Section of Urology, Department of Surgery, Medical College of Georgia-Augusta University, Augusta, GA.
Medical College of Georgia, Augusta, GA.
Urol Oncol. 2021 Nov;39(11):782.e7-782.e14. doi: 10.1016/j.urolonc.2021.02.017. Epub 2021 Mar 22.
Current guidelines support active surveillance (AS) for select patients with favorable intermediate risk (FIR) prostate cancer (CaP). A significant proportion of FIR CaP patients undergoing surgical treatment are found to have evidence of adverse pathology. Our objective was to determine the incidence and predictors of pathologic upgrading in FIR AS patients undergoing radical prostatectomy.
The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting (WW) database was used to identify men younger than 80 years with National Comprehensive Cancer Network FIR CaP initially opting for AS and/or WW between 2010 and 2015 and subsequently underwent radical prostatectomy at least one year following diagnosis. Patients were assigned into one of three subgroups based on their intermediate risk factor: Gleason Score 7(3 + 4) (Group 1), prostate specific antigen level of 10-20 ng/ml (Group 2), and cT2b-c (Group 3). Pathologic upgrading was present in Group 1 if pathologic GS was 7 (4 + 3) or worse. For patients in Groups 2 and 3, upgrading occurred if pathologic GS was 7 (3 + 4) or worse. Oncologic and sociodemographic predictors of pathologic upgrading were evaluated univariable and multivariable logistic regression analysis.
18,760 patients were identified. Pathologic upgrading occurred in 138 (13.3%), 59 (25.0%), and 8,011 (45.8%) patients in groups 1, 2, and 3 respectively. Pathologic downgrading occurred in 226 (21.7%) patients in group 1. Significant predictors of pathologic upgrading on multivariable analysis included older age at diagnosis: 70 to 79 vs. 40 to 49 years (Groups 1 and 3, P < 0.05), a more recent diagnosis: 2014 to2015 vs. 2010-2011 (Groups 2 and 3, P < 0.005), higher volume disease: 37.5% to 49.9% vs. 0% to 12.4% (Groups 2 and 3, P < 0.005), and clinically palpable disease (Groups 1 and 2, P < 0.05). Additional risk factors for upgrading included uninsured or Medicaid status, diagnosis in a Western region (Group 2), African American ethnicity and higher socioeconomic status (Group 3) CONCLUSIONS: FIR CaP is a clinically heterogeneous risk group with incidence of pathologic upgrading ranging from 13.3% in those with GS 7 (3 + 4) to 45.8% in those with cT2b-c disease. Risk of pathologic upgrading in FIR CaP patients initially managed with AS and/or WW is significantly associated with multiple patient-level oncologic and sociodemographic variables.
目前的指南支持对具有有利中间风险（FIR）前列腺癌（CaP）的患者进行主动监测（AS）。在接受手术治疗的 FIR CaP 患者中，有相当一部分患者发现存在不良病理证据。我们的目的是确定在接受根治性前列腺切除术的 FIR AS 患者中，病理升级的发生率和预测因素。
使用监测、流行病学和最终结果前列腺与观察等待（WW）数据库，确定年龄小于 80 岁的男性，他们患有国家综合癌症网络 FIR CaP，最初选择在 2010 年至 2015 年期间进行 AS 和/或 WW，并随后在诊断后至少一年接受根治性前列腺切除术。根据中间风险因素，患者被分为三组之一：Gleason 评分 7（3+4）（第 1 组）、前列腺特异性抗原水平为 10-20ng/ml（第 2 组）和 cT2b-c（第 3 组）。如果病理 GS 为 7（4+3）或更差，则第 1 组中存在病理升级。对于第 2 组和第 3 组的患者，如果病理 GS 为 7（3+4）或更差，则会发生升级。使用单变量和多变量逻辑回归分析评估肿瘤学和社会人口统计学预测因素与病理升级的关系。
共确定了 18760 名患者。在第 1、2 和 3 组中，病理升级分别发生在 138（13.3%）、59（25.0%）和 8011（45.8%）名患者中。在第 1 组中，226 名患者发生了病理降级。多变量分析中显著的病理升级预测因素包括：诊断时年龄较大：70-79 岁与 40-49 岁（第 1 组和第 3 组，P <0.05），最近诊断：2014-2015 年与 2010-2011 年（第 2 组和第 3 组，P <0.005），肿瘤体积较大：37.5%至 49.9%与 0%至 12.4%（第 2 组和第 3 组，P <0.005），以及临床可触及的疾病（第 1 组和第 2 组，P <0.05）。升级的其他危险因素包括无保险或医疗补助状态、西部地区的诊断（第 2 组）、非裔美国人种族和较高的社会经济地位（第 3 组）。
FIR CaP 是一组具有临床异质性的风险群体，其病理升级发生率从 GS 7（3+4）的 13.3%到 cT2b-c 疾病的 45.8%不等。最初接受 AS 和/或 WW 治疗的 FIR CaP 患者的病理升级风险与多个患者肿瘤学和社会人口统计学变量显著相关。
