Adverse Disease Features in Gleason Score 3 + 4 "Favorable Intermediate-Risk" Prostate Cancer: Implications for Active Surveillance

Alessandro Morlacco, John C. Cheville, Laureano J. Rangel, Derek J. Gearman, Robert Jeffrey Karnes

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

Background: According to a recent National Comprehensive Cancer Network (NCCN) guidelines update, patients with Gleason score (GS) 3 + 4 prostate cancer (PCa) and "favorable intermediate-risk" (FIR) characteristics might be offered active surveillance (AS). However, the risk of unfavorable disease features and its prediction in this subset of patients is not completely understood. Objective: To identify the risk of unfavorable disease and potential predictors of adverse outcomes among GS 3 + 4 FIR PCa patients. Design, setting, and participants: The study included patients with biopsy GS 3 + 4 and otherwise fulfilling the NCCN low-risk definition (prostate-specific antigen [PSA] <10 ng/ml, cT2a or lower) undergoing radical prostatectomy (RP) from 2006 to 2014 at a single institution. Outcome measurements and statistical analysis: Complete information on PSA, PSA density (PSAD), clinical stage, percentage of positive cores, percentage of maximum surface specimen involvement, and RP pathology were available. GS upgrade and downgrade, non-organ-confined and non-specimen-confined disease, unfavorable disease (pT3-T4 and/or pN1 and/or a pGS ≥4 + 3) were the outcomes. Statistical analysis included descriptive statistics and multivariable logistic regression. Results and limitations: A total of 156 patients (13.1%) experienced GS upgrade; 201 (16.9%) were downgraded. Overall, 205 men (17.2%) harbored non-organ-confined disease, and 295 (24.8%) had unfavorable disease. Age (odds ratio [OR]: 1.06), percentage surface involvement (OR: 1.01), and PSAD (OR: 1.83) were the only significant predictors of upgrade. Age (OR: 1.05), clinical stage (OR: 1.74), percentage of positive cores >50% (OR 1.57), percentage of surface area (OR: 1.02), and perineural invasion (OR: 1.89) were significant predictors of unfavorable disease at RP. The retrospective design is a limitation. Conclusions: AS is a possible option for a subset of men with FIR GS 3 + 4. However, clinical models alone have a limited role in GS upgrade prediction, and alternative tools warrant further investigation. Patient summary: Patients with Gleason score 3 + 4 at biopsy, low prostate-specific antigen, and low stage might consider the option of active surveillance, but the use of clinical information alone might be not adequate for thorough risk-adapted counseling. Active surveillance might be an option for a selected subset of men with favorable intermediate Gleason Score (GS) 3 + 4; however, clinical models alone have a limited role in GS upgrade prediction in this setting, and alternative tools may warrant further investigation.

Original languageEnglish (US)
JournalEuropean Urology
DOIs
StateAccepted/In press - 2016

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Neoplasm Grading
Prostatic Neoplasms
Prostate-Specific Antigen
Biopsy
Counseling
Neoplasms
Guidelines

Keywords

  • Active surveillance
  • Downgrade
  • Eligibility
  • Gleason 3 + 4
  • Gleason score
  • Prostate cancer
  • Radical prostatectomy
  • Unfavorable disease
  • Upgrade

ASJC Scopus subject areas

  • Urology

Cite this

Adverse Disease Features in Gleason Score 3 + 4 "Favorable Intermediate-Risk" Prostate Cancer : Implications for Active Surveillance. / Morlacco, Alessandro; Cheville, John C.; Rangel, Laureano J.; Gearman, Derek J.; Karnes, Robert Jeffrey.

In: European Urology, 2016.

Research output: Contribution to journalArticle

@article{105b47658b104c408e45f4e4728c8e40,
title = "Adverse Disease Features in Gleason Score 3 + 4 {"}Favorable Intermediate-Risk{"} Prostate Cancer: Implications for Active Surveillance",
abstract = "Background: According to a recent National Comprehensive Cancer Network (NCCN) guidelines update, patients with Gleason score (GS) 3 + 4 prostate cancer (PCa) and {"}favorable intermediate-risk{"} (FIR) characteristics might be offered active surveillance (AS). However, the risk of unfavorable disease features and its prediction in this subset of patients is not completely understood. Objective: To identify the risk of unfavorable disease and potential predictors of adverse outcomes among GS 3 + 4 FIR PCa patients. Design, setting, and participants: The study included patients with biopsy GS 3 + 4 and otherwise fulfilling the NCCN low-risk definition (prostate-specific antigen [PSA] <10 ng/ml, cT2a or lower) undergoing radical prostatectomy (RP) from 2006 to 2014 at a single institution. Outcome measurements and statistical analysis: Complete information on PSA, PSA density (PSAD), clinical stage, percentage of positive cores, percentage of maximum surface specimen involvement, and RP pathology were available. GS upgrade and downgrade, non-organ-confined and non-specimen-confined disease, unfavorable disease (pT3-T4 and/or pN1 and/or a pGS ≥4 + 3) were the outcomes. Statistical analysis included descriptive statistics and multivariable logistic regression. Results and limitations: A total of 156 patients (13.1{\%}) experienced GS upgrade; 201 (16.9{\%}) were downgraded. Overall, 205 men (17.2{\%}) harbored non-organ-confined disease, and 295 (24.8{\%}) had unfavorable disease. Age (odds ratio [OR]: 1.06), percentage surface involvement (OR: 1.01), and PSAD (OR: 1.83) were the only significant predictors of upgrade. Age (OR: 1.05), clinical stage (OR: 1.74), percentage of positive cores >50{\%} (OR 1.57), percentage of surface area (OR: 1.02), and perineural invasion (OR: 1.89) were significant predictors of unfavorable disease at RP. The retrospective design is a limitation. Conclusions: AS is a possible option for a subset of men with FIR GS 3 + 4. However, clinical models alone have a limited role in GS upgrade prediction, and alternative tools warrant further investigation. Patient summary: Patients with Gleason score 3 + 4 at biopsy, low prostate-specific antigen, and low stage might consider the option of active surveillance, but the use of clinical information alone might be not adequate for thorough risk-adapted counseling. Active surveillance might be an option for a selected subset of men with favorable intermediate Gleason Score (GS) 3 + 4; however, clinical models alone have a limited role in GS upgrade prediction in this setting, and alternative tools may warrant further investigation.",
keywords = "Active surveillance, Downgrade, Eligibility, Gleason 3 + 4, Gleason score, Prostate cancer, Radical prostatectomy, Unfavorable disease, Upgrade",
author = "Alessandro Morlacco and Cheville, {John C.} and Rangel, {Laureano J.} and Gearman, {Derek J.} and Karnes, {Robert Jeffrey}",
year = "2016",
doi = "10.1016/j.eururo.2016.08.043",
language = "English (US)",
journal = "European Urology",
issn = "0302-2838",
publisher = "Elsevier",

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TY - JOUR

T1 - Adverse Disease Features in Gleason Score 3 + 4 "Favorable Intermediate-Risk" Prostate Cancer

T2 - Implications for Active Surveillance

AU - Morlacco, Alessandro

AU - Cheville, John C.

AU - Rangel, Laureano J.

AU - Gearman, Derek J.

AU - Karnes, Robert Jeffrey

PY - 2016

Y1 - 2016

N2 - Background: According to a recent National Comprehensive Cancer Network (NCCN) guidelines update, patients with Gleason score (GS) 3 + 4 prostate cancer (PCa) and "favorable intermediate-risk" (FIR) characteristics might be offered active surveillance (AS). However, the risk of unfavorable disease features and its prediction in this subset of patients is not completely understood. Objective: To identify the risk of unfavorable disease and potential predictors of adverse outcomes among GS 3 + 4 FIR PCa patients. Design, setting, and participants: The study included patients with biopsy GS 3 + 4 and otherwise fulfilling the NCCN low-risk definition (prostate-specific antigen [PSA] <10 ng/ml, cT2a or lower) undergoing radical prostatectomy (RP) from 2006 to 2014 at a single institution. Outcome measurements and statistical analysis: Complete information on PSA, PSA density (PSAD), clinical stage, percentage of positive cores, percentage of maximum surface specimen involvement, and RP pathology were available. GS upgrade and downgrade, non-organ-confined and non-specimen-confined disease, unfavorable disease (pT3-T4 and/or pN1 and/or a pGS ≥4 + 3) were the outcomes. Statistical analysis included descriptive statistics and multivariable logistic regression. Results and limitations: A total of 156 patients (13.1%) experienced GS upgrade; 201 (16.9%) were downgraded. Overall, 205 men (17.2%) harbored non-organ-confined disease, and 295 (24.8%) had unfavorable disease. Age (odds ratio [OR]: 1.06), percentage surface involvement (OR: 1.01), and PSAD (OR: 1.83) were the only significant predictors of upgrade. Age (OR: 1.05), clinical stage (OR: 1.74), percentage of positive cores >50% (OR 1.57), percentage of surface area (OR: 1.02), and perineural invasion (OR: 1.89) were significant predictors of unfavorable disease at RP. The retrospective design is a limitation. Conclusions: AS is a possible option for a subset of men with FIR GS 3 + 4. However, clinical models alone have a limited role in GS upgrade prediction, and alternative tools warrant further investigation. Patient summary: Patients with Gleason score 3 + 4 at biopsy, low prostate-specific antigen, and low stage might consider the option of active surveillance, but the use of clinical information alone might be not adequate for thorough risk-adapted counseling. Active surveillance might be an option for a selected subset of men with favorable intermediate Gleason Score (GS) 3 + 4; however, clinical models alone have a limited role in GS upgrade prediction in this setting, and alternative tools may warrant further investigation.

AB - Background: According to a recent National Comprehensive Cancer Network (NCCN) guidelines update, patients with Gleason score (GS) 3 + 4 prostate cancer (PCa) and "favorable intermediate-risk" (FIR) characteristics might be offered active surveillance (AS). However, the risk of unfavorable disease features and its prediction in this subset of patients is not completely understood. Objective: To identify the risk of unfavorable disease and potential predictors of adverse outcomes among GS 3 + 4 FIR PCa patients. Design, setting, and participants: The study included patients with biopsy GS 3 + 4 and otherwise fulfilling the NCCN low-risk definition (prostate-specific antigen [PSA] <10 ng/ml, cT2a or lower) undergoing radical prostatectomy (RP) from 2006 to 2014 at a single institution. Outcome measurements and statistical analysis: Complete information on PSA, PSA density (PSAD), clinical stage, percentage of positive cores, percentage of maximum surface specimen involvement, and RP pathology were available. GS upgrade and downgrade, non-organ-confined and non-specimen-confined disease, unfavorable disease (pT3-T4 and/or pN1 and/or a pGS ≥4 + 3) were the outcomes. Statistical analysis included descriptive statistics and multivariable logistic regression. Results and limitations: A total of 156 patients (13.1%) experienced GS upgrade; 201 (16.9%) were downgraded. Overall, 205 men (17.2%) harbored non-organ-confined disease, and 295 (24.8%) had unfavorable disease. Age (odds ratio [OR]: 1.06), percentage surface involvement (OR: 1.01), and PSAD (OR: 1.83) were the only significant predictors of upgrade. Age (OR: 1.05), clinical stage (OR: 1.74), percentage of positive cores >50% (OR 1.57), percentage of surface area (OR: 1.02), and perineural invasion (OR: 1.89) were significant predictors of unfavorable disease at RP. The retrospective design is a limitation. Conclusions: AS is a possible option for a subset of men with FIR GS 3 + 4. However, clinical models alone have a limited role in GS upgrade prediction, and alternative tools warrant further investigation. Patient summary: Patients with Gleason score 3 + 4 at biopsy, low prostate-specific antigen, and low stage might consider the option of active surveillance, but the use of clinical information alone might be not adequate for thorough risk-adapted counseling. Active surveillance might be an option for a selected subset of men with favorable intermediate Gleason Score (GS) 3 + 4; however, clinical models alone have a limited role in GS upgrade prediction in this setting, and alternative tools may warrant further investigation.

KW - Active surveillance

KW - Downgrade

KW - Eligibility

KW - Gleason 3 + 4

KW - Gleason score

KW - Prostate cancer

KW - Radical prostatectomy

KW - Unfavorable disease

KW - Upgrade

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U2 - 10.1016/j.eururo.2016.08.043

DO - 10.1016/j.eururo.2016.08.043

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C2 - 27574819

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JO - European Urology

JF - European Urology

SN - 0302-2838

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