title: Upgrading and upstaging at radical prostatectomy in the post-prostate-specific antigen screening era: an effect of delayed diagnosis or a shift in patient selection?
abstract: Prostate cancer management changed in recent times given the recommendation against prostate-specific antigen screening, adherence to active surveillance, and "cytoreductive" surgery. We hypothesized that radical prostatectomy (RP) findings changed as well. All consecutive RPs (n=1348) and first time prostate needle biopsies (n=1719) in a period of 9 years were reviewed. The cohort was separated into 3 groups: (1) from May 2006 to April 2009, (2) from May 2009 to April 2012, and (3) from May 2012 to April 2015. The number of RPs decreased 15% from 551 in group 1 to 476 in group 2 and decreased a further 35% to 311 in group 3. Pure Gleason 6 (grade group 1) decreased from 46% in group 1 to 24% in group 2 (P<.001) to 12% in group 3 (P<.001). Gleason score 4+3=7 (grade group 3) increased from 9.8% in group 1 to 13.4% in group 2 (P=.07) to 20.6% in group 3 (P=.01). Gleason score 8, 9, or 10 (grade groups 4 and 5) increased from 0.9% in group 1 to 8.4% in group 2 (P<.001) to 13.2% in group 3 (P=.04). Pathologic stage pT3 or above increased from 15.5% in group 1 to 29.2% in group 2 (P<.01) to 38.3% in group 3 (P=.01). In needle biopsies, there was no difference in number of cancer diagnoses, number of positive cores, or distribution of grades among 3 groups. More patients with low-risk disease are opting for active surveillance, and patients with high-risk disease are offered cytoreductive surgery. Lack of similar changes in needle biopsies suggests that a decrease in screening is not playing a role in the changes seen at RPs.
authors.affiliation: Department of Pathology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Liz
authors.initials: L
authors.lastname: Edmund
authors.affiliation: Division of Urology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Katherine L
authors.initials: KL
authors.lastname: Rotker
authors.affiliation: Department of Pathology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Nelli S
authors.initials: NS
authors.lastname: Lakis
authors.affiliation: Division of Urology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Brito
authors.affiliation: Department of Pathology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Marcos
authors.initials: M
authors.lastname: Lepe
authors.affiliation: Department of Pathology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Kara A
authors.initials: KA
authors.lastname: Lombardo
authors.affiliation: Division of Urology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Renzulli
authors.affiliation: Department of Pathology, Lifespan Academic Medical Center and Alpert Medical School of Brown University, Providence, RI, 02903. Electronic address: Andres_Matoso@brown.edu.
authors.forename: Andres
authors.initials: A
authors.lastname: Matoso
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001707:Biopsy, Needle; D065426:Cytoreduction Surgical Procedures / Q000379:methods*; D057210:Delayed Diagnosis; D055088:Early Detection of Cancer / Q000379:methods*; D006801:Humans; D007610:Kallikreins / Q000097:blood*; D008297:Male; D008875:Middle Aged; D060787:Neoplasm Grading; D009367:Neoplasm Staging; D018579:Patient Selection; D011237:Predictive Value of Tests; D017430:Prostate-Specific Antigen / Q000097:blood*; D011468:Prostatectomy; D011471:Prostatic Neoplasms / Q000097:blood / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D057832:Watchful Waiting
chemical_list: C549870:KLK3 protein, human; D007610:Kallikreins; D017430:Prostate-Specific Antigen
keywords: Mass screening; Neoplasm grading; Prostate-specific antigen; Prostatic neoplasms; Watchful waiting