Rubix cube.

The NCCN/D’Amico risk groups for prostate cancer are widely used, but they predict an endpoint (biochemical recurrence) that some argue is less than clinically meaningful. We now have newer genomic tests that accurately predict distant mets, but they have no clear role in current clinical practice. Thankfully, a new study in JCO marries these clinical and genomic risk groups. Here’s how it works: the NCCN risk groups get points (Low=0, Favorable Intermediate=1, Unfavorable Intermediate=2, and High=3) and Decipher genomic scores get similar points (<0.45=0, 0.45-0.6=1, >0.6=2). You can then add these up to calculate 3- or 6-tier risk classifications. Compared to the old NCCN groups, two-thirds(!) of patients were reclassified across the new 6-tier risk groups. Figure 4 looks like a rubix cube, but what really stands out is 1) a large number of high risk patients become VERY high risk, 2) a large number of low risk patients become VERY low risk, and 3) the favorable/unfavorable intermediate risk category gets a little more clarification. Which means 1) we can know who to treat more aggressively (just not with what), 2) we can more confidently offer active surveillance, and 3) we can better choose the intensity of therapy. This is all great, but what we’re really left wondering is: Can Dan Spratt fix the college playoff system next?