Reverse stage shift at a tertiary care center: escalating risk in men undergoing radical prostatectomy

Abstract

Background: The objective of this study was to evaluate changes in clinical and pathologic characteristics of prostate cancer in patients who underwent surgery at a large tertiary care center in the context of increased use of active surveillance (AS) and minimally invasive surgery (MIS).

Methods: The authors retrospectively reviewed 6624 patients with localized prostate cancer who underwent radical prostatectomy from 2000 to 2010 at Memorial Sloan-Kettering Cancer Center. Patients were stratified by surgical approach (open, laparoscopic, or robotic) and by risk category (low, intermediate, or high). Patients with low-risk disease, without intervention, and with a minimum follow-up of 6 months were considered to have elected AS.

Results: The number of patients who had AS increased from <20 per year between 2000 and 2004 to ≥ 100 per year between 2007 and 2009. Over the same decade, the number of patients who underwent MIS (laparoscopic or robotic) increased from zero to 63% of all surgical cases. The percentage of patients in the intermediate-risk and high-risk categories increased over time, whereas the percentage of patients in the low-risk category decreased (odds ratio [OR] per year, 0.91; 95% confidence interval [CI], 0.89-0.92; P < .0005). The proportion of patients who underwent surgery with Gleason 6 tumors decreased over time (OR per year, 0.87; 95% CI, 0.85-0.88; P < .0005), whereas pathologic stage and Gleason score increased (P < .0005). The proportion of low-risk patients decreased across all types of surgery, and the largest decrease was observed for robotic surgery (P < .0005).

Conclusions: A reverse stage shift was observed in patients who underwent radical prostatectomy after 2000 despite the introduction and rapid proliferation of MIS. This shift may have been caused in part by the increased use of AS and an institutional focus on the treatment of higher risk disease.

Copyright © 2011 American Cancer Society.

Figures

Figure 1

Proportion of radical prostatectomy cases classified by NCCN risk stratification. Solid line indicates low-risk. Dashed line indicates intermediate-risk. Grey line indicates high-risk.

Figure 2

Proportion of radical prostatectomy cases classified as low-preoperative risk. Solid line indicates open radical prostatectomy. Dashed line indicates laparoscopic radical prostatectomy. Grey line indicates robotic-assisted laparoscopic prostatectomy.

Figure 3

Biopsy features over time. Solid line indicates biopsy grade 6. Dashed line indicates T1c disease. Grey line indicates PSA.

Figure 4

Pathologic features over time. Solid line indicates pathologic Gleason 6. Dashed line indicates organ-confined disease.

Figure 5

Number of patients enrolled into active surveillance by year.