Adverse Pathologic Features at Radical Prostatectomy: Effect of Preoperative Risk on Oncologic Outcomes

Abstract

BackgroundUp to 30% of patients with low-risk prostate cancer (PCa) are found to have features of aggressive disease at radical prostatectomy (RP). Several predictive nomograms and novel genomic markers have been developed to estimate the risk of adverse pathology in men eligible for active surveillance (AS). However, oncologic risk associated with these findings remains unknown. ObjectiveTo determine if the presence of adverse pathologic features at RP in patients eligible for AS is prognostic of poor oncologic outcome independent of pretreatment risk status. Design, setting, and participantsA total of 2660 patients underwent immediate RP at our institution between 1998 and 2008. Patients were stratified as low, intermediate, or high risk according to the D’Amico clinical risk criteria. Outcome measurements and statistical analysisThe rates of adverse pathology were reported, and the 5-yr risk of biochemical recurrence (BCR) was calculated in the presence of aggressive disease. Results and limitationsThe 5-yr risk of BCR in patients with extracapsular extension (n=937) was 43% (95% confidence interval [CI], 40–46) overall but only 15% (95% CI, 11–22) for those who met the criteria for low risk (n=181). For the 473 patients with pathologic Gleason score 4+3, the risk of recurrence at 5 yr was 41% (95% CI, 37–46) overall, 13% (95% CI, 5–27) for low-risk men (n=41), 41% (95% CI, 35–47) for intermediate-risk men (n=287), and 51% (95% CI, 43–60) for high-risk men (n=145). Limitations include use of BCR as the study end point and surrogate for oncologic outcome in men who received curative treatment. ConclusionsThe presence of pathologically unfavorable disease in patients eligible for AS is not informative as to the safety of this treatment modality. We question the relevance of adverse pathology as the end point for predictive tools designed to guide treatment decisions in low-risk PCa. Patient summaryThe risk of biochemical recurrence associated with adverse pathologic findings at prostatectomy is reduced by approximately 50% in men with clinically low-risk prostate cancer.