Contemporary management and pathologic outcomes of men with low- and very low-risk prostate cancer.

Abstract

297 Background: The very-low risk (VLR) substratification of prostate cancer has been called into question with the 2022 American Urological Association (AUA) guidelines dropping this designation. Historical data suggested men with VLR disease have a reduced risk of disease progression compared to other low risk (LR) men. In this study, we evaluate contemporary initial management, disease progression, and predictors of upgrading for VLR and LR patients in a multi-centered hospital system. Methods: We retrospectively identified men diagnosed with VLR or LR prostate cancer across our eleven-hospital system (January 2018-September 2022). Active surveillance (AS) was defined as no treatment within 1 year of diagnosis. Adverse pathology at surgery was defined as Gleason Grade (GG) 3-5 or pT3b. Clinical variables were compared with appropriate statistical tests (Wilcoxon rank sum, Chi square, Fisher’s exact). A multivariable logistic regression model evaluated predictors of upgrading (≥GG2). Results: 566 patients (305 VLR, 261 LR) were included. AS was the initial management for 85% and 78% of VLR and LR patients, respectively (p=0.029). With a median follow up time of 26 months, VLR patients were less likely receive treatment versus LR patients (24% vs. 38%, p<0.001) or be reclassified to GG2-5 disease (24% vs. 39%, p<0.001). VLR patients had less volume of disease at diagnosis by percentage of positive cores (7% vs. 16%, p<0.001) and maximum core positivity (7% vs. 20%, p<0.001). On multivariable regression analysis, only pre-biopsy PI-RADS (OR 1.88 for PI-RADS 4 (p=0.030); OR 4.53 for PI-RADS 5 (p<0.001)) and percentage of positive cores (OR 1.02, p=0.039) were significant predictors of upgrading. Of men who receiving surgery, adverse pathology rates were similar for VLR and LR patients (14% vs. 19%, p=0.5). Conclusions: Men with VLR prostate cancer have lower treatment and upgrading rates than LR patients. VLR patients were more likely to be initially managed with AS and forgo definitive treatment, but rates of adverse pathology at surgery were similar. The findings support the AUA decision to drop the VLR substratification, but attention to high MRI PI-RADS and percentage of positive cores at diagnosis should be considered when evaluating risk of disease progression for men with GG1 prostate cancer.[Table: see text]