Hiten D. Patel, MD, MPH
In a single-center analysis reported in JAMA Oncology, Hiten D. Patel, MD, MPH, of The James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, and colleagues found that among men undergoing elective radical prostatectomy, those with low-volume intermediate-risk disease had significantly higher rates of adverse pathologic findings than did those with very low-risk and low-risk disease. Recent guidelines have indicated active surveillance may be considered in men with low-volume intermediate-risk disease.
The retrospective study included men with clinically localized very low-risk (n = 1,264), low-risk (n = 4,849), and low-volume intermediate-risk disease (n = 608) undergoing elective radical prostatectomy at The Johns Hopkins Hospital between 2005 and 2016. Low-volume intermediate-risk disease was defined as 1 to 2 cores, Gleason 3 + 4 = 7, and prostate-specific antigen (PSA) level < 20 ng/mL. Proportions of men found to have at least Gleason 4 + 3 = 7 disease and other adverse pathologic features were compared by risk group.
Rates of Adverse Pathologic Findings
The rate of adverse pathologic findings was 24.7% in the low-volume intermediate-risk group, compared with 5.8% in the low-risk group (relative risk [RR] = 4.50, P < .001) and 4.7% in the very low-risk group (RR = 5.14, P < .001). Outcomes were not significantly changed when the low-volume intermediate-risk population was restricted to patients who otherwise met criteria for very low-risk disease (T1c, PSA density < 0.15 ng/mL/cm3, ≤ 50% cancer in any core) or low-risk disease (≤ T2a, PSA < 10 ng/mL). No subgroup of the low-volume intermediate-risk group with rates of adverse pathologic findings similar to those in the very low-risk and low-risk groups could be identified on the basis of preoperative clinical or pathologic characteristics.
On multivariate analysis in the entire population, PSA density was a significant predictor of adverse pathologic findings (odds ratio [OR] per 0.01 change = 1.04, P < .001), with Gleason score having the largest effect (OR = 4.30 for grade group 2 vs grade group 1, P < .001).
The investigators concluded: “Nearly 25% of men (150 of 608) electing immediate radical prostatectomy with low-volume, Gleason 3 + 4 prostate cancer on biopsy are found to harbor adverse surgical pathologic findings. These data do not support the presence of a ‘favorable’ subgroup among included patients and could have important implications for active surveillance in similar patients with Gleason 3 + 4 = 7 prostate cancer.”