Elsevier

Urology

Volume 75, Issue 2, February 2010, Pages 414-418
Urology

Prostate Cancer
Treatment Outcomes of Radical Prostatectomy in Potential Candidates for 3 Published Active Surveillance Protocols

https://doi.org/10.1016/j.urology.2009.07.1353Get rights and content

Objectives

To examine the treatment outcomes of men who would have been eligible for active surveillance (AS) but underwent immediate radical retropubic prostatectomy (RRP). AS protocols are designed to spare the potential morbidity of treatment to patients with low-risk prostate cancer (PCa).

Methods

From a prospective RRP database, we evaluated the tumor features and treatment outcomes for men who would have met 1 of 3 published AS criteria: (1) clinically localized disease, Gleason ≤7, and no significant comorbidities (Patel et al, J Urol. 2004;171:1520-1524) (2) T1b-T2b N0M0 disease, Gleason ≤7, and prostate-specific antigen ≤15 ng/mL (Choo R et al. J Urol. 2002;167:1664-1669), or (3) T1c PCa (Mohler JL et al. World J Urol. 1997;15:364-368.).

Results

3959, 3536, and 2330 RRP patients, respectively, would have met these AS criteria. At surgery, 3%-4% had a Gleason score of 8-10, 16%-19% had positive surgical margins, 15%-18% had extracapsular tumor extension, 3%-5% had seminal vesicle invasion, and 0.4%-1% had lymph node metastasis. The 5-year progression-free survival rate ranged from 84%-89%. Metastasis occurred in 0.1%-1.2%, and 0.1%-0.9% died of PCa. On multivariate analysis, Gleason score >6 was the strongest predictor of biochemical progression.

Conclusions

A substantial proportion of men who might have been considered potential AS candidates had aggressive tumor features at RRP and/or progression. Biopsy Gleason score >6 was the strongest predictor of adverse outcomes, highlighting the importance of limiting AS to patients with Gleason ≤6. Overall, the accurate identification of patients with truly indolent PCa at the time of diagnosis remains challenging.

Section snippets

Material and Methods

Between 1983 and 2006, a total of 4265 men underwent open RRP by a single surgeon (W.J.C.). Patients who met the criteria for 3 published active monitoring protocols were identified: (1) clinically localized disease, biopsy Gleason score ≤7, and no significant co-morbidities (Patel et al)9; (2) clinical stage T1b-T2b N0M0 disease, biopsy Gleason score ≤7, and prostate-specific antigen ≤15 ng/mL (Choo et al)10; or (3) clinical stage T1c disease (Mohler et al).11

In men who met these criteria, but

Results

Of the 4265 original patients, 4060 (95%) had data available for analysis. A total of 3959, 3536, and 2330 men who would have met the Patel,9 Choo,10 and Mohler11 criteria for AS, respectively, were treated by immediate RRP. Table 1 shows the demographic information for patients meeting criteria for each of the 3 protocols. Most patients were white and had a biopsy Gleason score ≤6.

Table 2 shows the pathology tumor features and outcomes data for each subset of patients. Between 3% and 4% of

Comment

To limit the potential for “over-treating” low-risk prostate cancer, several active monitoring protocols have been reported for patients with favorable disease characteristics at the time of diagnosis. The ideal AS protocol would require: (1) an accurate preoperative tool to predict which individuals have truly indolent disease, (2) parameters that can be serially monitored to rapidly identify individuals with disease progression, and (3) the potential for delayed treatment with the same

Conclusions

AS protocols are offered to patients with low-risk prostate cancer. We retrospectively examined the pathology features and biochemical progression-free survival rates among men who would have met 3 active monitoring criteria from the published data but elected active treatment. Of these men, an appreciable proportion had aggressive features in the prostatectomy specimen and/or biochemical progression. Because of the limitations of current clinical staging, some men with apparent low-risk

Acknowledgment

C. Shad Thaxton acknowledges the Robert H. Lurie Comprehensive Cancer Center of Northwestern University for a Zell Family Faculty Award.

References (20)

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Supported by the Urological Research Foundation, Beckman Coulter, Inc., the Prostate SPORE grant (P50 CA90386-05S2) and the Robert H. Lurie Comprehensive Cancer Center grant (P30 CA60553) (to (W.J.C.).

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