PURPOSE: To determine the incidence of pathologic upgrading and upstaging for contemporary, clinically low-risk patients and identify predictors of having occult, advanced disease to inform selection of patients for active surveillance.
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MATERIALS AND METHODS: We studied 10,273 patients in the Surveillance, Epidemiology, and End Results database diagnosed with clinically low-risk disease (cT1c/T2a, Prostate specific antigen(PSA)< 10ng/mL, Gleason 3+3=6) in 2010-2011 and treated with prostatectomy. The primary outcome was the incidence of upgrading to pathologic Gleason score 7-10 or upstaging to pathologic T3-T4/N1 disease. Multivariable logistic regression of men with complete biopsy data (n=5,581) identified significant predictors of upgrading or upstaging, which were then used to create a risk-stratification table.
RESULTS: At prostatectomy, 44% of patients were upgraded and 9.7% were upstaged. Multivariable analysis of 5,581 patients showed age, PSA, and percent positive cores (all p< 0.001), but not race, were associated with occult, advanced disease. With these variables dichotomized at the median, age >60 (Adjusted Odds Ratio[AOR]1.39), PSA>5.0 (AOR1.28), and >25% positive cores (AOR1.76) were significantly associated with upgrading (all p< 0.001). Similarly, age >60 (AOR1.42), PSA>5.0 (AOR1.44), and >25% positive cores (AOR2.26) were associated with upstaging (all p< 0.001). Sixty percent of 5,581 low-risk patients with PSA 7.5-9.9 and >25% positive cores were upgraded. This study is limited by possible bias introduced by only using patients selected for prostatectomy.
CONCLUSIONS: Nearly half of clinically low-risk patients harbor Gleason ≥7 or ≥pT3 disease and should be risk-stratified by PSA and percent positive cores for consideration of further testing before deciding on active surveillance.
Dinh KT, Mahal BA, Ziehr DR, Muralidhar V, Chen YW, Viswanathan VB, Nezolosky MD, Beard CJ, Choueiri TK, Martin NE, Orio PF, Sweeney CJ, Trinh QD, Nguyen PL. Are you the author?
Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA; Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Brigham and Women's Hospital, Boston MA.
Reference: J Urol. 2015 Feb 10. pii: S0022-5347(15)00254-2.