title: Incidence and Predictors of Upgrading and Up Staging among 10,000 Contemporary Patients with Low Risk Prostate Cancer.
abstract: OBJECTIVE
  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.
  
  
  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.
authors: Harvard Medical School, Boston, Massachusetts.
authors: Kathryn T
authors: KT
authors: Dinh
authors: Harvard Medical School, Boston, Massachusetts.
authors: Brandon A
authors: BA
authors: Mahal
authors: Harvard Medical School, Boston, Massachusetts.
authors: David R
authors: DR
authors: Ziehr
authors: Harvard Medical School, Boston, Massachusetts.
authors: Vinayak
authors: V
authors: Muralidhar
authors: Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
authors: Yu-Wei
authors: YW
authors: Chen
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts.
authors: Vidya B
authors: VB
authors: Viswanathan
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts.
authors: Michelle D
authors: MD
authors: Nezolosky
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Clair J
authors: CJ
authors: Beard
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Toni K
authors: TK
authors: Choueiri
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Neil E
authors: NE
authors: Martin
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Peter F
authors: PF
authors: Orio
authors: Department of Medical Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Christopher J
authors: CJ
authors: Sweeney
authors: Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors: Quoc D
authors: QD
authors: Trinh
authors: Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: pnguyen@LROC.harvard.edu.
authors: Paul L
authors: PL
authors: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D008875:Middle Aged; D060787:Neoplasm Grading; D011237:Predictive Value of Tests; D011467:Prostate / Q000473:pathology*; D017430:Prostate-Specific Antigen / Q000097:blood; D011471:Prostatic Neoplasms / Q000453:epidemiology / Q000473:pathology*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate
chemical_list: D017430:Prostate-Specific Antigen
keywords: SEER program; neoplasm grading; neoplasm staging; prostatic neoplasms; watchful waiting