title: Clinical role of pathological downgrading after radical prostatectomy in patients with biopsy confirmed Gleason score 3 + 4 prostate cancer.
abstract: OBJECTIVE
  To identify preoperative factors predicting Gleason score downgrading after radical prostatectomy (RP) in patients with biopsy Gleason score 3+4 prostate cancer and to determine if prediction of downgrading can identify potential candidates for active surveillance (AS).
  
  
  METHODS
  We identified 1317 patients with biopsy Gleason score 3+4 prostate cancers who underwent RP at the Memorial Sloan-Kettering Cancer Center between 2005 and 2013. Several preoperative and biopsy characteristics were evaluated by forward selection regression, and selected predictors of downgrading were analysed by multivariable logistic regression. Decision curve analysis was used to evaluate the clinical utility of the multivariate model.
  
  
  RESULTS
  Gleason score was downgraded after RP in 115 patients (9%). We developed a multivariable model using age, prostate-specific antigen density, percentage of positive cores with Gleason pattern 4 cancer out of all cores taken, and maximum percentage of cancer involvement within a positive core with Gleason pattern 4 cancer. The area under the curve for this model was 0.75 after 10-fold cross validation. However, decision curve analysis revealed that the model was not clinically helpful in identifying patients who will downgrade at RP for the purpose of reassigning them to AS.
  
  
  CONCLUSIONS
  While patients with pathological Gleason score 3 + 3 with tertiary Gleason pattern ≤4 at RP in patients with biopsy Gleason score 3 + 4 prostate cancer may be potential candidates for AS, decision curve analysis showed limited utility of our model to identify such men. Future study is needed to identify new predictors to help identify potential candidates for AS among patients with biopsy confirmed Gleason score 3 + 4 prostate cancer.
authors.affiliation: Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Department of Urology, Tokyo Medical University, Tokyo, Japan.
authors.forename: Tatsuo
authors.initials: T
authors.lastname: Gondo
authors.forename: Bing Ying
authors.initials: BY
authors.lastname: Poon
authors.forename: Kazuhiro
authors.initials: K
authors.lastname: Matsumoto
authors.forename: Melanie
authors.initials: M
authors.lastname: Bernstein
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Sjoberg
authors.forename: James A
authors.initials: JA
authors.lastname: Eastham
mesh_terms: D000368:Aged; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D060787:Neoplasm Grading; D011237:Predictive Value of Tests; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000145:classification / Q000473:pathology* / Q000601:surgery*; D012189:Retrospective Studies
keywords: active surveillance; decision curve analysis; downgrading; prostate; prostatectomy; prostatic neoplasms
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