INTRODUCTION AND OBJECTIVE:
Current guidelines support active surveillance (AS) for select patients with favorable intermediate risk (FIR) prostate cancer (PCa). A significant proportion of FIR PCa patients undergoing surgical treatment are found to have evidence of adverse pathology. Our objective was to determine the incidence and predictors of pathologic upgrading in FIR AS patients undergoing radical prostatectomy (RP).
The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting (WW) database was used to identify men younger than 80 years with NCCN FIR PCa initially opting for documented AS/WW between 2010 and 2015 and subsequently underwent RP at least one year following diagnosis. Patients were assigned into one of three subgroups based on their intermediate risk factor: Grade Group (GG) 2, PSA 10-20 ng/ml, or cT2b-c. Pathologic upgrading was present in the GG2 group if pathologic grade was GG3 or worse. For patients in the PSA 10-20 ng/ml and cT2b-c groups, upgrading occurred if pathologic grade was GG2 or worse. Predictors of pathologic upgrading were evaluated using univariable and multivariable logistic regression analysis.
18,760 patients were identified. Pathologic upgrading occurred in 138 (13.3%), 59 (25.0%), and 8,011 (45.8%) patients in the GS 7(3+4), PSA 10-20 ng/ml and cTb-c groups, respectively. On multivariable analysis, predictors of pathologic upgrading included older age at diagnosis: 70-79 versus 40-49 years (OR 3.86, p=0.022 in GG2 group; OR 1.76, p<0.001 in cT2b-c group), a more recent diagnosis (OR 3.64, p=0.005 in PSA 10-20 group; OR 1.34, p<0.001 in cT2b-c group), higher volume disease (OR 17.34, p=0.004 in PSA 10-20 group; OR 1.80, p<0.001 in cT2b-c group), and clinically palpable disease (OR 9.82, p=0.032 in GG2 group, OR 4.57, p=0.042 in PSA 10-20 group). Additional risk factors in the PSA 10-20 group included uninsured (OR 12.52, p=0.035) or Medicaid status (OR 5.74, p=0.047) and diagnosis in a Western region (OR 4.10, p=0.035). Predictors in cT2b-c group included African American race (OR: 1.20, p=0.005) and higher socioeconomic status(OR 1.23, p<0.001).
FIR PCa is a clinically heterogeneous risk group with incidence of pathologic upgrading ranging from 13.3% in those with GS 7(3+4) to 45.8% in those with cT2b-c disease. Risk of pathologic upgrading in FIR PCa patients initially managed with AS/WW is significantly associated with multiple patient-level oncologic and sociodemographic variables.
Source of Funding: