Dr. Claire de la Calle

And before I even think about selection criteria for active surveillance, I really want to know, first of all, had they had the appropriate workup?

And I think it's premature, for example, to consider active surveillance in a newly diagnosed intermediate risk patient if they haven't had an MRI and followed by a targeted biopsy.

We know that MRI does lead to less misclassification of prostate cancer.

And I also, of course, I would like to have a fairly recent PSA, know what the PSA kinetics are, the PSA density, ideally a thorough review of the pathology, ideally with a GU pathologist.

to know what the type of pattern four is, for example.

And of course, I also want to know the patient's comorbidities, what their life expectancy might be, their family history and genetic background, and their personal cancer management goals as well.

Yes.

Yes, there are a lot of things.

I think one of the first and most important things to look at is the volume of Gleason pattern 4.

So we're talking about intermediate risk patient.

I'm assuming that they're gray group 2.

And so for those patients, the amount of pattern 4 we know is critical.

In fact, studies have shown that with each decile of percent pattern 4 or each additional number of positive cores,

then the risk of adverse outcome increases.

And we know that patients with low-volume gray group 2 disease and really minimal pattern 4 have outcomes that are approaching or essentially the same as patients with low-risk disease.

Although we know it's very important, at the same time, there are so many questions around volume of pattern 4 that still need to be answered, or at the very least, some sort of consensus that I hope eventually will be reached, because we don't really know what is the best way to quantify volume of pattern 4.

Is it the percent Gleason pattern 4, the maximal percent Gleason pattern 4 involvement, the length of the pattern 4?

the maximum length or the total length.

There's so many different ways one can do this.

So that's one important question that we need to address still.