Patients with Biopsy Gleason Score 3 + 4 Are Not Appropriate Candidates for Active Surveillance

Does the Gleason Score 7 Upgrading Always Predict Worse Prognosis?

OBJECTIVE

To determine the clinical significance of Gleason score(GS) 7 upgraded on radical prostatectomy(RP) and its impact on the prognosis of patients.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) database to study 8832 men diagnosed with M0 GS 3+4/4+3 prostate cancer (PCa) from 2010 to 2015 treated by RP. Logistic regression was used to analyze the effect of clinicopathological characteristics on the Gleason sore upgraded. Cox hazards regression analysis was performed to find significant factors of overall survival (OS).

RESULTS

A total of 6237 (70.6%) biopsy GS 3+4 patients and 2595(29.4%) biopsy GS 4+3 patients were included in the study. Univariate and multivariate logistic regression analysis found that prostate-specific antigen (PSA)>20ng/ml, T stage 3-4, lymph node metastasis are independent risk factors in predicting the incidence of GS upgraded after RP (all P<0.05). Through multivariate analysis, we found that black race, GS upgraded, chemotherapy played significant roles in predicting poor OS (all P<0.05). It was surprising to find that the biopsy GS upgraded in patients with PSA 0-4ng/ml and 4.1-10ng/ml had a significant association with poor OS (all P<0.05). Multivariate analysis showed that only in patients with PSA 4-10ng/ml, biopsy GS upgrade had a statistically important relationship with poor OS (P=0.046).

CONCLUSIONS

Not all patients with GS 7 upgraded had a worse prognosis than those without GS upgraded. Only in patients with PSA 4.1-10ng/ml, biopsy GS 7 upgraded was an independent risk factor affecting OS.

Active Surveillance for Incidental (cT1a/b) Prostate Cancer: Long-Term Outcomes of the Prospective Noninterventional HAROW Study

INTRODUCTION

Optimal treatment for incidental prostate cancer (IPC) after surgical treatment for benign prostate obstruction is still debatable. We report on long-term outcomes of IPC patients managed with active surveillance (AS) in a German multicenter study.

METHODS

HAROW (2008-2013) was designed as a noninterventional, prospective, health-service research study for patients with localized prostate cancer (≤cT2), including patients with IPC (cT1a/b). A follow-up examination of all patients treated with AS was carried out. Overall, cancer-specific, and metastasis-free survival and discontinuation rates were determined.

RESULTS

Of 210 IPC patients, 68 opted for AS and were available for evaluation. Fifty-four patients had cT1a category and 14 cT1b category. Median follow-up was 7.7 years (IQR: 5.7-9.1). Eight patients died of which 6 were still under AS or watchful waiting (WW). No PCa-specific death could be observed. One patient developed metastasis. Twenty-three patients (33.8%) discontinued AS changing to invasive treatment: 12 chose radical prostatectomy, 7 radiotherapy, and 4 hormonal treatment. Another 19 patients switched to WW. The Kaplan-Meier estimated 10-year overall, cancer-specific, metastasis-free, and intervention-free survival was 83.8% (95% CI: 72.2-95.3), 100%, 98.4% (95% CI: 95.3-99.9), and 61.0% (95% CI: 47.7-74.3), respectively. In multivariable analysis, age (RR: 0.97; p < 0.001), PSA density ≥0.2 ng/mL2 (RR: 13.23; p < 0.001), and PSA ≥1.0 ng/mL after surgery (RR: 5.19; p = 0.016) were significantly predictive for receiving an invasive treatment.

CONCLUSION

In comparison with other AS series with a general low-risk prostate cancer population, our study confirmed the promising survival outcomes for IPC patients, whereas discontinuation rates seem to be lower for IPC. Thus, IPC patients at low risk of progression may be good candidates for AS.

Active Surveillance-Is It Feasible for Intermediate-risk Localised Prostate Cancer?

Background

Although active surveillance (AS) is a well-recognised treatment option for localised low-risk prostate cancer (LRPC), its role in the management of localised intermediate-risk prostate cancer (IRPC) is not clear yet and the available literature is slightly contradictory.

Objective

To compare the outcome of AS between LRPC and IRPC patients.

Design, setting, and participants

Between November 2002 and August 2019, 372 men with localised prostate cancer (PC) underwent AS in our hospital based on local departmental protocol.

Outcome measurements and statistical analysis

The primary outcome measures were overall survival, disease progression–free survival, treatment-free survival, and biochemical recurrence–free survival. Survival times in the low- and intermediate-risk groups were compared using Cox regression analysis.

Results and limitations

Out of 372 localised PC patients, 276 (74%) had LRPC and 96 (26%) IRPC. Overall, 86 (31.2%) low-risk and 25 (26%) intermediate-risk patients developed disease progression, and 86 (31.2%) low-risk and 22 (23%) intermediate-risk patients underwent active treatment. Among the treated patients, eight (2.9%) LRPC patients and one (1%) IRPC patient developed biochemical recurrence. In total, only one patient (from the low-risk group) had metastasis and 25 patients passed away (18 from the low-risk and seven from the intermediate-risk group). No death was recorded due to PC in the cohort. There was no difference in any of the survival outcomes between LRPC and IRPC patients in unadjusted analysis as well as when analysis was performed after adjusting the potentially confounding factors. Limitations include relatively short median follow-up time and failure to objectively define the criteria for the selection of IRPC patients suitable for AS.

Conclusions

The option of AS could be considered for carefully selected and well-informed patients with IRPC provided close structured monitoring is maintained.

Patient summary

In this report, we looked at various survival outcomes of active surveillance between low- and intermediate-risk prostate cancer patients in a large British population. There was no difference in any of the survival outcomes between the two groups. We concluded that carefully selected intermediate-risk prostate cancer patients could be offed the option of active surveillance.

Role of multiparametric magnetic resonance imaging to predict postoperative Gleason score upgrading in prostate cancer with Gleason score 3 + 4

BACKGROUND

To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) in Gleason score (GS) 3 + 4 prostate cancer (PCa) and evaluate independent factors in mpMRI that can predict GS upgrading, we compared the outcomes of GS upgrading group and GS non-upgrading group.

PATIENTS AND METHODS

We analyzed the data of 539 patients undergoing radical prostatectomy (RP) for biopsy GS 3 + 4 PCa from two tertiary referral centers. Univariate and multivariate analyses were performed to determine significant predictors of GS upgrading. GS upgrading, the study outcome, was defined as GS ≥ 4 + 3 at definitive pathology at RP specimen.

RESULTS

GS upgrading rate was 35.3% and biochemical recurrence (BCR) rate was 8.0%. GS upgrading group was significantly older (p = 0.015), had significantly higher prebiopsy serum prostate-specific antigen (PSA) level (p = 0.001) and PSA density (p = 0.003), had a higher number of prostate biopsy (p = 0.026). There were 413 lesions (76.6%) of PI-RADS lesion ≥ 4, 236 (57.1%) for PI-RADS 4 and 177 (42.9%) for PI-RADS 5 lesion. Multivariate logistic regression analysis revealed that age (p = 0.045), initial prebiopsy PSA level (p = 0.002) and presence of PI-RADS lesion ≥ 4 (p = 0.044) are independent predictors of GS upgrading.

CONCLUSION

MpMRI can predict postoperative Gleason score upgrading in prostate cancer with Gleason score 3 + 4. Especially, presence of clinically significant PI-RADS lesion ≥ 4, the significant predictor of GS upgrading, in preoperative mpMRI needs to be paid attention and can be helpful for patient counseling on prostate cancer treatment.