CaP Active Surveillance

Short Summary

This 64-year-old man with NCCN favorable intermediate-risk prostate cancer (cT1cN0M0, Grade Group 2 with < 1 mm pattern 4) continues on active surveillance with stable PSA kinetics (PSAD 0.11 ng/mL/cc) and a stable PI-RADS 3 lesion on recent multiparametric MRI. We will repeat a serum PSA in 6 months and proceed with a scheduled surveillance MRI-targeted and systematic prostate biopsy in 12 months.

Chief Complaint

Patient presents to the office today for follow-up of prostate cancer on active surveillance, diagnosed in 2022 for cT1cN0M0 Grade Group 2 (Gleason 3+4=7).

Prostate Cancer History

Mr. Arthur Pendelton was initially referred by his PCP, Dr. Sarah Jenkins, and community urologist, Dr. Mark Vance, in 2022 after an elevated PSA of 5.2 ng/mL prompted an evaluation. Initial TRUS-guided biopsy in 05/2022 revealed Grade Group 1 adenocarcinoma in 2 of 12 cores, and subsequent confirmatory MRI-fusion biopsy in 06/2023 demonstrated low-volume Grade Group 2 (Gleason 3+4=7, < 5% pattern 4) in 1 targeted core with a Decipher genomic classifier score of 0.32 (low risk). His most recent multiparametric MRI at Metro Imaging Center in 03/2025 showed a stable 48 cc prostate with a persistent 7 mm PI-RADS 3 lesion in the right mid-gland peripheral zone without extraprostatic extension. His latest PSA from last week is 5.4 ng/mL, which divided by his 48 cc gland volume yields a favorable PSA density of 0.11 ng/mL/cc. He remains an ideal candidate for active surveillance given his low genomic risk, low PSA density, and minimal pattern 4 volume.

Key Information

• Diagnosis: 2022, Grade Group 1 (Gleason 3+3=6) in 2 of 12 cores, max 15% core involvement, PSA 5.2 ng/mL at diagnosis.

• Biopsy History:

  • 05/2022: 45 cc gland; Grade Group 1 (Gleason 3+3=6), 2/12 cores positive, max 15% involvement.
  • 06/2023: 46 cc gland; Grade Group 2 (Gleason 3+4=7), 1/14 cores positive (ROI target), 20% core involvement, < 1 mm pattern 4 (< 5%).

-MRI History:

• 04/2023: 46 cc gland, 7 mm PI-RADS 3 lesion in right mid-gland peripheral zone, performed at Metro Imaging Center.
• 03/2025: 48 cc gland, stable 7 mm PI-RADS 3 lesion in right mid-gland peripheral zone, performed at Metro Imaging Center.

-Genomics history:

• 07/2023: Decipher Prostate Biopsy genomic classifier score 0.32 (Low Risk).

-PSAD: 0.11 ng/mL/cc

-PSA Range: PSA has ranged from 4.8 ng/mL to 5.6 ng/mL over 2022–2025.

-Last DRE: Last DRE 14/04/2025 showed a symmetrically enlarged, smooth prostate (~45 g) with no palpable nodules or induration.

-Tentative plan: Repeat surveillance MRI-targeted and systematic transperineal prostate biopsy in 04/2026 (3 years post-confirmatory biopsy).

HPI Today 04/14/2025

• Patient returns to review his recent surveillance MRI and PSA results; he notes he feels reassured that his numbers are "holding steady and not jumping around."

• Denies gross hematuria, dysuria, pelvic pain, or bone pain; reports mild baseline lower urinary tract symptoms characterized by slow stream and nocturia x 1, stating "as long as I take my Flomax at night, I barely notice any slowdown."

• Multiparametric MRI of the prostate performed on 28/03/2025 at Metro Imaging Center demonstrates a 48 cc gland with a stable 7 mm PI-RADS 3 lesion in the right mid-gland peripheral zone and no lymphadenopathy. I personally reviewed and independently interpreted the scan and concur with findings.

• Serum total PSA drawn on 07/04/2025 at Quest Diagnostics is 5.4 ng/mL (previously 5.1 ng/mL in 10/2024), demonstrating stable PSA kinetics.

-PSAD: 0.11 ng/mL/cc

PMH, PSH, MEDS, ALLERGIES, SH, and FH: This information was reviewed with the patient and in the EMR, with appropriate updates made.

• FH: Updated to note his maternal aunt was recently diagnosed with breast cancer at age 71 (father had localized prostate cancer diagnosed at age 78).
• MEDS: Continues tamsulosin 0.4 mg PO daily and rosuvastatin 10 mg PO daily.

PHYSICAL EXAMINATION: Constitutional: Well-appearing, well-nourished man in no acute distress, alert and oriented x 3. Psychiatric: Cooperative, normal mood and affect, intact judgment and insight, linear thought content without anxiety regarding surveillance. GU exam: DRE reveals normal sphincter tone, a smooth, benign-feeling prostate of approximately 45 g without discrete nodules, induration, or tenderness.

Assessment and Plan

Mr. Pendelton is a 64-year-old man with NCCN favorable intermediate-risk prostate cancer (cT1cN0M0, Grade Group 2, Gleason 3+4=7 with < 5% pattern 4) managed on active surveillance since 2022. His disease parameters remain completely stable with a PSAD of 0.11 ng/mL/cc and a stable mpMRI.

1. Malignant neoplasm of prostate (C61)

   • Assessment: Favorable intermediate-risk prostate cancer on active surveillance. Stable PSA (5.4 ng/mL), low PSAD (0.11 ng/mL/cc), low-risk Decipher (0.32), and stable PI-RADS 3 lesion on 03/2025 mpMRI.
   • Plan: Continue active surveillance protocol. Check serum PSA in 6 months (10/2025). Plan for routine 3-year surveillance transperineal MRI-fusion biopsy in 04/2026.
   • Counseling: Discussed the natural history of low-volume Grade Group 2 disease with low genomic risk and low PSA density. Reviewed that stable imaging and PSA kinetics strongly support safe continuation of surveillance, avoiding overtreatment morbidity unless biopsy progression occurs.

2. Benign prostatic hyperplasia with lower urinary tract symptoms (N40.1)

   • Assessment: Mild, well-controlled LUTS (AUA symptom score 6) on alpha-blocker monotherapy, no retention.
   • Plan: Continue current medical management and monitor symptoms at 6-month intervals. Medication regimen reviewed, including risks, benefits, adherence, and need for adjustments. Decision made to continue tamsulosin (Flomax®) 0.4 mg PO daily based on the patient’s condition and response to treatment.

3. Family history of malignant neoplasm of breast and prostate (Z80.3, Z80.42)

   • Assessment: Father with late-onset prostate cancer and new history of maternal aunt with breast cancer at age 71. Does not strictly meet NCCN criteria for mandatory germline testing, though discussed as an option.
   • Plan: No acute intervention required today; patient declines formal genetic counseling referral at this time.

Orders

• Total PSA (to be drawn in 10/2025)
• Prescription renewal: tamsulosin (Flomax®) 0.4 mg PO daily, #90, 3 refills.

Follow UP

Return to clinic in 6 months (10/2025) with a repeat serum PSA prior to the visit.

Future Considerations

As above, no further considerations based on current literature.

Short Summary

This 64-year-old man with NCCN favorable intermediate-risk prostate cancer (cT1cN0M0, Grade Group 2 with < 1 mm pattern 4) continues on active surveillance with stable PSA kinetics (PSAD 0.11 ng/mL/cc) and a stable PI-RADS 3 lesion on recent multiparametric MRI. We will repeat a serum PSA in 6 months and proceed with a scheduled surveillance MRI-targeted and systematic prostate biopsy in 12 months.

Consent for using AI-assisted documentation tools was obtained from the patient and all other participants before this encounter. All questions were addressed, and the patient understands that declining these tools is an option.