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available at http://www.ncbi.nlm.nih.gov/pubmed/30611659 Editorial Comment: In this prospective evaluation of the Oncotype DX genomic test 1,200 men with very low, low or favorable intermediate risk prostate cancer were enrolled in a multicenter evaluation of the Genomic Prostate Score (GPS). A total of 114 men underwent radical prostatectomy and pathological outcomes were compared with pretreatment GPS. GPS was shown to refine the risk of adverse pathology within each stratile of National Comprehensive Cancer Network (NCCN ) risk (very low, low and favorable intermediate), and the predictive ability remained in multivariate analysis accounting for Gleason score, prostate specific antigen and tumor stage. The study suggests that preoperative GPS can be predictive of risk of adverse pathology in men undergoing radical prostatectomy. However, it is unclear how this knowledge might influence management with the exception of the very low risk cases, ie GPS less than 19, where the risk of adverse pathology is predicted to be 5.9%, with all other stratiles of NCCN/GPS risk demonstrating adverse pathology more than 10% of the time. It is difficult to understand the validity of the predictions since only 10 of 114 patients fell into the very low risk category, and only 1 of these 10 patients had adverse pathology. In the second analysis of the study the authors report that decisional conflict regarding therapy was decreased following knowledge of GPS score. Following GPS score and physician counseling the rate of low decisional conflict improved from 42% to 68%, although it is not well presented how this factor influenced treatment decision since it appears a number of men with low GPS and low NCCN risk of adverse pathology chose treatment. This finding perhaps illustrates that the perception of risk is often in the eye of the beholder, and that physician biases and influence regarding GPS are difficult to separate from the influence of GPS on the patient. I do not believe this data representation allows an adequate assessment of this issue. Samir S. Taneja, MD Suggested Reading Salmasi A, Said J, Shindel AW et al: A 17-gene genomic prostate score assay provides independent information on adverse pathology in the setting of combined multiparametric magnetic resonance imaging fusion targeted and systematic prostate biopsy. J Urol 2018; 200: 564. Nyame YA, Grimberg DC, Greene DJ et al: Genomic scores are independent of disease volume in men with favorable risk prostate cancer: implications for choosing men for active surveillance. J Urol 2018; 199: 438. 212 PROSTATE CANCER Copyright © 2019 American Urological Association Education and Research, Inc. Unauthorized reproduction of this article is prohibited.