Pathologic Staging Results in Substantially Higher Risk-stratification Compared with that Predicted by Clinical Risk-stratification in Men with Adenocarcinoma of the Prostate

Abstract

Purpose/Objective(s)We compared preoperative clinical staging with pathologic staging following prostatectomy in men with adenocarcinoma of the prostate. We also evaluated the incidence of positive nodes at the time of surgery and compared it to the predicted risk based on the Roach formula.Materials/MethodsData were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) for the years 2004-2005. Men with adenocarcinoma of the prostate who had complete clinical TNM staging information were included, and descriptive statistics were performed.ResultsA total of 59,351 subjects were identified, of whom 14,842 had a prostatectomy with complete pathologic staging. Clinical T-stage was T1c in 65.3%, T2c in 15.8%, T2a in 7.3%, T2b in 2.9%, and was T3 or greater in 3.6%. Pathologic T-stage was T2c in 63%, T2a in 14.6%, T3a in 10.7%, T3b in 6.6%, T2b in 2.7% and T4 in 2.3%. No subjects had a pathologic T-downstaging. Of 14,842 patients with pathologic nodal data, 2.3% had positive nodes, the majority falling into the high risk group. Only 2.9% of clinically or pathologically staged patients had metastatic disease at presentation. There were 12,441 subjects with AJCC stage I-III disease with complete clinical and pathologic TNM staging, Gleason sum, and PSA data. When stratified into low, intermediate and high risk groups based on the D'Amico criteria, 75.7% of clinically staged low risk patients were up-risk-stratified to the high-risk group after prostatectomy. Amongst intermediate risk group patients, 84.6% were up-risk-stratified. Only 0.9% of patients were down-risk-stratified. Utilizing the Roach formula for subjects who had pathologic nodal evaluation, those with a predicted likelihood of positive nodes of 0-5%, 5.1-10%, 10.1%-15%, and >15% were found to have 0.2%, 0.4%, 1.1%, and 6.5% incidence of positive nodes respectively.ConclusionsComplete pathologic staging results in a higher risk-stratification than that predicted by clinical criteria in the majority of patients. This finding can confound the interpretation of outcomes in matched cohort studies comparing surgical to non-surgical treatments for prostate cancer. Nodal positivity is uncommon in men with prostate cancer at diagnosis. Predictive nomograms based on older surgical series significantly overestimate the actual risk of node positive disease in the current era. Purpose/Objective(s)We compared preoperative clinical staging with pathologic staging following prostatectomy in men with adenocarcinoma of the prostate. We also evaluated the incidence of positive nodes at the time of surgery and compared it to the predicted risk based on the Roach formula. We compared preoperative clinical staging with pathologic staging following prostatectomy in men with adenocarcinoma of the prostate. We also evaluated the incidence of positive nodes at the time of surgery and compared it to the predicted risk based on the Roach formula. Materials/MethodsData were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) for the years 2004-2005. Men with adenocarcinoma of the prostate who had complete clinical TNM staging information were included, and descriptive statistics were performed. Data were obtained from the Surveillance, Epidemiology, and End Results Program (SEER) for the years 2004-2005. Men with adenocarcinoma of the prostate who had complete clinical TNM staging information were included, and descriptive statistics were performed. ResultsA total of 59,351 subjects were identified, of whom 14,842 had a prostatectomy with complete pathologic staging. Clinical T-stage was T1c in 65.3%, T2c in 15.8%, T2a in 7.3%, T2b in 2.9%, and was T3 or greater in 3.6%. Pathologic T-stage was T2c in 63%, T2a in 14.6%, T3a in 10.7%, T3b in 6.6%, T2b in 2.7% and T4 in 2.3%. No subjects had a pathologic T-downstaging. Of 14,842 patients with pathologic nodal data, 2.3% had positive nodes, the majority falling into the high risk group. Only 2.9% of clinically or pathologically staged patients had metastatic disease at presentation. There were 12,441 subjects with AJCC stage I-III disease with complete clinical and pathologic TNM staging, Gleason sum, and PSA data. When stratified into low, intermediate and high risk groups based on the D'Amico criteria, 75.7% of clinically staged low risk patients were up-risk-stratified to the high-risk group after prostatectomy. Amongst intermediate risk group patients, 84.6% were up-risk-stratified. Only 0.9% of patients were down-risk-stratified. Utilizing the Roach formula for subjects who had pathologic nodal evaluation, those with a predicted likelihood of positive nodes of 0-5%, 5.1-10%, 10.1%-15%, and >15% were found to have 0.2%, 0.4%, 1.1%, and 6.5% incidence of positive nodes respectively. A total of 59,351 subjects were identified, of whom 14,842 had a prostatectomy with complete pathologic staging. Clinical T-stage was T1c in 65.3%, T2c in 15.8%, T2a in 7.3%, T2b in 2.9%, and was T3 or greater in 3.6%. Pathologic T-stage was T2c in 63%, T2a in 14.6%, T3a in 10.7%, T3b in 6.6%, T2b in 2.7% and T4 in 2.3%. No subjects had a pathologic T-downstaging. Of 14,842 patients with pathologic nodal data, 2.3% had positive nodes, the majority falling into the high risk group. Only 2.9% of clinically or pathologically staged patients had metastatic disease at presentation. There were 12,441 subjects with AJCC stage I-III disease with complete clinical and pathologic TNM staging, Gleason sum, and PSA data. When stratified into low, intermediate and high risk groups based on the D'Amico criteria, 75.7% of clinically staged low risk patients were up-risk-stratified to the high-risk group after prostatectomy. Amongst intermediate risk group patients, 84.6% were up-risk-stratified. Only 0.9% of patients were down-risk-stratified. Utilizing the Roach formula for subjects who had pathologic nodal evaluation, those with a predicted likelihood of positive nodes of 0-5%, 5.1-10%, 10.1%-15%, and >15% were found to have 0.2%, 0.4%, 1.1%, and 6.5% incidence of positive nodes respectively. ConclusionsComplete pathologic staging results in a higher risk-stratification than that predicted by clinical criteria in the majority of patients. This finding can confound the interpretation of outcomes in matched cohort studies comparing surgical to non-surgical treatments for prostate cancer. Nodal positivity is uncommon in men with prostate cancer at diagnosis. Predictive nomograms based on older surgical series significantly overestimate the actual risk of node positive disease in the current era. Complete pathologic staging results in a higher risk-stratification than that predicted by clinical criteria in the majority of patients. This finding can confound the interpretation of outcomes in matched cohort studies comparing surgical to non-surgical treatments for prostate cancer. Nodal positivity is uncommon in men with prostate cancer at diagnosis. Predictive nomograms based on older surgical series significantly overestimate the actual risk of node positive disease in the current era.