Given the huge variations in AS protocols, it would be impossible for the AUA to have precise guidelines that every institution will follow. You all had a very hard job to do and it was a great first step. As you know I had some issues with it, but on the whole it was excellent. Kudos to you all for getting even that much agreement.
The genomic tests (Prolaris, Oncotype Dx, and Decipher) have never been prospectively validated (only retrospectively validated), and the AUA is right to hold the line for better studies in the future. However for the patient and the physician on the front line, they don't have the luxury of taking the AUA aloof position, they have to make treatment decisions now with the best info they have available. I know many physicians, including ROs who do SRT and AS urologists who use those tests routinely. Some of them are now Medicare approved and insurance may cover them. If I had clearly favorable or clearly unfavorable risk factors, I would not use them. However, if I were sitting with equivocal results, I definitely would.
Statement 33 does not in any way contradict what I said. Klotz started his protocol allowing in patients with GS 3+4. So "adverse reclassification" would have to be GS 4+3. Here's what he wrote:
The authors' [Klotz et al.] approach has been to use PSADT less than 3 years (20% of patients) or grade progression to Gleason 4+3 or higher (5%).
He's made some changes since the start. He now only allows GS 3+4 if pattern 4 is less than 10%. He also eliminated PSADT < 3 years as a treatment trigger. PRIAS, in contrast, uses it.