Long-term and pathological outcomes of low- and intermediate-risk prostate cancer after radical prostatectomy: implications for active surveillance

Valentin H Meissner,Kathleen Herkommer,Mira Woll,Jürgen E Gschwend,Donna P Ankerst,Stefan Schiele

doi:10.1007/s00345-021-03717-2

Valentin H Meissner, Kathleen Herkommer + Show 4 more

Open Access

https://doi.org/10.1007/s00345-021-03717-2

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Abstract

PurposeThe safety of active surveillance (AS) in favorable intermediate-risk (FIR) prostate cancer (PCa) remains uncertain. To provide guidance on clinical decision-making, we examined long-term and pathological outcomes of low-risk and intermediate-risk PCa patients after radical prostatectomy (RP).MethodsThe study involved 5693 patients diagnosed between 1994 and 2019 with low-risk, FIR, and unfavorable intermediate-risk (UIR) PCa (stratification according to the AUA guidelines) who underwent RP. Pathological outcomes were compared, and Kaplan–Meier analysis determined biochemical recurrence-free survival (BRFS) and cancer-specific survival (CSS) at 5, 10, 15, and 20 years. Multiple Cox regression was used to simultaneously control for relevant confounders.ResultsThose at FIR had higher rates of upgrading and upstaging (12.8% vs. 7.2%, p < 0.001; 19.8% vs. 12.0%, p < 0.001) as well as pathological tumor and node stage (≥ pT3a: 18.8% vs. 11.6%, p < 0.001; pN1: 2.7% vs. 0.8%, p > 0.001) compared to patients at low risk. The 20-year BRFS was 69%, 65%, and 44% and the 20-year CSS was 98%, 95%, and 89% in low-risk, FIR, and UIR patients. On multiple Cox regression, FIR was not associated with a worse BRFS (HR 1.07, CI 0.87–1.32), UIR was associated with a worse BRFS (HR 1.49, CI 1.20–1.85).ConclusionPatients at FIR had only slightly worse pathological and long-term outcomes compared to patients at low risk, whereas the difference compared to patients at UIR was large. This emphasizes AS in these patients as a possible treatment strategy in well-counseled patients.

Highlights

Active surveillance (AS) has become a widely accepted standard of care in low-risk prostate cancer (PCa) to reduce overtreatment and associated morbidity
We retrospectively identified patients diagnosed between 1994 and 2019 with low-risk, FIR or unfavorable intermediate-risk (UIR) histologically confirmed PCa treated with radical prostatectomy (RP)
The current study provides additional data that a positive family history or a fatal family history of PCa is not associated with a higher risk of worse long-term outcomes, i.e., biochemical recurrence-free survival (BRFS) and cancer-specific survival (CSS), respectively, in FIR PCa patients

Summary

Introduction

Active surveillance (AS) has become a widely accepted standard of care in low-risk prostate cancer (PCa) to reduce overtreatment and associated morbidity. A further study reported higher rates of adverse pathological outcomes and shorter times to biochemical recurrence in FIR PCa patients compared to patients at low risk after radical prostatectomy (RP) [12]. Another large comparative cohort study of men treated with RP reported worse overall survival in patients classified at FIR compared to low risk [13]. Results of these and previous studies regarding metastasis and survival outcomes did not comprehensively control for relevant confounders and were often limited by either the low number of patients included or the short duration of follow-up. Information on risk factors, such as ethnicity or a positive family history, were lacking

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