How do you incorporate absolute percent pattern 4 (APP4) into your risk stratification, specifically your recommendation for ADT for intermediate prostate cancer?

Summary: The short answer is that APP4 is unlikely to improve risk prognostication to the extent to which other advanced biomarkers (GC, MMAI, etc.) do. It is also unlikely either alone or in combination with standard clinical factors to serve as a predictive biomarker. Nevertheless, it is certainly reasonable to use NCCN risk grouping alone (or NCCN risk grouping augmented by APP4) for clinical decision-making when commercial biomarkers are unavailable, although data are lacking on the best way to incorporate APP4 into this. A suggestion is offered below, and I use this measure qualitatively as opposed to algorithmically in clinical decision-making. Optimally patients could be enrolled on NRG-GU010 which includes genomic classifier testing...