AUA 2018: Which Patients with Low Risk Prostate Cancer Are Still Receiving Radical Prostatectomy? Impact of Patient Selection on Inverse Stage Migration

San Francisco, CA (UroToday.com) The increasing utilization of conservative approaches such as active surveillance in select patients with low risk prostate cancer substantially reduce the proportion of patients with favorable disease characteristics undergoing radical prostatectomy.  In this study, the authors sought to describe the stage migration towards more aggressive disease characteristics in patients treated by radical prostatectomy.

At two European tertiary care centers from 2006-2016, 17,091 patients underwent radical prostatectomy.  Of those, 4,822 patients were included in the analysis based upon low risk criteria.  The authors used cT1/T2a, Gl 3+3, PSA<10 ng/ml to define low risk.  Statistically, the authors performed Lowess smoother weighted functions, Multivariate Cox regression analysis and studies for temporal trends.

Descriptive statistics include a median age of 63 and preoperative PSA of 5.7 ng/ml.  Pathologically, 35% Gleason 6, 65% Gleason 7 and 1% > Gleason 8.  91% of patients had negative surgical margins and 42% pN0. 

In this study, the proportion of patients with low risk disease decreased from 67.1% in 2006 to 17.6% in 2017 (p<0.001).  Median PSA at diagnosis increased from 5.52 ng/ml to 6.32 from 2006 to 2017.  The rate of low risk individuals upstaged to >pT3b disease increased 1.2% from 2006 to 4.1% in 2016 (p=0.01).  Upgrading on final pathology increased from 42% to 81% (p<0.001).  Multivariate analysis determined 5-year biochemical recurrence to be 8.2% in 2006 to 10.4% in 2016 (p<0.01).

In summary, contemporary low risk prostatectomy patient cohorts have higher PSA, clinical stage, and proportion of positive cores.   A greater risk of upgrading on final pathology is evident as well. This in turn has resulted in higher biochemical recurrence rates.  Dr. Zaffulo states that more accurate preoperative patient selection is needed, as a stage migration is evident. 

Presented by: Emanuele Zaffuto, MD, IRCCS Ospedale San Raffaele, Milan, Italy
Co-Authors: Nicola Fossati, Giorgio Gandaglia, Elio Mazzone, Francesco Cianflone, Paolo Dell'Oglio, Marco Bandini, Armando Stabile, Marco Bianchi, Federico Dehò, Andrea Gallina, Milan, Italy, Rocco Damiano, Catanzaro, Italy, Firas Abdollah, Detroit, MI, Pierre I. Karakiewicz, Montreal, Canada, Felix Preisser, Markus Graefen, Derya Tilki, Hamburg, Germany, Francesco Montorsi, Alberto Briganti, Milan, Italy

Written by:  David B. Cahn, DO, MBS Fox Chase Cancer Center Philadelphia, PA @dbcahn at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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