Abstract
ObjectiveTo determine the accuracy of the contemporary Epstein criteria for predicting insignificant and organ-confined prostate cancer in a North African ethnic group of patients who were eligible for active surveillance based on these criteria, but had been subjected to radical prostatectomy. Patients and methodsA total of 340 North African men underwent radical prostatectomy for clinically localized prostate cancer at two academic institutions between January 2006 and September 2013. In 74 of these patients (21.76%), prostate cancer had been assumed to be insignificant based on the contemporary Epstein criteria. The radical prostatectomy specimens were analyzed in order to identify the rate of pathologically unfavorable prostate cancer, defined as either pathologic Gleason score 7–10 and/or a tumor volume>0.5cc, and/or non-organ-confined disease (stage≥pT3a and/or pN1 and/or positive surgical margins). ResultsGleason sum upgrading (≥7) was necessary in 16 (21.6%) and upstaging of the radical prostatectomy specimens in 18 patients (24.3%). Simultaneous upstaging and upgrading of the specimens was observed in 12 patients (16%). A tumor volume≤0.5cc was found in 42 patients (57%). The rate of multifocality of prostate cancer (≥2 foci) was 59.5%. The accuracy of the contemporary Epstein criteria for predicting insignificant prostate cancer was 57%, while it predicted organ-confined disease in 85%. ConclusionThe contemporary Epstein criteria used for the identification of clinically insignificant prostate cancer have been found to underestimate the real state of prostate cancer in as many as 43% of our patients. They were a good tool for predicting organ-confined rather than insignificant prostate cancer in our North African patients. Therefore, caution is advised when the decision on the implementation of active surveillance or focal therapy is solely based on these criteria.
Highlights
As a consequence of the widespread use of assessment of the prostate-specific antigen (PSA) and digital rectal examination (DRE) in combination with extended-core prostate biopsy strategies, there is some concern about the risk of overdiagnosis and overtreatment of some forms of prostate cancer which have a protracted natural history and pose little threat to the patients during their lifetime
The contemporary Epstein criteria used for the identification of clinically insignificant prostate cancer have been found to underestimate the real state of prostate cancer in as many as 43% of our patients
Simultaneous upstaging and upgrading of the prostatectomy specimens was observed in 12 patients (16%)
Summary
As a consequence of the widespread use of assessment of the prostate-specific antigen (PSA) and digital rectal examination (DRE) in combination with extended-core prostate biopsy strategies, there is some concern about the risk of overdiagnosis and overtreatment of some forms of prostate cancer which have a protracted natural history and pose little threat to the patients during their lifetime. The major obstacle to the widespread use of these conservative therapies remains the difficulty in precisely identifying low-risk PCa patients based on their pre-treatment clinical and pathologic features only [5,6]. The age-standardized incidence rate (ASIR) and the age-standardized mortality rate (ASMR) of PCa in Morocco (18.5 per 100,000 and 12.9 per 100,000, respectively, based on GLOBOCAN 2012 data [9]), have constantly increased during the last decades and are among the highest in the Middle East and North Africa (MENA Region). In contrast to western and developed countries where nowadays the usefulness of PSA screening is being questioned, the upward trends in incidence and mortality due to PCa and the high rate of advanced disease in newly diagnosed patients in Morocco and the MENA region will inevitably result in a widespread use of PSA screening and extended-core prostate biopsy. The Epstein criteria are among the most commonly used tools to identify patients with Ins-PCa who will be eligible for AS [10]
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