Radical prostatectomy then and now: Surgical overtreatment of prostate cancer is declining from 2009 to 2016 at a tertiary referral center

In the era of increasing scrutiny of delivery of quality care, efforts to decrease surgical overtreatment of insignificant prostate cancer (iCaP) continue.

To quantify the incidence of surgical overtreatment over time among a contemporary series of men diagnosed with CaP.

We retrospectively reviewed the medical records and pathologic specimens for men with CaP who underwent radical prostatectomy between January 2009 and December 2016 at a tertiary referral center. Overtreatment, defined as presence of iCaP in radical prostatectomy specimens, was the primary endpoint. iCaP was defined as a tumor of Gleason score no more than 6 and a tumor diameter ≤10 mm (volume <0.5 cc). Independent predictors of iCaP were determined using a multivariable model.

A total of 1,283 men were eligible for analysis. Overtreatment was found in 86 (6.7%) patients. The frequency of overtreatment significantly decreased from 15% (24/165) in 2009 to 3% (4/134) of patients in 2016 (P < 0.001). In the multivariable analysis, prostate-specific antigen density ≥0.15 vs. <0.15 (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.15-0.64, P < 0.01), biopsy Gleason score 3+4 vs. 3+3 (OR 0.15, 95% CI 0.08-0.29, P < 0.01), African American vs. White ethnicity (OR 0.13, 95% CI 0.02-0.96, P = 0.045), and year of surgery (OR 0.88, 95% CI 0.77-0.99, P = 0.03) remained significant predictors of iCaP at surgery. Over the years of study, the odds of overtreatment decreased by 12% annually (OR 0.88, 95 CI 0.77-0.99, P = 0.03). At the same time, the pathological evidence of advanced disease at surgery (≥T3a with/without lymph node involvement) remained unchanged.

Surgical overtreatment of CaP has declined to a rate of approximately 3% at this tertiary referral center; further decline is likely. The decline probably has a multifactorial explanation: decreased rate of overdiagnosis, better patient selection for surgery, or change in the referral pattern.

Urologic oncology. 2018 Jul 28 [Epub ahead of print]

Amirali Salmasi, Izak Faiena, Jason Wu, Anthony E Sisk, Ankush Sachveda, Jacob J Vandel, Karim Chamie, Leonard S Marks, Robert E Reiter

Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, CA; Institute of Urologic Oncology, University of California, Los Angeles, CA. Electronic address: ., Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, CA; Institute of Urologic Oncology, University of California, Los Angeles, CA., Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, CA., Department of Pathology, David Geffen School of Medicine, University of California, Los Angeles, CA., Institute of Urologic Oncology, University of California, Los Angeles, CA., Department of Urology, David Geffen School of Medicine at University of California, Los Angeles, CA; Institute of Urologic Oncology, University of California, Los Angeles, CA; Jonsson Comprehensive Cancer Center, David Geffen School of Medicine, University of California, Los Angeles, CA.

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