Evaluating the Safety of Active Surveillance: Outcomes of Deferred Radical Prostatectomy after an Initial Period of Surveillance

Abstract

Purpose: As enrollment in active surveillance expands, it is increasingly important to assess the potential risks of deferred treatment. We evaluated the risk of prostate specific antigen recurrence in a large cohort of men who underwent radical prostatectomy after initial active surveillance.

Materials and methods: The study included men who underwent radical prostatectomy after a period of active surveillance. At diagnosis the men had GG (Gleason Grade Group) 1 or 2, clinical T2 or less and low or intermediate risk disease. They were stratified by a composite variable of GG and the volume of high grade cores at diagnosis. Pathological characteristics and recurrence after radical prostatectomy were evaluated.

Results: Of 1,916 men enrolled in active surveillance between 1994 and 2017, 448 (23.4%) underwent deferred radical prostatectomy. Median time to radical prostatectomy was 27 months (IQR 15.5-46.5). At diagnosis 388 men (86.6%) had GG1 disease, 31 (6.9%) had GG2 disease with 1 high grade core and 29 (6.5%) had GG2 disease with 2 or more high grade cores. GG2 with 2 or more high grade cores at diagnosis was associated with an increased risk of recurrence compared to GG1 disease (HR 3.29, 95% CI 1.49-7.26, p <0.01). GG2 disease with 1 high grade core did not significantly differ from GG1.

Conclusions: Our results support the careful use of active surveillance in men with GG2 and 1 high grade core at diagnosis. Men with 2 or more high grade (GG2 or greater) cores at diagnosis may benefit from immediate treatment.

Keywords: local; neoplasm recurrence; prostatectomy; prostatic neoplasms; risk; watchful waiting.