Patients with favorable intermediate-risk prostate cancer (PCa) make up a clinically heterogeneous risk group, with the risk of pathologic upgrading among those initially managed with active surveillance (AS) or watchful waiting (WW) significantly associated with multiple patient-level oncologic and sociodemographic variables, according to investigators.
Using the Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting database, a team led by Zachary Klaassen, MD, MSc, of the Medical College of Georgia-Augusta University and the Georgia Cancer Center in Augusta, studied 18,760 men with favorable intermediate-risk PCa who initially opted for AS and/or WW and who subsequently underwent radical prostatectomy. They divided patients into 3 subgroups: Gleason score 7 (3+4) (group 1), PSA level of 10-20 ng/mL (group 2), and cT2b-c disease (group 3).
Pathologic upgrading occurred in 138 (13.3%), 59 (25.0%), and 8011 (45.8%) of patients in groups 1, 2, and 3, respectively, Dr Klaassen and his colleagues reported in Urologic Oncology. The investigators defined pathologic upgrading as development of Gleason score 4+3 or worse for patients in group 1 and Gleason score 3+4 or worse for patients in groups 2 and 3.
Pathologic downgrading occurred in 226 patients (21.7%) in group 1.
Among patients in groups 2 and 3, those diagnosed in 2014-2015 had significant 3.6-fold and 1.3-fold increased odds of pathologic upgrading, respectively, compared with those diagnosed in 2010-2011. Also in these groups, patients with 37.5%-49.9% percent positive cores had significant 17.3-fold and 1.8-fold increased odds of pathologic upgrading, respectively, compared with those who had 0%-12.4% percent positive cores.
Among patients in group 2, the uninsured and those on Medicaid had significant 12.5-fold 5.7-fold increased odds of pathologic upgrading, respectively, compared with insured patients, according to the investigators.
In group 3, Black patients had significant 1.2-fold increased odds of pathologic upgrading compared with White patients.
Among patients in groups 1 and 2, those with cT2a cancer had significant 9.8-fold and 4.6-fold increased odds of pathologic upgrading, respectively, compared with those who had cT1c cancer.
Sayyid RK, Reed WC, Benton JZ, et al. Pathologic upgrading in favorable intermediate-risk active surveillance patients: Clinical heterogeneity and implications for active surveillance decision. Published online March 22, 2021. Urol Oncol. doi:10.1016/j.urolonc.2021.02.017