Evaluating the Safety of Active Surveillance: Outcomes of Deferred Radical Prostatectomy after an Initial Period of Surveillance.

As enrollment in active surveillance (AS) expands, it is increasingly important to assess potential risks of deferred treatment. We evaluated the risk of prostate specific antigen (PSA) recurrence in a large cohort of men undergoing radical prostatectomy (RP) after initial AS.

The study included men undergoing RP after a period of AS with Gleason grade group (GG) 1 or 2 at diagnosis, clinical ≤T2, and a low or intermediate risk disease at diagnosis. Men were stratified by a composite variable of GG and volume of high-grade cores at diagnosis. Pathological characteristics and recurrence after RP were evaluated.

Of 1,916 men enrolled in AS between 1994 and 2017, 448 (23.4%) underwent deferred RP. Median time to RP was 27 months (IQR 15.5-46.5). At diagnosis, 388 men (86.6%) had GG1 disease, 31 men (6.9%) had GG2 disease with one high-grade core, and 29 men (6.5%) had GG2 with ≥2 high-grade cores. GG2 with ≥2 high-grade cores at diagnosis was associated with an increased risk of recurrence when compared to GG1 disease (HR 3.29, 95%CI 1.49 to 7.26, p<0.01), while GG2 with one high-grade core did not significantly differ from GG1.

Our results support the careful use of AS in men with GG2 and one high-grade core at diagnosis. Men with ≥2 high-grade (GG≥2) cores at diagnosis may benefit from immediate treatment.

The Journal of urology. 2019 Apr 08 [Epub ahead of print]

Ashwin S Balakrishnan, Janet E Cowan, Matthew R Cooperberg, Katsuto Shinohara, Hao G Nguyen, Peter R Carroll

Department of Urology and the UCSF - Helen Diller Family Comprehensive Cancer Center, University of California San Francisco , San Francisco , CA.