pre-treatment assessment, clinicians can ensure appropriate risk stratification and treatment selection for patients with favorable intermediate risk prostate cancer, optimizing outcomes related to mortality, morbidity, and quality of life.