Adverse Pathological Findings at Radical Prostatectomy following Active Surveillance: Results from the Movember GAP3 Cohort

Simple Summary Active surveillance (AS) is a standard option for low-risk prostate cancer patients wishing to preserve their quality of life by avoiding or delaying radical treatment side effects. We investigated the consequences of postponing radical prostatectomy (RP) according to stringent or more expansive criteria at inclusion in active surveillance. Features at radical prostatectomy of men withdrawn from AS showed that most of them still have favorable pathology. Frequency of unfavorable pathology was associated with wider entry criteria, PSA density (PSAD) and age, and time spent in active surveillance. Nonetheless, they are restricted to local tumor extension and positive surgical margins, but do not include tumor grade or lymph node involvement. The prognostic implications of these findings remain uncertain, and a longer follow-up is needed. Background: Little is known about the consequences of delaying radical prostatectomy (RP) after Active Surveillance (AS) according to stringent or wider entry criteria. We investigated the association between inclusion criteria and rates, and timing of adverse pathological findings (APFs) among patients in GAP3 cohorts. Methods: APFs (GG >= 3, pT >= 3, pN > 0 and positive surgical margins [R1]) were accounted for in very low-risk (VLR: grade group [GG] 1, cT1, positive cores < 3, PSA < 10 ng/mL, PSA density [PSAD] < 0.15 ng/mL/cm(3)) and low-risk (LR: GG1, cT1-2, PSA <= 10 ng/mL) patients undergoing subsequent RP. The Kaplan-Meier method and log-rank test analyzed APF-free survival. Stratified mixed effects models analyzed association. Results: Out of 21,169 patients on AS, 1742 (VLR: 721; LR: 1021) underwent delayed RP. Most (60.8%) did not have APFs. APFs occurred more frequently (44.6% vs. 31.7%; OR 1.54, p < 0.001) and earlier (median time: 40.3 vs. 62.6 months; p < 0.001) in LR patients, and consisted of pT >= 3 (OR 1.47, p = 0.013) or R1 (OR 1.80, p < 0.001), but not of GG >= 3 or node involvement. Age (OR 1.05, p < 0.001), PSAD (OR 23.21, p = 0.003), and number of positive cores (OR 1.16, p = 0.004) were independently associated with APFs. Conclusions: AS stands as a safe option for low-risk patients, and most do not have APFs at surgery. Wider entry criteria are associated with pT3 and R1. The prognostic implications remain uncertain.

Automated summary

Active surveillance is a safe option for low-risk prostate cancer patients, and most patients do not show adverse pathological findings at surgery. However, wider entry criteria are associated with higher tumor extension and positive surgical margins.