More Testing Before Surveillance May Benefit Older Patients With Prostate Cancer

Study findings suggest that patients aged >65 years with biopsy-confirmed Gleason score 6 prostate cancer may benefit from additional testing (eg, multiparametric magnetic resonance imaging and targeted biopsy) before participating in active surveillance (JAMA Netw Open. 2020;3[4]:e202041.).

“Several factors, including increasing prostate-specific antigen (PSA) level, clinical tumor category, percentage of positive biopsy results, and PSA density, have been noted to be associated with clinically significant prostate cancer at radical prostatectomy,” explained lead investigator Daniel W. Kim, MD, MBA, Department of Radiation Oncology, Dana-Farber Cancer Institute, Brigham and Women’s Hospital, Boston, Massachusetts, and colleagues.

“Until now, to our knowledge, no study has incorporated these factors within predefined age strata to ascertain whether a cohort of patients at high risk can be identified for whom additional evaluation and possible treatment is indicated rather than active surveillance,” they continued.

Thus, Dr Kim et al conducted a prospective cohort study of 3191 men (median age, 62 years) with Gleason score 6 prostate cancer who underwent radical prostatectomies between February 28, 1992, and February 15, 2016, at the Martini-Klinik Prostate Cancer Center, Hamburg, Germany. The purpose of their study was to determine whether being aged >65 years was tied to an increased chance of adverse pathological findings at radical prostatectomy, defined as TNM category pT3/T4 or R1 or Gleason score 8, 9, or 10.

“We dichotomized age at 65 years, a commonly used cutoff, to enable clinical utility of the results,” said the investigators, who used a Wilcoxon rank sum test and Maental-Haenszal χ2 test to compare the proportion of clinical characteristics at presentation among patients aged >65 years versus ≤65 years.

The unadjusted and adjusted odds ratios (ORs) of adverse pathological findings at radical prostatectomy were calculated using univariable and multivariable logistic regressions adjusted for pre–radical prostatectomy PSA level, clinical tumor category, year of diagnosis, percentage of positive biopsy results, and PSA density.

Data analysis was conducted on May 24, 2019, and P values were 2-sided, with statistical significance set at P <.05

Overall, 2809 (88.3%) patients had T category 1c prostate cancer, and the median PSA level was 6.74 ng/mL. Patients aged >65 years had a significantly lower median percentage of positive biopsy results than those aged ≤65 years (16.7% vs 20.0%, respectively; P = .01) as well as a lower PSA density (0.13 ng/mL vs 0.15 ng/mL, respectively; P <.001).

Although increases in the proportion of positive biopsy results (adjusted OR per 1-unit increase, 1.02; 95% CI, 1.01-1.02; P <.001) and PSA density (adjusted OR per 1-unit increase, 4.28; 95% CI, 1.66-11.01; P = .003) were tied significantly to increased odds of adverse pathological findings at radical prostatectomy, patients aged >65 years had a higher risk for adverse pathological findings at radical prostatectomy than those aged ≤65 years (adjusted OR, 1.28; 95% CI, 1.00-1.62; P = .048).

These study results point to an association between age >65 years and adverse pathological findings at radical prostatectomy.

“Specifically, if being older than 65 years was not associated with increased risk, one would have expected men older than 65 years to have a lower risk of having adverse pathological findings given the more favorable percentage of positive biopsy results and PSA density levels,” Dr Kim and co-investigators said.

“These findings suggest that men older than 65 years with biopsy-confirmed Gleason score 6 prostate cancer may benefit from additional testing, such as multiparametric magnetic resonance imaging and targeted biopsy before proceeding with active surveillance. If higher grade or stage disease is detected, this information could be used to guide the use and duration of androgen deprivation therapy in men considering radiotherapy,” they concluded.—Hina Porcelli