(Not so low) intermediate risk prostate cancer.

The biologic behaviors of intermediate risk prostate cancer is a grab bag. Thus the emergence of the low-intermediate risk (LIR) subgroup eligible for active surveillance per NCCN guidelines. But keep in mind, the LIR designation is based only on clinicopathologic criteria readily available via biopsy (read: predominantly Gleason 3, <50% of cores involved). A Hopkins study reported last week in JAMA Onc examined the risk of discovering adverse pathological features (read: predominantly Gleason 4, seminal vesicle invasion, nodal met) when prostatectomy is opted by men with LIR and low risk (LR) disease. Only 1 in 20 LR patients were discovered to have adverse features compared to 1 in 4 LIR patients. And even with the retroscope, there were no identifiable pre-op criteria which could tease out the LIR patients harboring bad disease. Given what we now know about sampling error with the standard 12-core biopsy technique, it makes us wonder if only the patients predominantly Gleason 3 on targeted biopsies with low PSA should be grabbed out of the treatment bag and placed on active surveillance.