title: Risk of Pathologic Upgrading or Locally Advanced Disease in Early Prostate Cancer Patients Based on Biopsy Gleason Score and PSA: A Population-Based Study of Modern Patients.
abstract: OBJECTIVE
  Radiation oncologists rely on available clinical information (biopsy Gleason score and prostate-specific antigen [PSA]) to determine the optimal treatment regimen for each prostate cancer patient. Existing published nomograms correlating clinical to pathologic extent of disease were based on patients treated in the 1980s and 1990s at select academic institutions. We used the Surveillance, Epidemiology, and End Results (SEER) database to examine pathologic outcomes (Gleason score and cancer stage) in early prostate cancer patients based on biopsy Gleason score and PSA concentration.
  
  
  METHODS
  This analysis included 25,858 patients whose cancer was diagnosed between 2010 and 2011, with biopsy Gleason scores of 6 to 7 and clinical stage T1 to T2 disease, who underwent radical prostatectomy. In subgroups based on biopsy Gleason score and PSA level, we report the proportion of patients with pathologically advanced disease (positive surgical margin or pT3-T4 disease) or whose Gleason score was upgraded. Logistic regression was used to examine factors associated with pathologic outcomes.
  
  
  RESULTS
  For patients with biopsy Gleason score 6 cancers, 84% of those with PSA <10 ng/mL had surgical T2 disease with negative margins; this decreased to 61% in patients with PSA of 20 to 29.9 ng/mL. Gleason score upgrading was seen in 43% (PSA: <10 ng/mL) to 61% (PSA: 20-29.9 ng/mL) of biopsy Gleason 6 patients. Patients with biopsy Gleason 7 cancers had a one-third (Gleason 3 + 4; PSA: <10 ng/mL) to two-thirds (Gleason 4 + 3; PSA: 20-29.9 ng/mL) probability of having pathologically advanced disease. Gleason score upgrading was seen in 11% to 19% of patients with biopsy Gleason 4 + 3 cancers. Multivariable analysis showed that higher PSA and older age were associated with Gleason score upgrading and pathologically advanced disease.
  
  
  CONCLUSIONS
  This is the first population-based study to examine pathologic extent of disease and pathologic Gleason score upgrading based on clinically available information in modern patients. These data inform the selection of radiation therapy strategies and an understanding of whether prostatectomy alone is likely to be curative for patients with early prostate cancers.
authors.affiliation: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Caster
authors.affiliation: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Aaron D
authors.initials: AD
authors.lastname: Falchook
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Laura H
authors.initials: LH
authors.lastname: Hendrix
authors.affiliation: Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Electronic address: Ronald_chen@med.unc.edu.
authors.forename: Ronald C
authors.initials: RC
authors.lastname: Chen
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D001706:Biopsy; D003657:Decision Making; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D049451:Nomograms; D011467:Prostate / Q000737:chemistry / Q000473:pathology*; D017430:Prostate-Specific Antigen / Q000032:analysis*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000737:chemistry / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery*; D018426:SEER Program
chemical_list: D017430:Prostate-Specific Antigen