Incidence and Predictors of Upgrading and Up Staging among 10,000 Contemporary Patients with Low Risk Prostate Cancer.
PURPOSE
We determined the incidence of pathological upgrading and up staging for contemporary, clinically low risk patients, and identified predictors of having occult, advanced disease to inform the selection of patients for active surveillance.


MATERIALS AND METHODS
We studied 10,273 patients in the SEER database diagnosed with clinically low risk disease (cT1c/T2a, prostate specific antigen less than 10 ng/ml, Gleason 3 + 3 = 6) in 2010 to 2011 and treated with prostatectomy. The primary outcome was the incidence of upgrading to pathological Gleason score 7-10 or up staging to pathological T3-T4/N1 disease. Multivariable logistic regression of cases with complete biopsy data (5,581) identified significant predictors of upgrading or up staging, which were then used to create a risk stratification table.


RESULTS
At prostatectomy 44% of cases were upgraded and 9.7% were up staged. Multivariable analysis of 5,581 patients showed age, prostate specific antigen and percent positive cores (all p < 0.001) but not race were associated with occult, advanced disease. With these variables dichotomized at the median, age older than 60 years (AOR 1.39), prostate specific antigen greater than 5.0 ng/ml (AOR 1.28) and more than 25% positive cores (AOR 1.76) were significantly associated with upgrading (all p < 0.001). Similarly, age older than 60 years (AOR 1.42), prostate specific antigen greater than 5.0 ng/ml (AOR 1.44) and more than 25% positive cores (AOR 2.26) were associated with up staging (all p < 0.001). Overall 60% of 5,581 low risk cases with prostate specific antigen 7.5 to 9.9 ng/ml and more than 25% positive cores were upgraded. This study is limited by possible bias introduced by only using patients selected for prostatectomy.


CONCLUSIONS
Nearly half of clinically low risk patients harbor Gleason 7 or greater, or pT3 or greater disease, and should be risk stratified by prostate specific antigen and percent positive cores for consideration of further testing before deciding on active surveillance.
['Dinh|Kathryn T|KT|', 'Mahal|Brandon A|BA|', 'Ziehr|David R|DR|', 'Muralidhar|Vinayak|V|', 'Chen|Yu-Wei|YW|', 'Viswanathan|Vidya B|VB|', 'Nezolosky|Michelle D|MD|', 'Beard|Clair J|CJ|', 'Choueiri|Toni K|TK|', 'Martin|Neil E|NE|', 'Orio|Peter F|PF|', 'Sweeney|Christopher J|CJ|', 'Trinh|Quoc D|QD|', 'Nguyen|Paul L|PL|']
D000328:Adult D000368:Aged D000369:Aged, 80 and over D001707:Biopsy, Needle D005500:Follow-Up Studies D006801:Humans D015994:Incidence D008297:Male D008404:Massachusetts D008875:Middle Aged D060787:Neoplasm Grading D011237:Predictive Value of Tests D011467:Prostate D017430:Prostate-Specific Antigen D011471:Prostatic Neoplasms D012189:Retrospective Studies D018570:Risk Assessment D015996:Survival Rate
SEER program neoplasm grading neoplasm staging prostatic neoplasms watchful waiting