Filippou P., Welty C.J., Cowan J.E., Perez N., Shinohara K., Carroll P.R.
European Urology 2015
Background: Biopsy progression on active surveillance (AS) for prostate cancer (PCa) often reflects failure of the initial biopsy to detect cancer present at enrollment. The risks for delayed treatment among men who progress on AS are not well defined. Objective: To report outcomes for men who underwent surgery after AS compared to men who underwent immediate surgery and the influence of selection bias on this outcome. Design, setting, and participants: AS-eligible (ASE) men who underwent radical prostatectomy (RP) after a median of 20 mo of AS were compared to ASE men who underwent RP within 6 mo of diagnosis. A subset of men on AS who underwent RP after upgrade to Gleason 3 + 4 was compared to matched controls with similar pretreatment biopsy features who underwent immediate RP. Outcome measurement and statistical analysis: Rates of adverse pathology (upstaging, positive surgical margin, or Gleason upgrading) were examined. Logistic regression was used to determine associations between treatment subgroup and adverse pathology. Results and limitations: Of 157 ASE men who underwent delayed RP after AS, 54 were upgraded to Gleason 3 + 4 before surgery. ASE men who underwent immediate RP had lower probability of adverse pathology than ASE men who underwent delayed RP (hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.21-0.55). The rate of adverse pathology did not differ between immediate and delayed RP patients matched for pretreatment characteristics (HR 0.79, 95% CI 0.27-2.28). The observational design of this study is its main limitation. Conclusions: When compared to men with similar pretreatment biopsy features, those who underwent delayed RP were not at higher risk of adverse pathology. Patient summary: The oncologic safety of delayed treatment when indicated for men enrolled in active surveillance for prostate cancer is important. We found that men who underwent delayed surgery had similar outcomes to men who underwent immediate prostatectomy. In a large active surveillance cohort, men with low-risk prostate cancer who underwent prostatectomy after upgrading while on active surveillance had similar pathologic outcomes to men with similar preoperative risk features who underwent immediate prostatectomy.