Association of Age With Risk of Adverse Pathological Findings at Radical Prostatectomy in Men With Gleason Score 6 Prostate Cancer

Fewer systematic prostate core biopsies in clinical stage T1c prostate cancer leads to biochemical recurrence after brachytherapy as monotherapy

BACKGROUND

After brachytherapy, fewer prostate biopsy cores at diagnosis can underestimate the pathological characteristics of prostate cancer (PCa) with lower concordance, resulting in improper treatment, particularly in patients with low-risk nonpalpable cT1c PCa. The aim of this study was to assess the relationship between the number of biopsy cores at diagnosis and long-term clinical outcomes after brachytherapy for cT1c PCa.

METHODS

We reviewed 516 patients with localized cT1c PCa with Gleason scores of 3 + 3 = 6 or 3 + 4 = 7 who underwent brachytherapy as monotherapy without hormonal therapy between January 2005 and September 2014 at our institution. Clinical staging was based on the American Joint Committee on Cancer manual for staging. Thus, the cT1c category is based solely on digital rectal examination. The primary outcome was biochemical recurrence (BCR). Based on the optimized cutoff value for biopsy core number obtained from receiver operating characteristic analysis, patients were divided into the biopsy cores ≤8 (N = 123) and ≥9 (N = 393) groups. The BCR-free survival rate was compared between the groups. Prognostic factors for BCR were evaluated, including age, initial prostate-specific antigen (PSA) level, Gleason score, positive core rate, PSA density, prostate magnetic resonance imaging findings, and biopsy core number.

RESULTS

The median patient age was 66.0 years (interquartile range [IQR]: 61.0-71.0 years), and the median follow-up time was 11.1 years (IQR: 9.5-13.3 years). The median number of core biopsies was 12 (IQR: 9-12). The area under the curve was 0.637 (95% confidence interval [CI]: 0.53-0.75), and the optimal biopsy core cutoff value for BCR prediction was 8.5 (sensitivity = 43.5%, specificity = 77.1%). Although fewer patients had Gleason scores of 3 + 4 = 7 (19/123 [15%] vs. 125/393 [32%], p < 0.02) in the biopsy cores ≤8 group, the 10-year BCR-free survival rate was significantly lower in the biopsy cores ≤8 group than in the biopsy cores ≥9 group (93.8% vs. 96.3%, p < 0.05). Multivariate analysis revealed that a lower biopsy core number (hazard ratio: 0.828, 95% CI: 0.71-0.97, p < 0.03) and a Gleason score of 3 + 4 = 7 (hazard ratio: 3.26, 95% CI: 1.37-7.73, p < 0.01) significantly predicted BCR.

CONCLUSIONS

A low number of prostate core biopsies results in worse BCR-free survival after brachytherapy as monotherapy in patients with cT1c PCa.

Age 70 +/- 5 Years and Cancer-Specific Outcomes After Treatment of Localized Prostate Cancer: A Systematic Review

A secondary analysis of 2 randomized Radiation Therapy Oncology Group trials demonstrated that age ≥70 years was a favorable prognostic factor among men treated with external beam radiation therapy (EBRT). In contrast, several series based on men undergoing radical prostatectomy (RP) suggested that older age was an unfavorable prognostic factor. Our study was initiated to determine whether these observations reflect a true but paradoxical underlying age-related treatment-dependent biological phenomenon. We conducted a systematic review (PubMed, January 1, 1999-January 30, 2023) evaluating the effect of age on cancer-specific outcomes after definitive local treatment with either RP or EBRT. Our main objective was to assess possible interactions between age (using a cutoff of 70 +/- 5 years) and treatment type, with regard to adverse cancer-specific outcomes (eg, pathology, biochemical failure, distant metastasis, or prostate cancer-specific survival). Forty-five studies were selected for inclusion in this systematic review, including 30 and 15 studies with patients treated with RP and EBRT, respectively. Among patients treated with RP, 10 (50%) of these studies suggested that older age was associated with worse outcome(s) after RP. None suggested that age was a favorable prognostic factor after RP. Among the EBRT-based studies, 8 (53%) suggested that older age was associated with better outcomes, with an additional 3 studies (21%) trending to support a better outcome. None of these studies involving EBRT suggested that older age was an adverse prognostic factor. This systematic review suggests that age using a categorical cutoff of 70 +/- 5 years may be an adverse prognostic factor for men undergoing RP but a favorable prognostic factor for men treated with EBRT. Further research is needed to validate these findings.

Association of Age With Risk of Adverse Pathological Findings in Men Undergoing Delayed Radical Prostatectomy Following Active Surveillance

OBJECTIVES

To determine if older men with Gleason grade group (GG) 1 prostate cancer have a higher risk of having adverse pathology at radical prostatectomy after initially being managed with active surveillance (AS).

METHODS

A total of 365 patients with GG1 prostate cancer initially managed with AS followed by delayed radical prostatectomy were identified. The primary outcome was adverse pathology after delayed radical prostatectomy in the men that were <65 years vs. men ≥65 years at the initiation of AS. Adverse pathology was defined as GG ≥3 or pT3 or pN1. Multivariable Cox proportional hazards regression models were used to calculate risk of adverse pathological findings at radical prostatectomy by age group.

RESULTS

At diagnosis, there were no significant differences in median prostate specific antigen density, percent positive biopsy cores, multiparametric magnetic resonance imaging (mpMRI) results or composite genomic classifier scores (derived from three commercially available genomic tests) between the two age groups. Men ≥65 years had more adverse pathology at radical prostatectomy (59.2% vs. 44.1%, P <0.01) and lower rates of biopsy upgrade-free survival and adverse pathology-free survival (log-rank P <0.01). On multivariable analysis age ≥65 years (Hazard Ratio (HR) 2.21, 95% Confidence Interval (CI) 1.57, 3.12) was associated with adverse pathology at radical prostatectomy. In separate multivariable analyses done for each age group, mpMRI (HR 3.33, 95% CI 1.01, 10.95) was predictor of adverse pathology in the group ≥65 years.

CONCLUSION

Older patients might require closer monitoring on AS and additional testing such as mpMRI might improve their risk stratification.

The impact of age on pathological insignificant prostate cancer rates in contemporary robot-assisted prostatectomy patients despite active surveillance eligibility

BACKGROUND

To assess insignificant prostate cancer(iPCa) rates after robot-assisted radical prostatectomy (RARP) in contemporary patients who were preoperatively eligible for active surveillance(AS). IPCa indicates no risk of PCa progression.

METHODS

We retrospectively analysed 2,837 RARP patients (2010-2019) who fulfilled at least one AS entry criteria set - Prostate Cancer Research International - Active Surveillance(PRIAS), University of California San Francisco(UCSF), National Comprehensive Cancer Network(NCCN) or University of Toronto. We utilized four different iPCa definitions, (1) based on pT2 and Gleason score ≤6 and also cumulative tumor-volume (2) ≤2.5mL, (3) ≤0.7mL or (4) ≤0.5mL. For each AS set we tested the rates of iPCa and compared between age <70 vs. ≥70 yrs. This was complemented by multivariable logistic regression(LRM) predicting iPCa, adjusted for age and clinical AS variables. Finally, within the subgroup, who had iPCa, we tested rate of those, who were deemed preoperatively AS ineligible.

RESULTS

Between most(PRIAS) and least stringent(TORONTO) AS sets, iPCa(1) was correctly predicted in 70-57%. Similarly, for iPCa definitions 2-4, rates were (2)59-42%, (3)34-19% and (4)27-14%. Senior patients harbored decreased proportions of iPCa. LRM confirmed that advanced age is associated with a lower chance of iPCa. More stringent AS sets lead to higher rates of AS ineligibility, e.g. 53% for PRIAS, despite iPCa.

CONCLUSIONS

AS sets show limited accuracy for stricter iPCa definitions, which further declined with advanced age. Greater AS stringency resulted in more AS ineligible patients despite harboring iPCa. In consequence, patients are at risk for overtreatment. Clinicians must consider age and different AS sets that result in highly variable detection rates of iPCa.

Prostate Cancer Biomarker Development: National Cancer Institute's Early Detection Research Network Prostate Cancer Collaborative Group Review

Prostate cancer remains the most common non-skin cancer and second leading cause of death among men in the United States. Although progress has been made in diagnosis and risk assessment, many clinical questions remain regarding early identification of prostate cancer and management. The early detection of aggressive disease continues to provide high curative rates if diagnosed in a localized state. Unfortunately, prostate cancer displays significant heterogeneity within the prostate organ and between individual patients making detection and treatment strategies complex. Although prostate cancer is common among men, the majority will not die from prostate cancer, introducing the issue of overtreatment as a major concern in clinical management of the disease. The focus of the future is to identify those at highest risk for aggressive prostate cancer and to develop prevention and screening strategies, as well as discerning the difference in malignant potential of diagnosed tumors. The Prostate Cancer Research Group of the National Cancer Institute's Early Detection Research Network has contributed to the progress in addressing these concerns. This summary is an overview of the activities of the group.See all articles in this CEBP Focus section, "NCI Early Detection Research Network: Making Cancer Detection Possible."