Effects of Initial Gleason Grade on Outcomes during Active Surveillance for Prostate Cancer

Background: Whether men with Gleason 3 + 4 prostate cancer are appropriate active surveillance (AS) candidates remains a matter of debate. Objective: to evaluate the effects of initial Gleason grade 3 + 3 or 3 + 4 on clinical outcomes during AS. Design, setting, and participants: We retrospectively reviewed outcomes for men on AS between 1990 and 2016 with Gleason 3 + 3 or 3 + 4 who had two or more biopsies. Outcome measurements and statistical analysis: We evaluated associations of diag- nostic grade with reclassification (upgrade >= 3 + 4), treatment, metastasis, adverse surgical pathology, and biochemical recurrence (BCR) after deferred radical prostatectomy (RP), with a sensitivity analysis for the amount of pattern 4 disease. Results and limitations: Of 1243 men, 1119 (90%) had Gleason 3 + 3 and 124 (10%) 3 + 4 on initial biopsy. The 5-yr unadjusted reclassification-free survival was 49% regardless of grade, while patients with Gleason 3 + 4 had lower treatment-free survival (49% vs 64%; p < 0.01). On multivariate Cox analysis, grade was associated with lower risk of reclassification (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.46-0.95) and higher risk of treatment (HR 1.37, 95% CI 1.01-1.85). After RP, patients starting with Gleason 3 +4 had lower unadjusted 2-yr BCR-free survival (69% vs 93%; p = 0.01) and a higher risk of recurrence (HR 3.67, 95% CI 130-10.36). Grade was not associated with metastasis (<1% at 5 yr) or adverse pathology. In sensitivity analyses, a single high-grade core was associated with lower risk of reclassification and multiple high-grade cores were associated with a higher risk of treatment. The number of high-grade cores was not independently associated with BCR. Limitations include selection bias, a limited number of intermediate-risk patients, and length of follow-up. Conclusions: Gleason 3 + 4 at diagnosis was associated with risk of reclassification, treatment, and BCR. The number of high-grade cores may help in stratifying men with Gleason 3 + 4 disease. Patient summary: Some men with Gleason 3 + 4 prostate cancer may be appropriate surveillance candidates, but longer follow-up and evaluation of more patients are necessary. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.