This is a good news/bad news blog.

The good news is the introduction of multiparametric MRI (mpMRI) into the world of prostate cancer (PCa), putting an end to the harms of overdiagnosis and overtreatment. Two major examples:

• When mpMRI is the next step after a high PSA, the scan determines biopsy need (or not).
• If a biopsy is positive, mpMRI’s visual portrait facilitates treatment planning.

Matching treatment to the disease maximizes the chance of treatment success yet minimizes side effect risks. For low risk PCa patients, doctors increasingly recommend Active Surveillance (AS) as a way to defer treatment. Holding off on treatment means holding off on side effect risks.

The bad news, however, is that not all low risk PCa behaves the same way. An unknown number of patients who appear to have low risk PCa and opt for AS may be harboring more dangerous disease at a cellular level, unable to be identified by mpMRI or biopsy alone. A mistaken risk level can spell trouble.

Risk stratification for Active Surveillance

Evaluating patients for AS is called risk stratification. Standard risk factor scoring systems include PSA, Gleason score from the biopsy, Grade Group (GG), and tumor stage. Here’s a chart of conventional guidelines:

Risk level	PSA	Gleason score	Grade Group	Stage	Additional notes
Low	<10	≤6 (3+3)	1	T1–T2a	All criteria must be met
Favorable intermediate	10–20	7 (3+4)	2	T2b–T2c	Only ONE intermediate risk factor present
Unfavorable intermediate	10–20	7 (4+3)	3	T2b–T2c	Multiple intermediate risk factors OR Gleason 4+3 OR ≥50% positive cores
High	>20	≥8	4–5	≥T3a	Any ONE criterion qualifies as high risk

In addition, recent studies demonstrate that combining mpMRI results with PSA density (PSAd) may offer good predictability for the presence of clinically significant PCa.

Clinical decision-making for Active Surveillance needs genomic information

Assigning a risk level based on standard risk factor scoring systems may not be enough to know if AS is a safe choice. Genomic testing analyzes a PCa patient’s DNA (genome, or genetic map) to find genetic mutations known to be linked with higher risk PCa. Such cancer cell lines behave in ways that enable them to evade or survive treatment. Patients with such cell lines are not good candidates for AS, even if all their risk factors point to low risk disease.

Thus, genomic testing can identify warning signs. Armed with correct information, a patient’s risk level may be changed from low risk to intermediate risk. Two recent studies illustrate how genomic classifiers have a potential key role in risk stratification for AS:

1. A January 2026 paper described results of using a genomic prostate score (GPS/Oncotype DX) to predict worse PCa findings.^[i] They found that it performed better than mpMRI coupled with PSA density (PSAd), especially when there was uncertainty as to whether a patient with favorable risk PCa could safely choose AS or needed active treatment.
2. At the 2025 Society of Urologic Oncology meeting, a team presented their study using the Decipher genomic classifier to improve risk stratification for patients considering AS. They showed that genomic risk “could further differentiate progression patterns within the same GG [Grade Group] and help personalize AS intensity. … Integration of Decipher with Grade Group may refine biopsy intervals, support continued AS in patients with favorable genomics, and identify those who may require earlier definitive treatment.”^[ii]

Though some experts recommend increased use of genomic classifiers at the time of PCa diagnosis, such utilization is not yet considered a standard of care across all cases. Also, genomic analysis is not evenly applied; underprivileged and minority patients appear underserved in this and other areas.^[iii] 

Genomic testing can make a difference either for or against opting for AS. A review that synthesized data from previously published papers on the impact of genomic classifiers (GC) reported this:

… very low- or low-risk patients with PCa were more likely to have their risk levels classified as the same or lower (GPS, 100% to 88.1%; Decipher, 87.2% to 82.9%; Prolaris, 76.9%). However, 1 randomized trial found that GC testing with GPS reclassified 34.5% of very low-risk and 29.4% of low-risk patients to a higher risk category. Twelve observational studies indicated that treatment decisions after GC testing either remained unchanged or slightly favored active surveillance. In contrast, analyses from a single randomized trial found fewer choices for active surveillance after GPS testing.^[iv]

At the Sperling Prostate Center, we offer genomic testing for appropriate patients who are considering AS. We also provide Focal Laser Ablation and focal TULSA for AS candidates who would prefer an active treatment but are concerned about the urinary or sexual side effects of surgery or radiation.

Focal therapy is a middle ground between AS and whole-gland treatments. It offers excellent cancer control while preserving healthy tissue and normal gland function. After focal treatment, patients continue to monitor for recurrence using mpMRI and PSA density, just as they would during Active Surveillance, but without the worry of cancer growing in their body, or missing a treatment window. If you or a loved one is diagnosed with PCa and considering AS, contact us to learn more.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Ozawa Y, Moschovas MC, Sandri M, Sharma R et al. Predictive Value of the Oncotype Genomic Prostate Score for Adverse Pathology in Active Surveillance Candidates. Prostate. 2026 Jan 18.
[ii] Zhang A et al. Stratifying Risk in Active Surveillance for Prostate Cancer Using Decipher Genomic Classifiers and Gleason Grade Group. Poster presentation delivered at the 2025 SUO meeting. Dec. 2-5, Phoenix AS.
[iii] Ozay ZI, Agarwal N. Race, Ethnicity, and Tumor Genomic Testing in Prostate Cancer. JAMA Netw Open. 2025 May 1;8(5):e259128.
[iv] Tabriz AA, Boyer MJ, Gordon AM, Carpenter DJ et al. Impact of Genomic Classifiers on Risk Stratification and Treatment Intensity in Patients With Localized Prostate Cancer : A Systematic Review. Ann Intern Med. 2025 Feb;178(2):218-228.